Comprehensive Overview of Cognitive Behavioral Therapy for Child Trauma and Abuse

1. Cognitive Behavioural Therapy for Child Trauma and Abuse Jackie Feather PhD DipClinPsych March 19 2011 NZCCP Auckland

2. Overview • Theoretical frameworks • Research and development • Clinical use • Summary and feedback

3. Theoretical frameworks informing CBT for child trauma and abuse Contextual/systemic frameworks Cultural considerations Attachment theory Neurobiology Developmental psychology Psychotraumatology CBT Abuse-focus Scientist-practitioner

4. Contextual/systemic frameworks • An ecological perspective - recognises the many interconnected systems in which a young person exists (Bronfenbrenner, 1979) • Systemic approaches - emphasise the influence of interaction patterns on individuals and relationships within families (Macdonald, Lambie, & Simmonds, 1995) • Cultural world views - shape the conceptualisation and path of an individual and family’s response to abuse and trauma, and have an effect on treatment (Elliott & Urquiza, 2006)

5. Aotearoa/NZ cultural context • Treaty Principles: a guide for policy and practice • Partnership - working together in a spirit of co-operation • Participation – promotes active involvement of all parties • Active protection – includes constant monitoring for safety and improvement Fig 1: My own transition in thinking

6. Attachment theory • An attachment-based model of intervention -focuses on the role of the therapist in providing a secure base from which both children and caregivers can explore new ways of relating (Pearce & Pezzot-Pearce, 1994) • Traumatised and abused children may require a longer, more gradual process to develop a trusting relationship with their therapist, particularly if their trauma and attachment histories are early and long-standing (Perry et al., 1995) • Attachment theory - highlights the importance of the child’s relationships in contributing to and ameliorating the effects of CA trauma

7. Neurodevelopmental theories • Considerable evidence to suggest that traumatic experiences as a child have a profound effect on the developing brain (Nemeroff, 2004) • Bruce Perry’s model describes how the trauma of abuse can affect the developing brain and shape children’s physiology and related responses. He proposes that CA can result in: • deprivation of sensory stimuli (via neglect, insecure attachment) and/or • overactivation of neural pathways (via the trauma of physical abuse, sexual abuse, and/or witnessing domestic violence), leading to a persistent pattern of hyperarousal or dissociation (Perry et al., 1995)

8. Developmental theories • Piaget’s theory: • Preoperational (2-7 years) children learn how to represent the world mentally, but locked into own perspective, and have not yet grasped that there are other “selves” • Concrete operational (7-11 years) may be able to interrelate their own representations about concrete situations • Formal operational (11 years) begin to develop the cognitive abilities to think abstractly and self-reflect • Vygotsky’s theory suggests that a child must be developmentally capable of using thought as a form of “inner speech” for the self-regulation of behaviour

9. Developmental theories cont. • “Meta-cognition” (the ability to reflect about cognition, or “think about one’s thinking”; an inherent feature of CBT) may comprise a range of aspects that develop at different ages and stages (Bolton, 2005) • Recognition that thoughts are under a person’s control and regulating behaviour may appear as early as 6 or 7 years • Concepts such as shame may appear between early and middle childhood • Connection between beliefs (i.e., the capacity to theorise) may develop in later childhood or adolescence, although even preschoolers may have some aspects of this capacity

10. Psychotraumatology/PTSD • 1960s: trauma-specific syndromes recognised with common patterns of psychological distress from diverse traumatic events: • war experiences - “shell shock”, “Vietnam veteran’s syndrome” • interpersonal violence, particularly against women and children - “battered women syndrome” and “abused child syndrome” (van derKolk et al., 1996; Weaver & Clum, 1995) • 1980: new diagnosis of PTSD included in the DSM (American Psychiatric Association, 1980) • The PTSD diagnosis was intended to help victims of trauma gain understanding and acceptance and to promote appropriate treatment (Weisaeth, 2002)

11. PTSD in children • Similar to PTSD in adults, including the cardinal symptoms described in the DSM-IV-TR • But also differs - children may not meet criteria: • Re-experiencing • Nightmares • Traumatic play • Behavioural re-enactments - patterns of behaviour that incorporate aspects of the trauma e.g. sexualised behaviour • Psychophysiological re-enactments or ‘body memories’ e.g. physical health problems including headaches, backaches, stomach aches, skin rashes, shortness of breath, tightness in the chest, nausea (Terr, 1990)

12. PTSD in children cont. • Avoidance • Of people, places, events, situations that remind them of the abuse e.g. being alone • Hyperarousal • Internalising symptoms e.g. poor concentration and sleep problems • Externalising symptoms e.g. irritability, temper tantrums, exaggerated startle response, ‘freezing’ • Associated signs and symptoms • Intensification of normal fears • Magical thinking • Restricted affect/difficulty having tender loving relationships • Depression and sadness/pessimism • Aggressive behaviour

