Trauma-Focused Cognitive-Behavioral Therapy

1. Trauma-FocusedCognitive-Behavioral Therapy Anthony P. Mannarino, Ph.D. Judith A. Cohen, M.D. Center for Traumatic Stress in Children and Adolescents Allegheny General Hospital Drexel University College of Medicine Pittsburgh, PA

2. Why is it critical to involve parents in TF-CBT? • Most children do not present at mental health settings because of trauma exposure • Children have behavior problems • Parent/caretaker involvement is essential to address behavioral difficulties

3. Engaging Families in Treatment • Establish common ground/form an alliance • Recognize concrete barriers to participating in treatment • Emphasize importance/primacy of parental role • Be flexible about scheduling • Focus on what parents need and want from therapy • Provide education about psychotherapy (what to expect: it occurs over time, not all at once; things may worsen before they improve, etc) • Address such issues as stigma, cultural concerns, and previous experiences with therapists • Resistance or failure of engagement?

4. Engaging Families in Treatment (cont’d) • NO SHAME AND NO BLAME • Praise and reinforce parents/caretakers for bringing child for treatment

5. Psychoeducation • Goals: • Normalize child’s and parent’s reactions to severe stress • Provide information about psychological and physiological reactions to stress • Instill hope for child and family recovery • Educate family about the benefits and need for early treatment • Educate family about trauma reminders • PSYCHOEDUCATION GOES ON THROUGHOUT THERAPY!

6. Psychoeducation (Cont’d) • Provide general information about the event • Frequency • Who experiences it • What causes it • Provide information about common emotional and behavioral responses to the event(s) • Provide information about the child’s symptoms/diagnosis • Emphasize positive coping • Sources for psychoeducation: • www.NCTSN.org • www.aacap.org Facts for Families • “What Do You Know” game for SA, PA, DV

7. Parenting Skills • TF-CBT views parents as critical therapeutic agent for change • Explain the rationale for parent inclusion in treatment • Not because parent is part of the problem but because parent can be the child’s strongest source of healing • Emphasize positive parenting skills and enhance enjoyable child-parent interactions

8. Treatment of Parents Research Evidence that treating parent is important: • Deblinger et al. (1996): Treating parents resulted in decreased behavioral and depressive symptoms in child • Cohen and Mannarino (1996): Parents’ emotional reaction to trauma was the strongest predictor of treatment outcome (other than treatment type) • Cohen and Mannarino (1997): At the 12 month follow-up, parental support was significantly related to decreased symptoms in child

9. Complicated Caregiver Situations • When the caregiver is unsupportive or does not believe that the child was exposed to a trauma • When the caregiver is the perpetrator (e.g., sexual abuse; physical abuse; domestic violence

10. Common Parental Issues in Child Traumatization • Inappropriate self-blame and guilt • Inappropriate child blame • Overprotectiveness • Overpermissiveness • PTSD Symptoms

11. Praise and Positive Attention • Focus on actively praising the child • Praise a specific behavior • Provide praise ASAP after behavior occurs • Be consistent • Do not qualify your praise • Provide praise with same level of intensity as criticism

12. Selective Attention • No reaction to certain negative behaviors • Defiant or angry verbalizations to parent • Nasty faces, rolling eyes, smirking • Mocking, mimicking • Walk away, busy oneself with an activity • Remain calm, dispassionate • Expect a reactions of more provocative behavior

13. Time Out • Purpose: Interrupt child’s negative behaviors and allow him/her to regain control • Explain to child • Location: quiet, least stimulating • Duration: 1 minute per year of age • Timer starts when child stops screaming • Once in time out, parent should refrain from comments, and maintain calm demeanor. • Be consistent

14. Contingency Reinforcement Programs • Purpose: Decrease unwanted behaviors and increase desired behaviors • Select only one behavior to target • Explain process to child • Involve child in decisions about rewards • Add stars and give rewards weekly, and consistent.

15. Behavior Management • Reasonable developmental expectations • Limit-setting • Behavioral interventions for: • Anxieties • Sleep problems • Aggressive behaviors • Sexually inappropriate behaviors

16. Behavior Management Vignette #1 David is a 10 year-old boy who has recently been aggressive at home with siblings and at school and has been defiant with his mother and teachers. David witnessed domestic violence until last year when his mother left his father. His mother has tried to address his behavior but nothing works and David typically blames his mother for the father’s departure. David visits 1X/week with his Dad. His mother feels like the household is out of control At times she will threaten a consequence but typically does not follow through.

17. Behavior Management Vignette # 2 Kelly is a 4 year-old girl who was sexually abused over several months by her uncle. Now Kelly is touching her genitals and rubbing herself at school and at home. She has also started to touch her younger brother and two playmates. Kelly attends therapy with her mother who is very distressed with these behaviors but does not know how to respond. Her mother often becomes overwhelmed and upset when talking about the abuse and Kelly’s symptoms.