Trauma: What are the Effects and What Helps them Recover? Part 2

1. Trauma: What are the Effects and What Helps them Recover?Part 2 Jennifer Wilgocki, MS LCSW Adolescent Trauma Treatment Program Mental Health Center of Dane County, Inc. September 27, 2006

2. Trauma Principle #1 If everything is trauma, nothing is trauma.

3. Trauma Principle #2 It is the child’s experience of the event, not the event itself, that is traumatizing.

4. Trauma Principle #3 If we don’t look for or acknowledge trauma in the lives of children and adolescents, we end up chasing behaviors and limiting the possibilities for change.

5. Trauma Principle #4 The behavioral and emotional adaptations that maltreated children make in order to survive are brilliant, creative solutions, and are personally costly.

6. Trauma Principle #5 If you don’t ask, they won’t tell.

7. Kinds of Trauma Assessments Screening Clinical assessment Standardized instruments

8. Trauma Screening Screening does not mean diagnosing Screening is essential to a public health approach for detecting mental health issues, including trauma Screening is “the great equalizer”

9. Trauma Screening Some examples: grade-level screening in schools intake screening in outpatient clinic admissions screening in inpatient program dual diagnosis screening for trauma and AODA CPS/delinquency screening at intake

10. Clinical Assessment for Trauma Psychosocial History Trauma Exposure • e.g., Use of UCLA PTSD Index interview Mental Status Exam • Generic psychological symptoms • Anxiety, depression, anger, general externalization

11. Clinical Assessment for Trauma Posttraumatic stress triggers during assessment • Symptoms of PTSD • Dissociation • Sexual behaviors • Signs of hyperarousal and avoidance • Suicidality, danger to others

12. Clinical Assessment for Trauma Parent- versus child-report • Internalized vs. externalized symptoms Generic vs. trauma-specific • Need for both content domains

13. The Issue of Avoidance Child underreport of symptoms • Trauma effect • Fear of disclosure Parent underreport of child symptoms • Guilt • Denial Potential for apparent symptom increase after initial assessment Usefulness of validity scales

14. Standardized Instruments • a clinical interview and the use of standardized instruments are compatible • kids are used to taking tests • kids and caregivers tend to be interested in results

15. Standardized Instruments • results of standardized instruments should be part of psychoeducation • assessment data is powerful -- clinically and fiscally

16. Our Core Data Set UCLA PTSD Index (Steinberg et al) Trauma Symptom Checklist for Children (Briere) Children’s Depression Inventory (Kovacs) Revised Child Manifest Anxiety Scale (Reynolds) Personal Experience Screening Questionnaire (Winters) Child Behavior Checklist (Achenbach) Teacher Report Form (Achenbach)

17. Elements of Trauma-Informed Treatment • What is the diagnosis? • Is the diagnosis and/or symptomatology related to the trauma? • Can trauma-focused interventions be integrated with other treatment strategies which address non-trauma problems?

18. Elements of Trauma-Informed Treatment • Trauma-informed assessment • Trauma-informed treatment planning • Cognitive-Behavioral approach • Psychoeducation • Repetition of CBT concepts • Matching: dose, duration, type • Structure (trauma = chaos)

19. Trauma-informed and Evidence-based Using interventions that have scientific base Using interventions that have positive outcomes -- reduce symptoms and improve functioning Funders and other professionals (e.g. judges, CPS workers, school administrators) want interventions with an evidence-base

20. Sequenced Treatment Common myths: Creativity is squashed Therapeutic relationship matters less No flexibility Our experience with sequenced treatment: Creativity and flexibility are encouraged Therapeutic relationship is central

21. Exposure & Non-Exposure-based Therapy Exposure: eliciting client’s distress while recalling trauma material leading to decreased arousal over time Non-Exposure: building skills for coping and resiliency - may be preparation for exposure

22. Evidence-based Models:What we are Implementing Exposure CBITS Trauma-focused CBT Non-exposure SPARCS TARGET Combination EMDR TF-AODA

23. CBITSCognitive Behavioral Intervention for Trauma in Schools

24. What is CBITS? • Developed at Rand Corporation • Piloted in LA Unified School District • Targets the effects of violence • Exposure-based, skill-based curriculum • decrease symptoms of PTSD and depression • improve availability for learning • promote resilience, decrease stigma • build peer and parent support • increase attendance and GPA

25. Elements of CBITS Grade-level screening 10 group meetings • co-led by support staff and MHC therapist • maximum of 8 students, co-ed 1 to 4 individual meetings 1-2 parent education meetings 1-2 teacher education meetings

26. Screening 3-part self-report screener 9 Traumatic Life Events questions (Singer, et.al.’s Modified Life Events Scale) 17 PTSD Symptoms questions reexperiencing, avoidance, hyperarousal (Foa’s Child PTSD Symptom Scale) 26 Child Depression Symptoms questions (Kovac’s Children’s Depression Inventory)

