Treatment of Trauma in the Schools

1. Treatment of Trauma in the Schools Ally Burr-Harris, Ph.D. Center for Trauma Recovery Child Traumatic Stress Program University of Missouri – St. Louis Revised 11/8/04

2. Greater St. Louis Child Traumatic Stress Program • Free trauma-related assessment and treatment of children • Cognitive-behavioral, family systems treatment orientation • Consultation/training for professionals • School-based group therapy for children/adolescents exposed to violence • National Child Traumatic Stress Network (NCTSN) www.nctsnet.org

3. Natural disasters Kidnapping School violence Community violence Terrorism/war Homicide Physical abuse Sexual abuse Domestic violence Medical procedures Victim of crime Accidents Suicide Extreme neglect or deprivation Types of Traumas

4. Protective Factors for Post-Trauma Adjustment • Strong academic and social skills • Active coping, self-confidence • Social support • Family cohesion, adaptability, hardiness • High neighborhood/school quality • Strong religious beliefs, cultural identity • Effective coping and support by parents

5. Risk Factors for Post-Trauma Adjustment Problems • Severity of trauma • Extent of exposure • History of other multiple stressors • Proximity of trauma • Preexisting psychopathology • Interpersonal violence • Personal significance of trauma • Separation from caregiver • Extent of disruption in support systems • Lack of material/social resources • Parent psychopathology; parent distress • Genetic predisposition

6. Trauma Symptoms in Preschool Children • Regressive behaviors • Separation fears • Eating and sleeping disturbances • Physical aches and pains • Crying/irritability • Appearing “frozen” or moving aimlessly • Perseverative, ritualistic play • Reenactment of trauma themes • Fearful avoidance and phobic reactions • Magical thinking related to trauma

7. Trauma Symptoms inSchool-Age Children • Sadness, crying irritability, aggression • Nightmares • Trauma themes in play/art/conversation • School avoidance, failure • Physical complaints • Concentration problems • Regressive behavior • Eating/sleeping changes • Attention-seeking behavior • Withdrawal

8. Trauma Symptoms in Adolescents • Similar to adult response to trauma • Feelings of shame/guilt • Increased risk-taking behaviors • Withdrawal from peers/family • Pseudomature behaviors • Substance abuse • Delinquent behaviors • Change in school performance • Self-destructive behaviors

9. School Assessment of Trauma Symptoms • UCLA PTSD Index -Revised (Steinberg, Pynoos, Rodriguez, 2002) - screens for trauma exposure and trauma symptoms • Youth (school-age) version, parent version • Trauma Symptom Checklist for Children (TSCC, TSC/YC; Briere, 1995) - assesses for PTSD and other trauma symptoms such as depression, anger problems, etc. • Youth (school-age) version, parent version

10. Common Trauma-Related Diagnoses • Adjustment Disorder • Acute Stress Disorder • Posttraumatic Stress Disorder (PTSD) • Depression (Dysthymic Disorder, MDD) • Behavior Disorder (ADHD, ODD, Conduct Disorder) • Anxiety Disorder (GAD, Panic Disorder, Specific Phobia) • Reactive Attachment Disorder (RAD) • Bereavement

11. CBT Treatment Objectives • Break associations between negative feelings and trauma cues • Increase tolerance of trauma thoughts and memories • Decrease reliance on maladaptive coping • Facilitate processing of trauma • Correct trauma-related distortions • Model (therapist, parent) effective coping • Reinforce (therapist, parent) positive coping and respond effectively to behavior problems

12. Appropriate Clients • Functioning at 3 years or higher • PTSD symptoms • Trauma-related confusion or misconceptions • Substantiated abuse/trauma • Parents (nonoffending) supportive of treatment

13. Inappropriate Clients • Psychotic symptoms • Substance dependence/abuse • Suicidal intent, high self-harm risk • Questionable validity of abuse/trauma • Extremely resistant after “best sell” • High intensity trauma ongoing

14. OutpatientIndividual TF-CBT • Short-term (Average= 3 assessment sessions plus 12 treatment sessions) • Divided individual sessions for child and parent initially • Joint sessions begin once parent’s symptoms have decreased and coping skills are improved

