Post on 14-Aug-2020
Trauma-Informed Practice: What Child
Welfare Attorneys Can Do
October, 2012
Kimberly Shipman, Ph.D.
Kempe Center for Prevention and Treatment of Child Abuse and Neglect
Department of Pediatrics, School of Medicine
Kempe Center for the Prevention and Treatment of Child Abuse 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
• 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
Types of Childhood Trauma
5
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
Rates of Trauma Exposure
Cumulative Impact of Lifetime Victimization-
Trauma on Child Mental Health
Turner, Finkelhor, & Ormrod 2010
• Fear
• Sadness
• Anger
• Anxiety
• Depression
• Affective Dysregulation
– Physiological arousal
– Emotional distress
– Difficulty self-soothing
Affective Symptoms
• Avoidance
– Thoughts, feelings, places
– What happens when you avoid?
• Modeling maladaptive behaviors
– Sexualized behaviors
– Violent behaviors
– Bullying
• Traumatic Bonding
– Associating with aggressor
• Substance Abuse
• Self-Injury
• Suicidality
Behavioral Symptoms
• Irrational Beliefs-Themes
– Responsibility/Self-blame
– Overestimating danger
– Abandonment
• Distrust of others
• Distorted Self-Image
– ‘Damaged’
– Self as all about trauma
• Loss/Betrayal of Social Contract
• Accurate, but unhelpful, cognitions
Cognitive Symptoms
• PTSD
• Depressive disorders
• Other Anxiety disorders
• Behavior disorders
• ADHD
• Substance use disorders
Comorbidity is common
Trauma exposure and PTSD are often missed
Common diagnoses
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
Posttraumatic Stress disorder (DSM-IV/ ICD)
Assessing Lifetime Trauma Exposure
Steinberg et al., 2004)
Assessment Example Continued – Trauma Exposure
6
4 Months Ago
Mom’s boyfriend beat her up
CPSS: PTS
Symptom
Screener Reexp
• Infants – Physiological symptoms, high levels of distress
• Toddlers/Preschoolers – Reenactment
– Loss of previously acquired developmental skills
– New onset of aggression or separation anxiety
– New onset of fears that are not obviously related to the traumatic event
– Parental reactions may inadvertently reinforce children’s trauma-related fears
Scheeringa, 2008
PTSD in Infants and Young Children
Mental and Behavioral Health Problems
of Trauma-Exposed Youth
16
Mental and Behavioral Health Needs
Effective Mental Health Services
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)
• An evidence-based treatment for children ages 3-18
• Originally developed for sexual abuse
• 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, attachment theory, developmental neurobiology, family therapy, humanistic therapy
• Time limited, structured (12-20 sessions) active treatment
• Therapist is directive and active!
What is TF-CBT?
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
Trauma-Focused Cognitive
Behavioral Therapy
1/3 1/3 1/3
Sessions 1 - 4
Psychoeducation/Parenting Skills
Relaxation
Affective Expression and Regulation
Cognitive Coping
Sessions 5 - 8
Trauma Narrative Development and Processing
In vivo Gradual Exposure
Sessions 9 - 12
Conjoint Parent Child Sessions
Enhancing Safety and Future Development
TF-CBT Sessions Flow
Entire process is gradual exposure
Assessment
---------------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
Knowledge
Practice
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
welfare CEBC Scientific Rating Scale
CEBC Child Welfare Relevance
Rating
Nurturing Parent Program
Play Therapy
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?
0
8
16
24
32
40
48
56
T1 T2 T3
Severi
ty S
co
re
Administration
UCLA-RI PTSD –Symptom Severity
PTSD Overall Severity Re-experiencing
Avoidance
Tracking Outcomes
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 : kimberly.shipman@childrenscolorado.org