Domains of Impairment in Children exposed to Complex Trauma

1. Assessment and Treatment of Trauma in Children and Young People Robyn Lamb March 09

2. Domains of Impairment in Children exposed to Complex Trauma Attachment Biology Affect Regulation Dissociation Behavioural control Cognition Self concept

3. Initial contact Child Sexual Assault Service  Psychosocial Assessment Medical Assessment general / forensic What does the child/family need? Safety? Stabilization? Concrete services [referrals, legal information/assistance with reporting, liaison with CPS and other systems] What helps for those needs? Crisis response Advocacy Case management Psychoeducation

4. Hierarchy of needs Safety and basic physical and wellbeing MASLOW’S HIERARCHY Diagram of Maslow's hierarchy of needs.1. Physiological (Biological needs)2. Safety3. Love/Belonging4. Status (Esteem)5. Actualization

5. Assess before treating so that intervention can be matched to need Multidimensional approach Areas of competence and vulnerability are assessed in overlapping biological, emotional, social and cognitive domains Individual functioning is considered in the context of the child’s relationships and the family’s ecological niche

6. Assessment-Based Treatment for Traumatized Children: Using the Trauma Assessment Pathway Model (TAP) Al Killen Harvey 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.

7. *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)

8. *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

9. *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

10. 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 ofTrauma Treatment AliciaAlicia

11. *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

12. *Unique Client Picture Clinical Interviews Behavioral Observation Standardized Measures Alicia-integrating all because all are equally important.Alicia-integrating all because all are equally important.

13. 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.

14. *Standardize your Assessment ChoicesWhat 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.

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. *Treatment Triage What are the treatments that you have available at your site? What treatments are you as a therapist able to provide? Funding? Client Issues? …Reality!!!!!

18. *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.

19. *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?

20. *How do you discuss feedback with your clients? RobynRobyn

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 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

23. *Treatment Triage Select the treatment modality that is best for your client based upon the unique client picture and the evidence-based practices available: Trauma-Focused CBT TAP Model PCIT Abuse-Focused CBT Lieberman et al.’s Models for young children UCLA Trauma/Grief Focused Group Model Alicia’s first slide Lieberman’s models: Treatment of traumatic bereavement in infancy and early childhood & Child-Parent Psychotherapy with young witnesses of family violenceAlicia’s first slide Lieberman’s models: Treatment of traumatic bereavement in infancy and early childhood & Child-Parent Psychotherapy with young witnesses of family violence

24. We also created a pathway for other specialized services including psychiatry, hospitalization, a court preparation program (if child is testifying) and Parent-Child Interaction Therapy (PCIT). We also created a pathway for other specialized services including psychiatry, hospitalization, a court preparation program (if child is testifying) and Parent-Child Interaction Therapy (PCIT).

25. *Treatment through the TAP Model Using the Trauma Wheel & the Clinical Pathway

26. Characteristics of Treatments with good evidentiary support Tend to be behavioral or cognitive-behavioral (eg TFCBT); or use tailored responses (Ref Eliana Gil) Use specific procedures, not much “free-styling” Goal directed Skill-building oriented Use of practice and feedback methods Role play Homework