15. School-Based TF-CBT • Screen for trauma exposure/symptoms • Assess for treatment appropriateness • 10 to 12 individual sessions with parental involvement strongly encouraged for elementary age • 10 to 12 week group therapy with option of 2 individual sessions and 2 parent feedback sessions if possible

16. Trauma-Focused CBT: Components • Psychoeducation • Ensuring Environmental Safety • Stress Inoculation Training (coping skills) • Gradual Exposure • Affective and Cognitive Processing • Safety Skills • Parental Involvement • Behavior Management Skills Training • Family Sessions

17. Psychoeducation • Common reactions to trauma (parent, child) • PTSD in children • Accurate trauma-related information • Self-care after trauma; supporting child • Purpose, rationale, estimated length, typical course of treatment • Splinter or wound analogy • Ensuring safety • Healthy discipline; Healthy sexuality • Appropriate developmental expectations

18. Stress Inoculation Training (SIT) Techniques for reducing physiological stress reactions in response to trauma reminders Life Saver vs. Swim Lesson analogy

19. SIT Techniques • Deep breathing • Belly breathing, pinwheel • Mindfulness, visual imagery • “Safe place” • Progressive muscle relaxation • Tin soldier/Raggedy Ann • Raw/Cooked noodle • Developmentally appropriate script

20. SIT Techniques (cont.) • Thought-stopping/replacement • Stop sign, Change your channel • Cognitive coping skills (positive focus) • Mantra coaching “I’m safe now…I can do this…He’s locked up now…It wasn’t my fault…”

21. Gradual Exposure (GE) • Purpose is to gradually expose child to thoughts, memories, and other reminders of the trauma until child can tolerate those memories without significant emotional distress and no longer needs to avoid them. • Techniques used to disconnect cues of traumatic event from overwhelming negative emotions.

22. Gradual Exposure • Hierarchical exposure starting from moderate distress (e.g., facts about trauma) and working toward extreme distress (e.g., worst moment) • Modalities: play, art, visualization, narratives, drama, in vivo exposure (for feared but safe situations) • Reduce arousal through reprocessing and elaboration across sessions • Can use SIT skills during exposure phase

23. Exposure Examples • Writing anonymous book about trauma; advising others who face similar situations • Playing out trauma with toys and gradually incorporating positive resolution • Drawing pictures of trauma images and later shredding them • Getting rid of upsetting thoughts or images (thought funeral) • Writing rap song about impact of trauma • Sharing trauma narrative

24. Affective and Cognitive Processing (CP) • Feeling Identification and Expression • Feeling charades; Polaroid feeling chart; Feeling identification race • Cognitive Triangle • Thoughts, Feelings, Behaviors • Practice generating helpful thoughts • Train game

25. Affective and Cognitive Processing (cont.) • Identify trauma-related inaccurate or unhelpful thoughts using open-ended inquiry, impact statement, narrative, observation, or self-report measures • Why do you think this happened to you? • What caused it? • How trusting were you of other people? • How about now? • Why do bad things happen to good people? • What would keep it from happening again?

26. Common Trauma-Related Cognitive Distortions • Self-blame • Guilt, survivor guilt • Shame/embarrassment b/c of trauma or symptoms • Hero fantasies related to trauma • Overgeneralization of danger/risk • Minimization of trauma • Omen formation • Foreshortened future • Magical thinking • Revenge fantasies

27. Affective and Cognitive Processing (cont.) • Model helpful thoughts • Correct distortions • Younger children: Insert mantras • Coloring book example • Narrative: “It’s not your fault” • Older children: Help to reprocess

28. Methods for Challenging Distortions • Identify feelings, behaviors, outcomes related to negative thought and generate more helpful thought instead • One-down Columbo style approach • Mirror distortions in the extreme and push child to amend distortion • Progressive logical questioning • Cartoon bubbles • Role plays, talk shows, peer counseling • Books/narratives

29. Safety Skills • Recognize dangerous situations • Good touch/bad touch (SA cases) • Problem-solving skills • Support-seeking skills • Calming skills if risk of self-injury • Present carefully so as not to blame • Develop safety plan

30. Parental Involvement in Individual Treatment • Assessment feedback • Psychoeducation • Parallel work in areas of SIT, GE, and CP • Parenting Skills Building, Behavior Mgmt. • Joint parent-child sessions • Continuation of GE and CP jointly • Parent models positive coping with trauma • Parent assumes role of therapist as child’s supporter related to trauma

