Trauma-Focused Cognitive Behavioral Therapy

1. Trauma-Focused Cognitive Behavioral Therapy An overview of assessment and treatment

2. TF-CBT: Evidence-Based Practice • Empirical studies consistently demonstrated TF-CBT to reduce symptoms of PTSD, depression, and behavioral difficulties • Ethical, effective, insurance coverage • In randomized clinical trials TF-CBT resulted in greater gains in fewer clinical sessions than other therapies • In follow-up studies (up to 2 years after therapy), gains sustained over time • 80 percent+ of children show marked improvement in symptoms within 12 to 16 sessions • Parents report reduced depression, emotional distress, and PTSD symptoms, as well as an enhanced ability to support their children

3. Assessment An overview of identifying and differentiating complex symptoms

4. What? Where? When? What is trauma?

5. Signs? Symptoms? Information? How do we know?

6. Assess Symptoms for Treatment: TF-CBT? • Goals for assessment • What are symptoms? • What are cause of symptoms? • Plan treatment • Is TF-CBT appropriate for traumatized child? • For children with impairments in functioning • Children with a trauma history • Primary symptoms related to trauma • Behavioral reactions related to trauma

7. Assess Safety • Does the child reside with those involved in a traumatic event? • Treatment is not likely to be effective if the child continues to be exposed to the trauma. • Continuing with treatment may desensitize children to actual danger cues. • Was a CYF report filed? • If not, are you a mandated reporter? • If so, is there an active investigation? Some components of trauma treatment may need to be postponed until a legal process is complete.

8. Parents’ role in the treatment process is central. Parent treatment decreased behavioral and depressive symptoms in child (Deblinger et al. 1996). Parents’ emotional reaction was strong predictor of outcome (Cohen & Mannarino 1996). Parental support related to decreased symptoms in child (Cohen & Mannarino 1997). Assess Parents

9. Assess Parents cont’d • May not believe trauma occurred • May not believe trauma impact • Overwhelmed with own experience • Impact of trauma • Self-blame/guilt • Mental health, including substance abuse, intellectual disabilities • Suspicious of therapy (may make it worse) • Day-to-day stressors such as housing, finances, legal concerns • May be unwilling to change parenting approach

10. Assess Cultural Considerations • Linguistic competency • Bilingual/bicultural therapist • Translator • Broadening therapist’s understanding of cultural norms/expectations of parent/child interaction • Integration of cultural beliefs and practices • Inclusion of transgenerational family members • Eye contact • Somatic expression of symptoms • Differences between therapist and client/family

11. Assess Self (Mental Health Therapist) Key requirement of TF-CBT is therapist’s ability to tolerate talking openly about trauma Often graphic, upsetting accounts by children Therapists’ comfort with discussion, as well as appropriate emotional management, is a model for children and parents Be aware of personal triggers/assumptions Seek supervision Practice self-care

12. People, places, or activities that feel good, are relaxing, and bring you joy. Part of your job description! Critical in preventing burnout. Self-care

13. Trauma Symptoms Affective (Emotions) Behavioral Cognitive (Thoughts) Somatic (Physical)

14. Affective Trauma Symptoms Worry Sadness Anger Fear Numbness Irritability Decreased interest or happiness Sense of foreshortened future

15. Behavioral Trauma Symptoms Avoidance Sexualized behaviors Aggression Reenactment Angry outbursts Substance abuse Self-injury Clinginess to caregivers Regression in development Change in school performance Defiance Impulsivity

16. Cognitive Trauma Symptoms • Distrust • Irrational, inaccurate beliefs • Accurate, but harmful, thoughts • 9/11 • Poor self image • Intrusive thoughts

17. Somatic Trauma Symptoms Headaches Stomachaches Difficulty sleeping Increased startle response Appetite changes

18. Symptoms cont’d ADHD PTSD Distractible Does not follow through Reluctant to engage in tasks Loses things Is forgetful Fidgets Restlessness Impulsivity Difficulty concentrating Avoidance Forget things Hyperarousal

19. Symptoms cont’d ODD PTSD Angry outbursts Loses temper Is touchy Negativistic behavior Avoids tasks Aggression Angry Hyperarousal Irritable Avoidant

20. Symptoms cont’d Anxiety Disorder (other) PTSD Worry Jumpiness Somatic complaints Fear of dying Fear of specific situations/people Avoidance of feared things Recurrent thoughts Restlessness Sleep disturbance Fears Hyper startle response Somatic complaints Fear of death/harm Avoidance Intrusive thoughts Hyperarousal Nightmares