13. The TRAP acronym* Traumatic event Re-experiencing Avoidance Physiological arousal Terrible thing that happened Remembering even when you don’t want to Avoiding things that remind you Physical reactions in your body *

14. Exercise: The TRAP activity

15. Untreated PTSD • As children return to safety the initial feelings of helplessness and fear typically turn to anger, rage, shame and guilt • The behavioural and emotional changes that accompany PTSD can result in changes in the child’s attitude to life • Traumatised children cannot imagine themselves having a normal future e.g. having a job and getting married, or an exciting future - becoming an athlete or actor

16. PTSD and child abuse (CA) • Some abuse-focused clinicians argue the trauma/PTSD conceptualisation does not cover all manifestations of CA e.g. social problems, biological /neurological, other psychological disturbances – anger, shame, guilt (Briere, 1992; Herman, 1992) • CA is often prolonged and repeated - sequelae are more complex than the repetitive symptomatology of simple PTSD, e.g. identity, attachment • But “trauma” and “PTSD” provide useful frameworks for development of theory, research and practice in the field of CA (Briere & Scott, 2006)

17. Research on child trauma and abuse • Limited research in Australasia and internationally on effective psychotherapeutic interventions for child trauma and abuse (James & Mennen, 2001; McFarlane, 2000) • Overall prevalence of posttraumatic stress disorder (PTSD) is generally reported for about 1/3 of abused children, depending on the nature of the abuse (Ackerman, Newton, McPherson, Jones, and Dykman, 1998; Dubner and Motta, 1999; Linning & Kearney, 2004; McCloskey and Walker, 2000) • Initial studies suggested that trauma-focused cognitive behavioural therapy (TF-CBT) may be effective and long lasting in the treatment of PTSD in abused traumatised children (Cohen, Deblinger, Mannarino & Steer, 2003; Deblinger, Lippman and Steer, 1999; Kolko, 1996)

18. Development and evaluation of TF-CBT • Aim of the research: • To develop and evaluate the effectiveness of a TF-CBT programme for multiply-abused children referred to the Specialist Services of CYF, Puawaitahi, Auckland: • Locally developed • Evidence-based • Manualised • Clinical setting

19. Programme elements • Phase 1: Psychosocial strengthening • An essential part of the programme, based on local practice and research– with child and parent/caregivers (Barrett et al., 2001) • Phase 2: Coping skills • Based on the CBT “Coping Cat” programme for child anxiety • Efficacious, with reduction in anxiety symptoms maintained at 1- and 3-year follow-ups (Kazdin & Weiss, 1998; Kendall, Chansky, Kane, Kim, Kortlander, Ronan, Sessa and Siqueland, 1992; Kendall & Southam-Gerow, 1996) • Phase 3: Trauma processing • Imaginal exposure for treating PTSD using creative mediums as recommended in the child trauma literature (Smith, Perrin and Yule, 1998)

20. Research design • Scientist-practitioner clinical research • Participants: 16 multiply-abused children with PTSD - 9 girls, 7 boys • Design: Single-case multiple-baseline • Four studies - 4 children in each: • Pilot • Cultural trial • Completed protocol • Other therapists

21. Measures Structured Interview Screen • ADIS (Parent/Caregiver and Child) Full Assessment Battery (pre, post and 3, 6 & 12 month follow-up) ChildParent/CaregiverTeacher • CDI CBCL CBCL-TRF • STAIC • CPTS-RI • TSCC • CQ

22. Measures cont. Short Assessment Battery (weekly during baseline and treatment, and 3, 6, 12-month follow-up) • Children’s Posttraumatic Reaction Index (CPTS-RI, Fredrick, Pynoos & Nader, 1992) • Coping Questionnaire (CQ-C ; Kendall et al., 1992)

23. Participants - pilot study • Scott (14) – physical and emotional abuse • Jacob (13) - sexual abuse, domestic violence • Kirsty (9) - physical and emotional abuse, domestic violence • Jade (9) - witnessed mother’s suicide attempts, domestic violence

24. Results • PTSD symptoms decreased • Fewer or no bad dreams • Less upset when thinking about the abuse • Less jumpy or nervous • Self-reported coping increased • Improved during treatment • Maintained at follow-up

25. Fig 2. Study 1 Pilot: Decrease in PTSD Symptoms

26. Fig 3. Changes in PTSD symptoms (CPTS-RI scores) across baseline, treatment and follow-up for Jacob CPTS-RI score Very severe Severe Moderate Mild PTSD reaction Weeks

27. Fig 4. Study 1: Changes in PTSD symptoms (CPTS-RI scores) across baseline, treatment and 3, 6, and 12 month follow-ups

