Trauma-Informed Practice: What Child Welfare Attorneys Can Do

October, 2012 Kimberly Shipman, Ph.D.

Kempe Center for Prevention and Treatment of Child and Department of Pediatrics, School of Medicine

Kempe Center for the Prevention and Treatment of and Neglect, School of Medicine, University of Colorado http://www.kempe.org

In 1962, Dr. Kempe and his colleagues published "The Battered Child Syndrome" - Journal of the American Medical Association

Activities • Clinical Services for abused and neglected children and families • Training clinicians in evidence-based practices • Research • Medical and Legal Consultation and Advocacy • Cultural competence and partnering with the community, including youth and families • NCTSN member www.nctsn.org • Statewide collaborations with Denver Child Welfare (DHS)

Training Objectives

• What is Child Trauma? – Prevalence – Trauma symptoms – Trauma-informed lens for understanding child behavior

• Become an educated consumer of mental health services – Become familiar with EBTs – Questions to ask mental health providers

Types of Childhood Trauma

• Child abuse – Physical – Sexual – Emotional • Victim/Witness of Violence – Domestic – Community – School • Accidents (e.g., motor vehicle, fire, dog-bite) • Disasters • War/Terrorism and Refugee • Medical (e.g., diagnosis, invasive medical procedures) • Traumatic Grief Rates of Trauma Exposure

 Lifetime victimization in 2-17 year olds-National Survey • 80% reported at least 1 lifetime victimization (69.3% in last yr) • Multiple types of victimization is common (Mean # = 3.7 (Finkelhor, Ormrod, & Turner, 2009)

 Children often do not report traumatic events

5 Cumulative Impact of Lifetime Victimization- Trauma on Child Mental Health

Turner, Finkelhor, & Ormrod 2010 Affective Symptoms

• • Sadness • Anger • Anxiety • • Affective Dysregulation – Physiological arousal – Emotional distress – Difficulty self-soothing

Behavioral Symptoms

• Avoidance – Thoughts, feelings, places – What happens when you avoid? • Modeling maladaptive behaviors – Sexualized behaviors – Violent behaviors – • Traumatic Bonding – Associating with aggressor • • Self-Injury • Suicidality

Cognitive Symptoms

• Irrational Beliefs-Themes – Responsibility/Self- – Overestimating danger – • Distrust of others • Distorted Self-Image – ‘Damaged’ – Self as all about trauma • Loss/ of Social Contract • Accurate, but unhelpful, cognitions

Common diagnoses

• PTSD • Depressive disorders • Other Anxiety disorders • Behavior disorders • ADHD • Substance use disorders

Comorbidity is common Trauma exposure and PTSD are often missed Posttraumatic Stress disorder (DSM-IV/ ICD)

Exposure to a traumatic event - Experienced, witnessed, or confronted with actual or threatened death or injury to self or others - Response involved intense fear, helplessness or horror

Re-experiencing (=> 1)

Avoidance of stimuli associated with trauma (=>3)

Persistent increased arousal (=> 2)

Duration of symptoms is more than 1 month and causes clinically significant distress or impairment

Steinberg et al., 2004) Assessing Lifetime Trauma Exposure Assessment Example Continued – Trauma Exposure

6

4 Months Ago Mom’s boyfriend beat her up CPSS: PTS Symptom Screener Reexp PTSD in Infants and Young Children

• Infants – Physiological symptoms, high levels of distress

• Toddlers/Preschoolers – Reenactment – Loss of previously acquired developmental skills – New onset of or separation anxiety – New onset of that are not obviously related to the traumatic event – Parental reactions may inadvertently reinforce children’s trauma-related fears

Scheeringa, 2008

Mental and Behavioral Health Problems of Trauma-Exposed Youth Mental and Behavioral Health Needs

