4 Broad Themes of the MFT Trainees’ Qualitative Study Theme 1. Inadequacy of course work

1. How Prepared are MFT Trainees to work with Child Sexual Abuse?Colleen Friend, PhD & Vasavi Charathram, MS(Counseling) - California State University 4 Broad Themes of the MFT Trainees’ Qualitative Study • Theme 1. Inadequacy of course work • Theme 2. Availability and inadequacy of practical training • Theme 3. Preference for specific techniques • Theme 4. Recognition of need to have experience in working with CSA at different stages of MFT trainees’ development and education.

2. Key points Children with developmental disabilities are more at risk of sexual and physical abuse than the general public • Studies vary, but consistently show that there is a link between children with disabilities and abuse (Sobsey, 1991) • 1 in 3 children with an identified disability for which they receive special education services are victims of some type of maltreatment.

3. Developmentally Sensitive Applications of Trauma Focused-Cognitive Behavioral Treatment • Set ground rules at the onset and modify as needed - and have the child practice! • Short, simple sentences • Avoid shifting words (pronouns & unclear references) • Do not finish sentences for the child • Ensure a clear transition • Repeat what victim says to clarify what was said • Sexual knowledge inventory

4. Visual, Auditory & Kinesthetic Stimulation • Parents need to become Co-Regulating Agent for child’s behavior • Vigilance Symptom - safety can be a trigger too! • Watch for responses that ‘aimed to please’ • Avoid “yes/no” questions if possible • First try open-ended questions to see if child can respond in narrative • If the child does not seem to understand questions or is unable to provide narrative, then proceed to direct questions, multiple choice, or yes/no questions • Use of sensory focus questions • How did that make you feel? • Tell me what you heard? • Tell me what you saw? • Tell me what you felt?

5. Developmentally Sensitive Applications of Trauma Focused-Cognitive Behavioral Treatment Soft tone of voice and face Organize (time management, regularity) Offer choices Touch and physical proximity Hear what child is anxious about End and let go!

6. The Interview • Use of tools: drawings, dolls, photographs, mood charts • Pace the interview • Allow for long pauses - processing issues • Be careful not to interrupt • Be aware of interview stress - use breaks • Shorten interview - focus on questions to essential information rather than peripheral details • Consider multiple interviews - scaffolding

7. Forensic Interviewing with Pre-School Childrenby Jackie Block-Goldstein,MSW 1 in 4 girls is victim of sexual abuse Shift your goal from Prosecution to Protection ! 1 in 6 boys is a victim of sexual abuse At 27 months and younger, the child is unable to express the narrative verbally At 36 months and older, the child is able to give a narrative

8. Forensic Interviewing with Pre-School Childrenby Jackie Block-Goldstein,MSW Procedural Anatomical dolls - endorsed by APRI when used properly, 4 years old and older Explicit 2 Types of Memory Anatomical drawings, 2-3 years and older Free Drawing - best because it aids the narrative

9. Forensic Interviewing with Pre-School Children • ‘Good’ touch vs. ‘Bad’ touch, now ~ ‘Touch’ Inventory • Picture Test no longer used because it is time consuming • Prepare the young child before the interview, do your work in familiarizing yourself with the details • Rapport building with the child • Developmental screening of the child

10. Forensic Interviewing with Pre-School Children • Scaffolding Procedure • Explore Alternative Hypothesis • Standard Structural Protocol National Children’s Advocacy Center [NCAC] Model Extended Forensic Evaluation, since 1990s • Philadelphia Model very similar

13. Assessment: Ages & Stages Questionnaire3rd Edition 21 Questionnaires used to assist with screening and monitoring children from 1 thru 66 months of age. Designed to screen young children for developmental delays

14. Assessment: Ages & Stages Questionnaire -3rd Edition Each questionnaire contains 30 developmental items written in simple and straight-forward language. The items are organized into five areas: 1. Communication 4. Problem Solving 2. Gross Motor 5. Personal-Social 3. Fine Motor

15. “ Sample “

16. Assessment : Mental HealthAges & Stages Questionnaire : Social-Emotional Used in conjunction with ASQ-3 Seven Behavioral Areas: • Self-Regulation 5. Autonomy • Compliance 6. Affect and • Communication 7. Interaction • Adaptive with Functioning People

17. “ Sample “

18. Female, 5 yrs Human Figure Drawing

20. Additional Inferences ~

21. 9 Domains of CSBI: - Boundary Problems - Exhibitionism - Gender Role Behavior - Self-stimulation - Sexual Anxiety - Sexual Interest - Sexual Intrusiveness - Sexual Knowledge - Voyeuristic Behavior ChildSexualBehaviorInventoryQuestionnaire Developmentally Related Sexual Behavior - Reflects level of age- and gender-appropriate behavior Sexual Abuse Specific Items- SA Hx after controlling for effects of maternal education and family income.

