Assessment-Based Treatment for Traumatized Children: A Trauma Assessment Pathway Model TAP
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1. Assessment-Based Treatment for Traumatized Children: A Trauma Assessment Pathway Model (TAP) Presented by: Alicia Gilbert, PhD Robyn Igelman, PhD

2. Chadwick Center for Children and Families Intro to Chadwick and mention programs. Alicia mentions TAP coordinator role. Robyn talks about Treatment Outcome Office.Intro to Chadwick and mention programs. Alicia mentions TAP coordinator role. Robyn talks about Treatment Outcome Office.

3. Trauma Counseling Program Assessment-based individual, group and family therapy for children who have experienced traumatic events. Therapy and advocacy to domestic violence victims and their children at the Family Justice Center. School-based counseling services. Parent-child interaction therapy. Medication & psychological assessments. Crisis intervention, advocacy, information and referrals. Robyn Therapy provided by 40-member multi-ethnic and multi-disciplinary treatment staff. All of our staff are trained in EBPs including PCIT and TF-CBT Types of trauma: sexual abuse, physical abuse, DV, neglect, Include medical trauma and community violence Say TAP model developed based on clinical experiences and use of standardized assessment tools since 1994?Alicia is going to provide a brief overview of the Trauma Assessment Pathway model and its development.Robyn Therapy provided by 40-member multi-ethnic and multi-disciplinary treatment staff. All of our staff are trained in EBPs including PCIT and TF-CBT Types of trauma: sexual abuse, physical abuse, DV, neglect, Include medical trauma and community violence Say TAP model developed based on clinical experiences and use of standardized assessment tools since 1994?Alicia is going to provide a brief overview of the Trauma Assessment Pathway model and its development.

4. TAP Model Overview A treatment manual for traumatized children ages 2 to 18 years Incorporates assessment data, clinical interview, and observation to create a Unique Client Picture Includes specific components of trauma-specific treatment described by the Trauma Wheel Draft completed and undergoing revisions Alicia gives background on development of TAP model and refers to slide with website info Provide trainings on TAP to interested NCTSN sites (refer to contact info for trainings)Alicia gives background on development of TAP model and refers to slide with website info Provide trainings on TAP to interested NCTSN sites (refer to contact info for trainings)

5. What Is Assessment Based Treatment (ABT)? Development of clinical assessment-based treatment refers to the ?development of an integrated plan of prioritized interventions, that is based on the diagnosis and psychosocial assessment of the client, to address mental, emotional, behavioral, developmental and addictive disorders, impairments and disabilities, reactions to illnesses, injuries, and social problems.? (Social work, consolidated laws, effective Sept. 1, 2004) AliciaAlicia

6. Clinical Pathways A sequence or path that clinicians follow in making assessment, triage, and clinical decisions. Found increasingly useful within the medical field. Evaluation of UCLA?s Asthma Pathway showed substantial cost effectiveness and adherence to medical standards (Chest, 1998) Rady Children?s Hospital developed over 40 pathways, starting with Asthma in 1994, domestic violence in 2001, and TAP in 2005. TAP includes a pathway that directs triage, assessment, referrals, and clinical interventions. Alicia in standardizing the management of different medical and mental ailments, with the ultimate goal of improving care and reducing unnecessary health-care costsAlicia in standardizing the management of different medical and mental ailments, with the ultimate goal of improving care and reducing unnecessary health-care costs

7. The therapeutic goal is to resolve the impact of a single or series of traumatic experiences to the child and their family. Therapeutic decisions emerge from clinical and standardized assessment. Chadwick?s Philosophy of Trauma Treatment AliciaAlicia

8. 3 Components of TAP Assessment Creating a Unique Client Picture Triage Treatment Alicia-Today we?re Focusing on first two components of trainingAlicia-Today we?re Focusing on first two components of training

9. Assessment: Is the client appropriate for your Center and for the TAP Model? AliciaAlicia

10. Alicia-example of a phone triage or screening tool to determine if client is appropriate for services at your center. Need referral sources outside of center. Doing triage and assessment from the very beginning. Who will have the initial client contact and what is the necessary training to make triage decisions.Alicia-example of a phone triage or screening tool to determine if client is appropriate for services at your center. Need referral sources outside of center. Doing triage and assessment from the very beginning. Who will have the initial client contact and what is the necessary training to make triage decisions.