21. Symptoms cont’d Mood Disorder PTSD Sadness Anger Sleep difficulty Withdrawing from others Feeling alone Trouble feeling happiness or love Sadness Anger Sleep difficulty Withdrawing Avoidance Feeling alone Foreshortened future

22. Symptom Severity • Children present with mild to severe symptoms, regardless of severity of trauma • Big “T”/little “t” • Some children who have experienced trauma are asymptomatic • Delayed onset of symptoms • Avoidant coping strategies • Resilience • About half of sexually abused and one third of physically abused children will meet criteria for PTSD

23. Assess Risk and Protective Factors Risk Factors Protective Factors Severity of trauma (direct loss of life) History of trauma Preexisting mental health disorder Family history of mental illness Lack of supports/resources Reexposure to trauma Positive relationships with peers and family Access to resources Spiritual practice Mental and physical health

24. PTSD Diagnostic Criteria • Exposure to traumatic event • Experienced, witnessed, or confronted by death or injury to self or others AND • Responded with intense fear, helplessness, or horror • In children, this may be expressed by disorganized or agitated behavior • Symptoms last more than 1 month • Symptoms impair areas of functioning

25. PTSD Diagnostic Criteria: Reexperiencing • Persistent reexperiencing of one or more symptoms • Recurrent, intrusive recollections (children: repetitive play) • Recurrent distressing dreams (children: frightening dreams without recognizable content) • Acting or feeling as if event were recurring (children: reenactment) • Psychological distress at cues that resemble event • Physiological reactivity to cues that resemble event

26. PTSD Diagnostic Criteria: Avoidance • Avoidance and numbing as indicated by three or more symptoms • Avoidance of thoughts, feelings, conversations • Avoidance of activities, places, people • Inability to recall part of trauma • Diminished interest in activities • Estrangement from others • Restricted range of affect • Sense of foreshortened future

27. PTSD Diagnostic Criteria: Increased Arousal • Persistent symptoms of increased arousal as indicated by two ore more symptoms • Difficulty sleeping • Irritability or angry outbursts • Difficulty concentrating • Hypervigilance • Exaggerated startle response

28. PTSD Assessment • Observation • Clinical interview • Trauma must be explicitly discussed • Assess for nature of trauma • Assess for immediate response to trauma • Assess for reexperiencing • Assess for avoidance • Assess for hyperarousal • Assess for numbing

29. Along with a clinical interview, standardized rating scales, such as the UCLA PTSD index, are recommended. Utilizing rating scales at the beginning and end of treatment provides information about effectiveness and progress. Chose one type and use across agency for consistency. Rating Scales

30. UCLA PTSD Index Earthquake Fire, tornado, flood Accident War Hit, punched, kicked Beaten up, shot at, threatened Witnessed someone beaten up, shot at, threatened Witnessed a dead body Private parts touched Hearing about violent death or serious injury Painful and scary medical treatment Anything else scary, dangerous, or violent

31. Includes scoring criteria for diagnosis: DSM IV Full PTSD diagnosis likely Partial PTSD likely UCLA PTSD Index cont’d

32. Differentiating Etiology • Assessing the ONSET of symptoms is critical to providing appropriate and effective treatment • When did trauma occur? • When did symptoms occur? • Co-occurring diagnosis • Children may have a history of trauma and behaviors related to it, but other circumstances may be primary causes to behavior symptoms • Harsh and inconsistent parenting • Coercive discipline practices • Authoritarian interpersonal style

33. Differentiating Etiology cont’d • Assessment should include • Parent-child communication • Relational/affectional style • Methods of conflict management • Disciplining practices • Trust between family members • Family values • Social supports • Relationship satisfaction • Stress levels

34. When present in children, disruptive behaviors such as aggression or defiance should be treated first. When present in childrenor parents, severe depression or suicidality should be treated first. When present in childrenor parents, substance abuse should be treated first. Recommendations for Treatment

35. Treatment An overview of Utilizing Tf-cbt with Traumatized Children and their Families

36. Trauma-Focused Cognitive Behavioral Therapy • Treatment model for children and their families • Provides skills to understand and manage thoughts, feelings and behaviors related to traumatic events, as well as to enhance safety • Improves parenting skills and family communication • Short term approach ( 12-16 sessions ) • For children age 3-18 years of age

37. Who Uses TF-CBT? Clinical social workers Professional counselors Psychologists Psychiatrists Clinical counselors

38. Components Psychoeducation Behavior management Stress management Feeling identification Cognitive coping Trauma narrative Cognitive processing

39. Psychoeducation Intervention Parent Involvement • Accurate information helps children to understand what has happened to them and that it is not their fault. • Children are given information about: • Different types of trauma • Why different types of trauma occur • The effects of trauma • Why children have a hard time talking about trauma Provide an overview of the treatment model Review the child’s trauma symptoms Reiterate that early treatment is key Reassure parents that children will first be taught skills Educate parents about the specific type of trauma(s) that their child has experienced.