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. So here is the Treatment Pathway. These are some questions that we ask to find out what is the primary or most concerning initial problem in your client’s unique client picture. We understand that many children come in with a multitude of problems but this is a way to figure out where to begin. We placed safety and risk concerns on top for obvious reasons…to take care of any high risk or safety concerns first. I.e. SI, HI, drug use/abuse, abuse, eating disorders, DV, etc. If there are risk issues, deal with first. If you do not have to refer out, we suggest starting with psychoeducation & skill building to help the child learn ways to help themselves, in addition, depending on age, family dynamics, state laws, etc. we may bring in the family to help create a safer environment. This process continues for example…if after putting together the unique client picture, you feel that primary cause of their distress is problems with managing their emotions…you may go to the affect regulation spoke of the treatment wheel. Etc… So here is the Treatment Pathway. These are some questions that we ask to find out what is the primary or most concerning initial problem in your client’s unique client picture. We understand that many children come in with a multitude of problems but this is a way to figure out where to begin. We placed safety and risk concerns on top for obvious reasons…to take care of any high risk or safety concerns first. I.e. SI, HI, drug use/abuse, abuse, eating disorders, DV, etc. If there are risk issues, deal with first. If you do not have to refer out, we suggest starting with psychoeducation & skill building to help the child learn ways to help themselves, in addition, depending on age, family dynamics, state laws, etc. we may bring in the family to help create a safer environment. This process continues for example…if after putting together the unique client picture, you feel that primary cause of their distress is problems with managing their emotions…you may go to the affect regulation spoke of the treatment wheel. Etc…

29. Multiple modalities for treatment Play, Art, Craft, Sand tray Psychotherapy Expressive therapy

31. *Affect Regulation: Assumptions Expressing feelings and emotions is important. Symptoms are associated with underlying feelings and impacts behavior and social relationships. There is a need to validate, understand, and experience feelings before resolution of those feelings can occur. Alicia We don’t have time to go through in detail the various assumptions and tasks of each spoke of the trauma wheel but we wanted to provide you the slides for you, should you be interested in this information.Alicia We don’t have time to go through in detail the various assumptions and tasks of each spoke of the trauma wheel but we wanted to provide you the slides for you, should you be interested in this information.

32. *Affect Regulation: Tasks Feeling identification and labeling Express feelings congruent with feelings you are identifying Experience and communicate feelings Appropriately manage range of emotions Develop positive self-feelings Resolution of troubling emotions Acute stress reduction involves techniques that reduce triggered overwhelming states such as upsetting memories flashbacks intrusive emotion al states such as fear terror rage or dissociative states Progressive muscle relaxation When this happens you need to refocus the child's attention to immediate therapeutic environment and the client therapist relationship Grounding techiqies Controlled breathing Thought stopping/replacement Cognitive coping Count to ten/leave situation Acute stress reduction involves techniques that reduce triggered overwhelming states such as upsetting memories flashbacks intrusive emotion al states such as fear terror rage or dissociative states Progressive muscle relaxation When this happens you need to refocus the child's attention to immediate therapeutic environment and the client therapist relationship Grounding techiqies Controlled breathing Thought stopping/replacement Cognitive coping Count to ten/leave situation

33. Feelings

34. Feelings

35. *Skill Building and Psychoeducation: Assumptions The child and family lack the skills to effectively cope with trauma reactions of the child An increase in information and skills will increase knowledge and adaptive functioning. Increase in knowledge will decrease uncertainty and increase normalization. aliciaalicia

36. *Skill Building and Psychoeducation: Tasks Behavior management techniques Enhancement of positive behaviors/social skills Relaxation techniques Psychoeducation Dynamics of abuse Healthy relationships Age-appropriate development Communication and problem-solving Development of safety plans Reward positive behavior Praise Reflect Describe Name problem Generate total possible solutions (without evaluation) Evaluate and discard non-feasible alternatives Choose possible solution Try it out Check back and re-evaluate Ignore inappropriate behavior Give effective instructions Consequences for misbehavior Time-out Removal of privileges So the problem is that you don’t have any friends. Let’s make a list of all the possible ways to solve the problem. But you can’t say whether it is a good way or a bad way until we get them all out. Can you think of a way No Reward positive behavior Praise Reflect Describe Name problem Generate total possible solutions (without evaluation) Evaluate and discard non-feasible alternatives Choose possible solution Try it out Check back and re-evaluate Ignore inappropriate behavior Give effective instructions Consequences for misbehavior Time-out Removal of privileges So the problem is that you don’t have any friends. Let’s make a list of all the possible ways to solve the problem. But you can’t say whether it is a good way or a bad way until we get them all out. Can you think of a way No