27. CBITS Year 1Madison Schools 2004-05 730 students eligible for screening 13.4 % of the students screened reported significant exposure to violence and Symptoms of PTSD above clinical cut-off 33 no parent consent or other decline 58 parental opt-out of screening 12 students received CBITS after waitlist 45 students received CBITS w/out waitlist 90 students eligible for program 57 students assigned to groups 672 students screened for eligibility

28. CBITS: Year 2Madison Schools 2005-06 896 6th graderseligible for screening 10% of the students screened reported significant exposure to violence and Symptoms of PTSD above clinical cut-off 29 no parent consent or other decline 76 parental opt-out of screening 4 students received CBITS after waitlist 48 students received CBITS w/out waitlist 81 students eligible for program 52 students assigned to groups 820 students screened for eligibility

29. CBITS: Year 32006 - 07

30. Trauma-focused Cognitive Behavioral Therapy

31. Trauma-focused CBT Developed by Deblinger at CARES Institute in New Jersey and Cohen and Mannarino at Allegheny Hospital in Pittsburgh A “hybrid” treatment model that integrates trauma sensitive interventions with cognitive-behavioral strategies

32. Trauma-focused CBT 12-18 sessions with child 12-18 sessions with caregiver (individual and family) Exposure-based with trauma narrative

33. Trauma-focused CBT • Trauma-Focused CBT is the most rigorously tested treatment for abused children • 10 randomized trials • Improved PTSD, depression, anxiety, shame and behavior problems compared to supportive treatments • Improved parental distress, parental support, and parental depression compared to supportive treatment

34. Trauma-focused CBT Free 10-hour web-based training available through the Medical University of South Carolina. Free CEUs available www.tfcbt.musc.edu

35. Tameshia’s Story Tameshia is a 12 year old middle school student who was referred to ATTP by her school social worker for significant symptoms: • Day dreaming or otherwise distracted from her work • Difficulty making/keeping friends • Irritable, cries easily, exaggerated startle response • Bad dreams, intrusive thoughts • Sleep disturbance, needs to sleep with her mom • Often up and out of her seat and physically in and out of classroom

36. Tameshia’s Story Tameshia was awakened by the sounds of her uncle coming to her home in the middle of the night. He was covered in blood and Tameshia’s parents were emotionally distraught. The police arrived at her home and arrested her uncle on charges of having murdered Tameshia’s aunt earlier that night.

37. Tameshia’s Assessment Initial clinical assessment indicated: • Depression • Anxiety • Dissociation • Attention Problems • Behavioral Problems Tameshia’s symptoms met diagnostic criteria for full PTSD.

38. Tameshia’s Treatment 16 individual sessions with Tameshia for six months, most held at school. 2 parent sessions with her mother. No psychiatry or medications utilized on this case.

39. Tameshia’s Outcomes • Depression (CDI) Pre: 64 t score* Post: 43 t score • Dissociation (TSCC) Pre: 69 t score* Post: 47 t score • Anxiety (TSCC) Pre: 66 t score* Post: 39 t score • PTSD (UCLA PTSD Index) Pre: 39 raw* Post: 8 raw score *= clinically significant

40. Tameshia’s Outcomes Tameshia reported: • sleeping in her own bed again • having better focus in school • staying in her classroom more • feeling less distress and happier

41. Tameshia’s Outcomes “Tameshia developed a trauma narrative that tells the story of what she experienced, how she coped with this, and what she learned about her self….Tameshia made great progress. She met all of her treatment goals and reports great improvement in her trauma symptoms.” (excerpt from treating therapist’s Termination Summary)

42. Tameshia’s Outcomes Tameshia’s teacher reported that: • Tameshia stayed in her seat and in her classroom more • Tameshia’s concentration improved • Tameshia’s affect was brighter • She was more engaged in class • She was able to develop friendships with peers

43. SPARCSStructured Psychotherapy for Adolescents Responding to Chronic Stress

44. SPARCS • developed at Northshore Hospital, NY (DeRosa, et al) • targets the 6 domains of Complex PTSD • 22 group sessions • Non-exposure based intervention

45. SPARCS Goals: • to help traumatized adolescents make better choices for their lives • to cultivate healthier relationships • to activate meaning making • to rouse mindful action • to teach tools for coping with current and future stressors • to promote healing

46. SPARCS Collaborations Coventry Group Home Outpatient group at MHC Pre- and post-group measures * Youth Outcome Questionnaire * Coping scale * SIDES interview for Complex PTSD

47. TARGETTrauma Adaptive Recovery, Group Education, and Therapy

48. TARGET Developed by Julian Ford at U of CT 11-17 year olds with PTSD or Complex PTSD Provided in juvenile justice or residential treatment settings

49. TARGET • 10 group sessions • bodily self-regulation • affect regulation • autobiographical and working memory (information processing) • interpersonal problem solving • stress management

50. TARGET Collaborations Delinquency Supervision Programs - NIP and CAP (both in Madison) Day Treatment - Steps to Success at Family Service in Madison