40. Behavior Management Intervention (parent) Child Involvement • Guilt may prevent parents from controlling children’s disruptive, aggressive, and non-compliant behavior • Teach multiple strategies for addressing behaviors, including: • Praise • Ignoring • Timeout • Contingency reinforcement plans • Limit setting • Practice these strategies in session through role play • Help identify reinforcing activities and items • Provide input into home rules

41. Stress Management Intervention Parent Involvement • In order to control anxiety, children and their parents need to have a collection of strategies. • Controlled Breathing • Progressive Muscle Relaxation • Thought Stopping (only used when experiencing distressing trauma related memories ) • Parents learn strategies so that they can help their children to learn and practice skills at home. • To reinforce the skill, children can teach the skills to their parents • Parents of traumatized children are also stressed and can benefit from these strategies

42. Feeling Identification Intervention Parent Involvement • Assess child’s knowledge of emotions • Focus on identifying emotions experienced every day (not during the trauma) • Rate emotions • Express emotions appropriately • Label child’s feelings • Reinforce appropriate expression of feelings • Parents may have difficulty expressing emotions • Teach feeling identification • Remind them that they are a model for their child • Parents overwhelmed by their emotions • Provide opportunity to discuss feelings • Inform parents that their distress can lead to their child “shutting down” in protection • Refer the adult to individual therapy if needed.

43. Cognitive Coping Intervention Parent Involvement • Learning the difference and relationship between thoughts, feelings and behaviors • Identifying accurate/inaccurate and helpful/unhelpful thoughts • Replacing unhelpful/inaccurate thoughts and beliefs • Parents also experience stress • Parents also develop unhelpful thoughts • Parents can use positive self talk to challenge these unhelpful thoughts

44. Trauma Narrative Intervention Parent Involvement • What: strategy to teach children how to control their fear/distress about the traumatic event • When: after children have acquired skills to manage their emotions and developed coping skills • How: the therapist and child create a narrative or story about the child’s trauma • Why: break apart negative associations between thoughts/reminders of the trauma and negative emotions (fear, horror helplessness). • Explain purpose • Prepare parent that child’s distress may increase temporarily • Prepare parent to hear the narrative • Review parent’s understanding of the trauma • Ensure parent will be supportive • Encourage parent to use own stress management skills when hearing

45. Media Time line Photo journal Picture book Poem Story Graphic narrative Trauma Narrative cont’d

46. Cognitive Processing Intervention Parent Involvement • Outcome of trauma narrative • Writing the narrative reduces stress • To explore child’s thoughts and feelings about the trauma • Highlights significant/unresolved issues, including: • Shame and/or stigmatization • Feelings of responsibility • Inability to trust • Unhelpful perceptions about the body or personal safety • Parents examine their own thoughts about the child’s traumatic experience • Parents learn to challenge the child’s unhelpful thoughts

47. Concluding Therapy • Safety planning • How child can keep self safe • How others can keep child safe • Practicing safety skills • Completing post-treatment trauma scale • Reviewing • Hopes, dreams, goals • What they learned in therapy • Saying goodbye

48. Application An overview of TF-CBT In education and clinical practice

49. TF-CBT in Education: What To Do • Gather basic information from student • Few, open-ended questions • Non-leading • Facts, not process-oriented • Ensure safety as appropriate • Gather information from parent when appropriate • Refer to guidance counselor, school psychologist, principal for mental health resource • Collaborate with mental health treatment providers • Seek supervision about vicarious trauma

50. TF-CBT in Education: What To Do cont’d Children without interfering symptoms Children with interfering symptoms Structure Consistency Predictability Specific, positive praise when appropriate Planned ignoring when appropriate Use of time out when appropriate Contingency plan Structure Consistency Predictability Specific, positive praise when appropriate Planned ignoring when appropriate Use of time out when appropriate Contingency plan