Effective Mental Health Services

16 20 years of Research on EBTs Developed, Tested, and Ready for Implementation

• Trauma-Focused Cognitive-Behavioral Therapy – TF-CBT • Parent Child Interaction Therapy – PCIT • Abuse-Focused Cognitive Behavioral Therapy – AF-CBT • Cognitive Processing Therapy – CPT • Child-Parent Psychotherapy – CPP • Project SafeCare • The Incredible Years (TIY) series • Triple P • Other Parent Management Training (PMT) models • CBT for Children with Sexual Behavior Problems • Functional Family Therapy • Dialectic Behavior Therapy (DBT) • Multi-Dimensional Treatment Foster Care • Multisystemic Therapy (MST) • EMDR Characteristics of EBTs

• Research shows they work • Manual that guides the therapist • Upfront and ongoing assessment to guide treatment • Short-term treatment • Clear goals (e.g., reduce temper tantrums) • Therapist is directive • Sets agendas and plan for treatment, client has input • Present focused • Skills taught and practiced in session • Homework assigned (practice outside session) What is TF-CBT?

• An evidence-based treatment for children ages 3-18 • Originally developed for • Wide range of traumas • Caregivers (non-offending) are an integral part of treatment • Goal is to empower children and families to recover • Components-based treatment protocol • Integrates principles from CBT, , developmental neurobiology, family therapy, humanistic therapy • Time limited, structured (12-20 sessions) active treatment • Therapist is directive and active!

Trauma-Focused Cognitive Behavioral Therapy

Assessment and Engagement . Psychoeducation and Parenting Skills . Relaxation . Affective Modulation . Cognitive Processing . Trauma Narrative . In Vivo Desensitization . Conjoint parent-child sessions . Enhancing safety and social skills TF-CBT Sessions Flow

Entire process is gradual exposure 1/3 1/3 1/3

Assessment

Sessions 1 - 4 Sessions 5 - 8 Sessions 9 - 12  Psychoeducation  Trauma Narrative /Parenting Skills Development and  Conjoint Parent  Relaxation Processing Child Sessions

 Affective  In vivo Gradual  Enhancing Expression and Exposure Safety and Regulation Future  Cognitive Development

------PARENT-CHILD WORK THROUGHOUT ------

So what’s the problem? All sorts of “treatments” are available out there.

Isn’t all “counseling” the same? Large Gap Between Scientific Knowledge and Front-line Practice

Practice Knowledge So as a professional who has ability to identify kids in need and monitor mental health services…. What can I do?

Become familiar with available evidence- based treatments

• www.nctsn.org National Child Traumatic Stress Network • http://nrepp.samhsa.gov/ National Registry of Evidence-based Programs and Practices • www.cachildwelfareclearinghouse.org/ California Evidence-Based Clearinghouse for Child Welfare • www.wsipp.wa.gov Washington State Institute for Public Policy • www.childtrends.org/ Child Trends www.cachildwelfareclearinghouse.org . Built upon the OVC Guidelines Project . Revised the ranking criteria . Examined programs related to child CEBC Scientific Rating Scale welfare

CEBC Child Welfare Relevance Rating Nurturing Parent Program Play Therapy Another Resource: http://nrepp.samhsa.gov/

Ask questions of mental health providers to identify and monitor treatment… What Questions should I ask of Mental Health Providers?

• What treatment models do you use? Are they evidence-based? • Which treatment is best for this child and why? • Do you engage caregivers in treatment? What is their role? • How do you work with offending and/or nonoffending caregivers? • How will I know if the child and family is getting better? Use of outcome measures? • What information will treatment progress give me with regard to safety and permanency decisions? • How long will treatment take? • Assessment of trauma exposure? Will treatment directly address the trauma – how?

Tracking Outcomes

UCLA-RI PTSD –Symptom Severity

56

48

PTSD Overall 40 Severity Re-experiencing 32 Avoidance Severity Score Severity 24

16

8

0 T1 T2 T3

Administration

NCTSN Child Welfare Toolkit Trust your instincts and seek a second opinion….

Contact Information

Kimberly Shipman, Ph.D. • Address: Child Trauma Program The Kempe Center for the Prevention and Treatment of Child Abuse and Neglect Gary Pavilion at The Children’s Hospital Anschutz Medical Campus 13123 E 16th Ave B390 Aurora, CO 80045 • Email : [email protected]