28. Fig 7: Study 1 Pilot: Increase in Coping

29. Fig 4. Changes in coping (CQ scores) across baseline, treatment and follow-up for Jacob “Thinking about Rod threatening me and my mother” Completely able to help myself CQ score Not at all able to help myself Weeks

30. Fig 5. Study 1: Changes in child reported coping skills (average of CQ-C scores for 3 target concerns) across baseline, treatment and follow-up sessions

31. Fig 6: Study 2: Maori & Samoan Children Decrease in PTSD Symptoms

32. Fig 7. Study 2: Maori & Samoan Children Increase in Coping

33. Before we move on…a plug for single-case research designs • User-friendly in clinical settings • Graphed results provide visible evidence of treatment effects on targeted variables, as well as the influence of other documented variables • Changes in mean, level, slope, and trend are easily examined, and how a participant is responding to treatment can be interpreted at a glance (Kazdin, 1982) • Enables us to be scientist practitioners carrying out research in our own practice settings

34. Discussion • The phase-based manualised TF-CBT programme can be effective in ameliorating the effects of child abuse trauma • Flexibility required to meet the needs of individual children and families • Parent/caregiver involvement • Nature of trauma/presenting problems • Culture

35. What contributes to treatment success? • Contextual factors • Safety • Social support • Child factors • Developmental level (9+) • Connection/identity • Therapist factors • Respect • Collaboration • Empowerment

36. TF-CBT: Clinical Use

37. Assessment • Comprehensive assessment • Child • Parent/family • Teachers/other professionals • Enables targeted treatment • E.g., DO NOT re-process historical trauma if no trauma symptoms are present – why?

38. Therapist focus • Effective and sensitive use of TF-CBT for an individual child and family requires an ever-evolving formulation and therapist triple focus: • Developing the therapeutic relationship, inspiring hope and participation • Alleviating symptoms and enhancing coping strategies • Healing underlying causes of presenting problems

39. Treatment outline • Phase 1: Psychosocial Strengthening • Phase 2: Coping Skills • Phase 3: Trauma Processing • Phase 4: Special Issues • Parent/caregiver involvement • Liaison with other professionals

40. Therapy session format • Review out-of-session activities • Set agenda • Session activities • Homework, summary and feedback

41. Phase 1: Psychosocial Strengthening Sessions 1-3 • Rapport building, orientation to therapy • Relationships/social supports • Timeline • Orientation for parent/caregivers

42. Phase 2: Coping Skills Sessions 4-8 • Feelings (recognising and managing emotions) • Body reactions (recognising and self-calming) • Thoughts (awareness of self-talk) • Actions (active coping and problem solving) • Rating and Rewards (self-evaluation and reward) • Parent/caregiver session

43. Coping skills template Te Ara Whetu: The STAR Plan Scary feelings? Thinking bad things? Activities that can help Rating and rewards

44. Exercise: Self-help task #4

45. Phase 3: Trauma Processing Sessions 9-13 • Creation of a trauma narrative to allow emotional processing of traumatic memories using mediums chosen by the child e.g. sandtray, painting, clay, puppets • The child chooses trauma topics to work on from his or her timeline, with gradual exposure from least to most traumatic memories • The 4-step STAR plan is used to manage trauma symptoms • Parent/caregiver session

46. Phase 4: Special Issues Sessions 14 – 15 • E.g. anger management; separation, grief and loss; guilt and shame; personal safety Session 16 • Relapse prevention, celebration, saying goodbye

47. Summary and feedback • Questions? • What will you be taking away from this workshop? • Feedback

48. Further reading Feather, J. S. & Ronan, K. R. (2006). Trauma-focused cognitive behavioural therapy for abused children with posttraumatic stress disorder.New Zealand Journal of Psychology, 35, 132-145. Feather, J. (2004) Becoming a local scientist-practitioner. Social Work Now, 29, 24-28. Feather, J. S. (2007). Trauma-focused cognitive behavioural therapy for abused children with posttraumatic stress disorder: Development and evaluation of a manualised treatment programme. PhD thesis, Massey University, Albany, Auckland. http://muir.massey.ac.nz/handle/10179/535 Feather, J. S. & Ronan, K. R. (2009). Assessment and interventions for child trauma and abuse. In Taylor, J. & Themessl-Huber, M. (Eds.) Safeguarding children in the primary care context. UK: Jessica Kingsley Publishers. Feather, J. S. & Ronan, K. R. (2009). Trauma-focused CBT with maltreated children: A clinic-based evaluation of a new treatment manual. Australian Psychologist, 44, 174-194. Feather, J. S. & Ronan, K. R. (2010). Cognitive behavioural therapy for child trauma and abuse: A step-by-step approach. London, UK: Jessica Kingsley Publishers.