11. To get the full rich unique client picture, gather information via: Clinical Interviews Behavioral Observation Standardized Measures Alicia-integrating all because all are equally important.Alicia-integrating all because all are equally important.

12. Alicia-sites needs to determine what info is important for them to include and how are you going to gather the information. Ex of attachment measures ? rely on behavioral ops for this domain.Alicia-sites needs to determine what info is important for them to include and how are you going to gather the information. Ex of attachment measures ? rely on behavioral ops for this domain.

13. Standardize your Assessment Choices What measures exist to help you know your client? Robyn: Here is an example of what a thorough protocol could look like? you see along the top we have listed various informants from whom you can collect information ? you want to select a variety of informants from which to gather the information because we find that children, caregivers, and clinicians do not always identify the same issues or symptoms and children and really better at identifying internalizing symptoms, while caregivers are more adept at recognizing externalizing symptoms. And along the left hand side we have the content areas or various domains assessed?.again, you want to gather information in a variety of areas including trauma history, current symptoms, attachment and systems issues, and development. So creating a table like this is just one way for your site to determine which measures you want to include in your assessment protocol to determine the measures that are most appropriate for your population and setting.Robyn: Here is an example of what a thorough protocol could look like? you see along the top we have listed various informants from whom you can collect information ? you want to select a variety of informants from which to gather the information because we find that children, caregivers, and clinicians do not always identify the same issues or symptoms and children and really better at identifying internalizing symptoms, while caregivers are more adept at recognizing externalizing symptoms. And along the left hand side we have the content areas or various domains assessed?.again, you want to gather information in a variety of areas including trauma history, current symptoms, attachment and systems issues, and development. So creating a table like this is just one way for your site to determine which measures you want to include in your assessment protocol to determine the measures that are most appropriate for your population and setting.

14. Measurement Considerations Psychometric Properties Reliability and Validity Clinical Cutoffs Sensitivity to Change Feasibility Issues Time to administer Staff training Costs of using measures Language Multiple vs. Single Informants Real World Validity Clinical Utility Robyn Here are some things you want to think about when selecting measures to use at your site. Obviously, it is ideal if the measures you select are reliable (meaning you?ll get the same results if you give the measure to the same person more than once) and valid (meaning the tool is actually measuring what you want it to measure, and not something else) Another important issue to think about is whether or not the measure has a clinical cutoff score?likely, the measure will be more valuable if you have a cutoff point at which to decide when a client is distressed or elevated? homegrown measures that have not had any research may therefore not be able to provide the therapists with enough information to make it useful. Other issues include: Feasibility- or time to administer Real world validity ? or the generalizability of the measure to your particular population, and Language availability ? or is the measure available (and valid) in the language that you need. We often find that many of our measures were developed with non-hispanic populations and that the spanish translations are poor or difficult for our clients to understand. In these instances, it is important to recognize the limitations of your measure and to interpret any results with caution.Robyn Here are some things you want to think about when selecting measures to use at your site. Obviously, it is ideal if the measures you select are reliable (meaning you?ll get the same results if you give the measure to the same person more than once) and valid (meaning the tool is actually measuring what you want it to measure, and not something else) Another important issue to think about is whether or not the measure has a clinical cutoff score?likely, the measure will be more valuable if you have a cutoff point at which to decide when a client is distressed or elevated? homegrown measures that have not had any research may therefore not be able to provide the therapists with enough information to make it useful. Other issues include: Feasibility- or time to administer Real world validity ? or the generalizability of the measure to your particular population, and Language availability ? or is the measure available (and valid) in the language that you need. We often find that many of our measures were developed with non-hispanic populations and that the spanish translations are poor or difficult for our clients to understand. In these instances, it is important to recognize the limitations of your measure and to interpret any results with caution.

