Cognitive Behavioural 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.