31. Behavior Management • Caregiver interventions • Anger control skills with child • Skills training (problem-solving, social skills, communication) • Specific behavior plans (sleep problems, sexual behavior problems) • Intervene in relevant systems

32. Caregiver Interventions for Behavior Management • Create predictability for child • Make expectations clear • Reasonable developmental expectations • Don’t personalize child’s behavior • Avoid power struggles • “Emotionally unplug” when disciplining; “Emotionally plug in” when rewarding

33. Caregiver Interventions for Behavior Management • Identify triggers that upset child and plan ahead • Expect angry outbursts • Address aggressive/self-destructive behaviors quickly and firmly • Model self-control • Be patient and calm

34. Caregiver Interventions for Behavior Management • Consistent limit-setting • Predict increase in negative behavior • Reward positive behavior • PRIDE skills (from PCIT) • Naturally occurring reinforcers • Jump start material reinforcers when necessary • Ignore negative behavior • Give effective instructions • Time-out, removal of privileges

35. Anger Control Skills • Identify triggers or high-risk situations and plan ahead • Red button exercise • Increase awareness of physiological and cognitive components • Teach/rehearse management strategies • Counting, breathing • Relaxation (turtle technique) • Leave situation, SCAR • Exercise • Thought-stopping; replace with mantra

36. Traumatic Bereavement • PTSD in the case of traumatic loss often impedes the grieving process. The person focuses on the traumatic death rather than the loss. • After exposure, additional treatment components include recognition/acceptance of the loss, positive reminiscing, coping with future loss reminders, and addressing conflicting thoughts about the deceased.

37. Group CBT of PTSDin Children and Adolescents • Same components as Individual CBT • Members need to have similar level/type of trauma exposure • Provides opportunity for social skills-building, peer feedback, and stigma reduction • Advantageous if large-scale trauma or school setting with high violence rate • School-wide trauma exposure/symptom screening yields best referrals • Modules include traumatic bereavement

38. School TF-CBT group outline • How violence affects youths • Self assessment of symptoms • Psychoeducation • Recognizing/managing feelings • Positive coping strategies (SIT) • Coping with trauma cues • Challenging hurtful thoughts • How the violence affected me - GE • Individual session, group sessions • Challenging stuckpoints - CP • Traumatic bereavement, positive reminiscing

39. School TF-CBT GroupOutline Continued • Changing problem behaviors • Support-seeking • Anger management, emotional control • Communication skills, problem-solving • Building healthy relationships • Feeling good about myself • Positive self-esteem • Goal-setting • Group closure

40. Empirical Support for PTSD Treatment in children • TF-CBT (individual, group) - 13 randomized trials, mostly with SA samples - treatment effects for PTSD, depression, behavior problems, social competence, parental distress, and parental support • School-based TF-CBT (treatment effects for GPA, PTSD, school attendance and behavior) • CBT > Nondirective Supportive Therapy • Parent involvement in CBT improved child’s symptoms, even when child not involved in tx • SIT, EMDR

41. TF-CBT References • Deblinger, E., Heflin, A. H. (1996). Treating Sexually Abused Children and Their Nonoffending Parents: A Cognitive Behavioral Approach. Sage Publications, Inc. Thousand Oaks, CA. • Cohen, J. A., Mannarino, A. P., Deblinger, E. (2001). Child and Parent Trauma-Focused Cognitive Behavioral Therapy: Treatment Manual. Allegheny General Hospital, Center for Traumatic Stress in Children and Adolescents.

42. School-Based TF-CBT References • Burr-Harris, A. (Sept, 2004). School-Based Trauma-Focused Cognitive-Behavioral Group Therapy Manual (7th -12th grades). Greater St. Louis Child Traumatic Stress Program, University of Missouri-St. Louis • Layne, C. M., Saltzman, W. R., Pynoos, R. S. (2002). Trauma/Grief-Focused Group Psychotherapy Program. UCLA Trauma Psychiatry Service. • Jaycox, L. (2004). Cognitive Behavioral Intervention for Trauma in Schools. Longmont, Co: Sopris West Educ. Services. (ages 11-15).

43. We’re Done! • For additional questions, references, or referrals, contact Ally Burr-Harris, Ph.D. Phone: 314-516-5440 Email: Burrharrisa@msx.umsl.edu