15. Assessment Pathway Process Core measures administered Problem areas identified Other measures are administered to probe more deeply Robyn-mainly talking about how to use assessments to triage; Pathway process?Robyn-mainly talking about how to use assessments to triage; Pathway process?

16. Robyn-example of how we?ve used the NCTSN?s core clinical to integrate the pathway into our interview assessment process so that if there?s concerns in a particular area, you can administer one of your additional measures to probe more deeply and gather additional information.Robyn-example of how we?ve used the NCTSN?s core clinical to integrate the pathway into our interview assessment process so that if there?s concerns in a particular area, you can administer one of your additional measures to probe more deeply and gather additional information.

17. Therapists? Use of Assessment Measures: Guiding the assessment and providing feedback. RobynRobyn

18. How to make sense of assessment results: Know what each measure assesses and applicable populations Have a general understanding of each subscale Examine the validity scales (if any) Use assessment results as an adjunct to your clinical interview Clarify inconsistencies between assessment results and clinical impressions Robyn ? A couple of important points to draw your attention to are the validity scales and making sure that you take a look at these before interpreting the measure. There can be a variety of different validity scales depending on the measure including defensive responding, overreporting, social desirability. If any of these scales are significant, you need to be careful in how you interpret the meaning of the scores and you likely want to go back and review the measure item by item to see why the scale was elevated. Another important point to mention is that the measures are just one piece of your assessment process so you always want to try and integrate this information with information you gather from your clinical interview and other assessment methods. And Alicia will be talking more about this in a few minutes. Robyn ? A couple of important points to draw your attention to are the validity scales and making sure that you take a look at these before interpreting the measure. There can be a variety of different validity scales depending on the measure including defensive responding, overreporting, social desirability. If any of these scales are significant, you need to be careful in how you interpret the meaning of the scores and you likely want to go back and review the measure item by item to see why the scale was elevated. Another important point to mention is that the measures are just one piece of your assessment process so you always want to try and integrate this information with information you gather from your clinical interview and other assessment methods. And Alicia will be talking more about this in a few minutes.

19. How to make sense of assessment results (cont.): Involve the parents and children in your interpretive process Integrate results with clinical impressions & think about how the results can be used to plan treatment Don?t discount your clinical judgment!! Robyn- Essentially, you want to consult the manual to understand the scores and various subscales but you want to rely mostly on your clinical judgment and how the assessment results fit with what you already know about the client and family. A lot of times we get new therapists who believe the measure must be right even though their clinical impression was totally different. Robyn- Essentially, you want to consult the manual to understand the scores and various subscales but you want to rely mostly on your clinical judgment and how the assessment results fit with what you already know about the client and family. A lot of times we get new therapists who believe the measure must be right even though their clinical impression was totally different.

20. Problem Solving: What Happens When the Measures & Clinician Don?t Agree? At this point, there is a lot the therapist can do to better understand the meaning of the assessments, including talking with the child and family about the results, consulting with colleagues, examining individual items Read manual for guidance Consult supervisor or assessment coordinator What does it mean if there there are no significant problems identified? At this point, there is a lot the therapist can do to better understand the meaning of the assessments, including talking with the child and family about the results, consulting with colleagues, examining individual items Read manual for guidance Consult supervisor or assessment coordinator What does it mean if there there are no significant problems identified?

21. Robyn ? Finally, its especially helpful if you can figure out a nice way to display the results of your measures. Here is an example of our feedback sheet for a children?s depression inventory and the trauma symptom checklist for children. You can see the subscales are listed, critical items are identified and elevated scores are highlighted. You can also more easily track changes over time this way (see time 2).Robyn ? Finally, its especially helpful if you can figure out a nice way to display the results of your measures. Here is an example of our feedback sheet for a children?s depression inventory and the trauma symptom checklist for children. You can see the subscales are listed, critical items are identified and elevated scores are highlighted. You can also more easily track changes over time this way (see time 2).