22. ChildSexualBehaviorInventoryQuestionnaire

23. ** * *Developmentally Related Sexual Behaviors Child Sexual Behavior InventoryScore Sheet[CSBI] **Sexual Abuse Specific Items 59 and below Nonsignificant

24. Trauma Symptom Checklist for Young ChildrenTSCYC

25. TSCYC Questionnaire

26. TSCYC Questionnaire

30. The Application of Parent Child Interaction Therapy (PCIT) for Traumatized Children • Designed to treat children age s 2 through 7 years exhibiting disruptive behaviors • Work with caregiver and child together • Intervention done in ‘real’ time

31. The Application of Parent Child Interaction Therapy (PCIT) for Traumatized Children Two Phases: 1. Relationship Enhancement 2. Strategies to Improve Compliance

32. PCIT Phase One: Relationship Enhancement The focus is on enhancing the parent-child Interaction, also known as the Child-Directed Interaction, or CDI • Shift attention to child’s desired behavior • Focus on recognizing and praising positive child behavior • Avoid controlling and negative parent behaviors • Shape child behavior through selective attention

33. PCITPhase 2: Strategies to Improve Compliance The focus is on improving child compliance, often described as Parent-Directed Interaction, or PDI - Focus on giving clear and direct commands - Make sure parent follows through with commands - Structure child consequence for non-compliance -Teaching an effective time-out sequence - Develop a mastery of skills related to managing child’s non-compliance - Mastery of PDI skills signals end of treatment

34. Trauma-Focused Cognitive Behavioral Therapy (TF-CBT)for Traumatized Children & their Families Cognitive Triangle : Thoughts, Feelings & Behaviors Feeling Trigger Thinking Doing

35. Trauma-Focused Cognitive Behavioral Therapy (TF-CBT)for Traumatized Children and their Families • PRACTICEComponents • - Skill-building • - The Narrative Unfolds • - Personal and Body Safety ‘Pair positive, healthier emotions with traumatic memory to make it more approachable.’

36. (TF-CBT) P sycho Education & Parenting Skills R elaxation A ffective Expression & Regulation C ognitive Coping T rauma Narrative Development & Processing I n vivo Gradual Exposure C onjoint Parent-Child Sessions E nhancing Safety & Future Development

37. A Pilot Study ComparingTF-CBT to TF-Integrated Play Therapy 3 components of PTSD : Re-Experiencing, Avoidance, Hyperarousal Are certain children better matched to certain kinds of therapy?

38. Trauma-Focused Integrated Play Therapy TFIPT Combination of directed & nondirective approaches to advance structured, goal-oriented therapy Attends to developmental needs of young children

39. Post traumatic play appears to be child’s natural way to introduce gradual exposure, narrative formation and trauma processing

43. DiagnosticReferences Diagnostic and Statistical Manual, Version IV, Text Revised [DSM-IV-TR] [DSM-V, May 2013] Diagnostic Classification of Mental Health & Developmental Disorders of Infancy and Early Childhood: Revised Edition[DC:0-3R]

44. DSM-IV-TR Multi-axial Assessment Axis I Clinical Disorders Other Conditions That May Be a Focus of Clinical Attention Sexual Abuse of Child (Victim) Axis II Personality Disorders Mental Retardation Axis III General Medical Conditions Axis IV Psychosocial & Environmental Problems Axis V Global Assessment of Functioning

45. Diagnostic Classification of Mental Health & Developmental Disorders of Infancy and Early Childhood: Revised Edition [DC:0-3R]

46. DC: 0-3R Multi-axial Assessment Axis I: Clinical Disorders Other Relationship Disturbances Axis II: Relationship Classification Axis III: Medical & Developmental Disorders and Conditions Axis IV: Psychosocial Stressors Axis V: Emotional & Social Functioning

47. Thank you for helping us to heal!