22. How do you discuss feedback with your clients? RobynRobyn

23. Parent and client feedback: Dos & Don?ts DO: Allow one therapy session to discuss results and give feedback Elicit client feedback and impressions regarding assessment results Discuss results with parent and child to confirm clinical impressions Address areas of concern not initially revealed through clinical interview Most important: Engage them in the process!

24. Parent and client feedback: Dos & Don?ts (cont.) DON?T: Avoid discussing results with your clients Act like the assessments are a waste of time (because your clients will too!) Be afraid to share written feedback and printouts with parents and children Underestimate the ability of your clients to understand and appreciate your feedback

25. How to form your clinical hypothesis Consider all assessment feedback Which family members need to be included in treatment? What are the dynamics in the family? Family and client buy in Consider the cause of distress AliciaAlicia

26. Heuristics of Using the Clinical Pathway One skill builds upon another. All spokes of the Trauma Wheel will be addressed at some point during treatment. The length of time and intervention type depend upon the unique client picture. The wheel is fluid ? you move back and forth between spokes of the wheel. AliciaAlicia

27. Do an exercise with audience: pick one task for each spoke and have audience guess where it goes. Lisa leads The Trauma Wheel?now the concept of essential and common components of trauma treatment is nothing new. Research and presentations from others including Berliner, Lieberman, and many, many others suggest that there are essential components to trauma treatment. We took information from research and our clinical experience to form the Trauma Wheel. As you can see this incorporates many components we have already mentioned. The spokes of the wheel include the treatment components we felt were most essential in treating child trauma. These include? Also how you go about treatment will be determined by the child?s developmental functioning and culture in which they live and come from. Like many others, we believe that the therapeutic relationship is what holds everything together and keeps the treatment moving forward. Like tires of a wheel?the therapeutic relationship will require maintenance throughout treatment and should be revisited while going through the spokes of the trauma wheel.Do an exercise with audience: pick one task for each spoke and have audience guess where it goes. Lisa leads The Trauma Wheel?now the concept of essential and common components of trauma treatment is nothing new. Research and presentations from others including Berliner, Lieberman, and many, many others suggest that there are essential components to trauma treatment. We took information from research and our clinical experience to form the Trauma Wheel. As you can see this incorporates many components we have already mentioned. The spokes of the wheel include the treatment components we felt were most essential in treating child trauma. These include? Also how you go about treatment will be determined by the child?s developmental functioning and culture in which they live and come from. Like many others, we believe that the therapeutic relationship is what holds everything together and keeps the treatment moving forward. Like tires of a wheel?the therapeutic relationship will require maintenance throughout treatment and should be revisited while going through the spokes of the trauma wheel.

28. Case Example: Referral Information Interview with Child & Family Standardized Assessment Results Consider family buy-in & needs before making treatment decisions Re-Assess

29. On-going Re-assessment Weekly interviews/updated goals Progress notes Supervision Follow-up standardized measures Must use the same measures for each time period (to measure change over time) Can add measures over time (once added must continue to administer added measure to assess change over time). gailgail

30. nicolenicole

31. Alicia Kolko / berliner? Concept for different categories in the wheel emerged from research from kolko and berliner?Alicia Kolko / berliner? Concept for different categories in the wheel emerged from research from kolko and berliner?

32. You?re the Experts What are some basic assumptions you may have about traumatized clients? How have you validated those assumptions? What is your experience with using assessment measures? AliciaAlicia

33. Resources www.ChadwickCenter.org (Chadwick) www.nctsn.net (National Child Traumatic Stress Network) www.musc.edu/cvc/ (TF-CBT on-line and OVC guidelines) www.cachildwelfareclearinghouse.org

34. Contact Information Alicia Gilbert, PhD 858-966-8682 agilbert@rchsd.org Robyn Igelman, PhD 858-576-1700, ext. 3211 rigelman@rchsd.org


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