A Decade of ImplementingEvidence-Based Trauma Treatment for

Children in SC: Overview of TF-CBT and Project BEST

Presentation at the 2017 Palmetto Coordinated System of Care Conference, September 13, 2017, Columbia, SC.

Benjamin E. Saunders, PhDNational Crime Victims Research and Treatment Center

Department of Psychiatry and Behavioral ScienceMedical University of South Carolina

Charleston, SC

Topics for Today

1. Why worry about traumatic stress in children and youth?2. What is Trauma-Focused Cognitive-Behavioral

Therapy (TF-CBT)?3. What is Project BEST?4. Some lessons learned from 10 years of implementing

TF-CBT in South Carolina.

Colleagues

Elizabeth Ralston, PhDElizabeth Hinson, MSWCarole Swiecicki, PhDRachael Garrett, MSWLizabee Ciesar, MSWKathy Quinones, PhD

Kim Reese, MSWAliza MacClellan, MSWHeather Weimer, MSWPolly Sosnowski, MSW

Dee NortonChild Advocacy Center

Rochelle F. Hanson, PhDMichael de Arellano, PhD

Dan Smith, PhDHeidi Resnick, PhD

Angela Moreland, PhDJan Koenig, MEd

Faraday Davies, MAEmily FanguySara delMas

Medical University of South Carolina

Monica Fitzgerald, PhDUniversity of Colorado

SC Dept. of Mental Health SC Dept. of Social ServicesSC Network of Children’s Advocacy Centers

Thanks to The Duke Endowment for theirgenerous support of Project BEST.

Why Worry AboutTraumatic Stress in Childhood?

Assess Trauma History!

National Survey of Children’s Exposure to Violence II (N=4,503)

Violence Exposure in Childhood is Normative

American children and youth: 58% had experienced or witnessed at least one

victimization in the past year. 41% were physically assaulted in the past year. 10% were physically injured by violence in the past year. 15.1% experienced 6 or more victimizations in the past year.

70% of older adolescents had experienced a physical assault in their lives.

17% of older adolescent females had been sexually assaulted at least once in their lives.

41% of older adolescents had suffered some type of maltreatment by a caregiver in their lives.

72% of older adolescents had witnessed serious violence in the community or the home at least once in their lives.Finkelhor, D. Turner, H.A., Shattuck, A., & Hamby, S.L. (2013). Violence, crime, and abuse exposure in a national sample of children and youth: An Update. JAMA Pediatrics, 167(7), 614-621.

National Survey of Adolescents – Replication (N = 3,614)

Serious Traumatic Events are Common

Lifetime prevalence among U.S. adolescents:

38% - Witnessed serious community violence (Zinzow et al., 2009)

9% - Witnessed serious violence at home (Zinzow et al., 2009)

12% - Violent physical victimization by peer (Jackson et al., 2013)

17% - Sexual assault, 17 yo F (Saunders & Adams, 2014)

3% - Drug/Alcohol facilitated rape, 17 yo F (McCauley, 2009)

18% - Traumatic death loved one (Rheingold et al., 2012)

10% - Motor vehicle accident (Williams et al., 2015)

25% - Natural disasters (Saunders & Adams, 2014)

Potentially Traumatic Events are Normative Among U.S. Children

~75%

National Comorbidity Study Replication Adolescent Supplement

Childhood Adversity is BAD National survey of 6,483 adolescent-parent pairs. Assessed 12 childhood adversities (interpersonal loss, parental maladjustment,

maltreatment, family economic) Assessed DSM-IV anxiety, mood, behavior and substance use disorders. 58% of adolescents reported exposure to at least 1 adversity. 35% of all adolescents (60% of adversity exposed) reported multiple

adversities. Different types of adversities associated with different types of disorders

with different strengths of relationship. Inaccurate to just count them. Childhood adversities associated with 28% of onsets of all

psychiatric disorders.

McLaughlin, K.A., Green, J.G., Gruber, M.J., Sampson, N.A., Zaslavsky, A.M., & Kessler, R.C., (2012). Childhood adversities and first onset of psychiatric disorders in a national sample of US adolescents. Archives of General Psychiatry, 69(11), 1151-1160.

Psychological and Behavioral Impact of Childhood Victimization

Abuse and victimization in childhood correlated with: Trauma and Stressor-Related disorders (PTSD, acute stress disorder) Anxiety disorders (social phobia, generalized anxiety disorder) Depressive disorders (major depressive disorder) Sexual disorders (dysparunia, vaginismus, inhibited sexual desire) Substance use/abuse/dependence (drug, alcohol, tobacco) Delinquency and criminal behavior Violent behavior (peer aggression, dating violence, spouse/partner

violence) Neurobiological development Physical health (smoking, health risk behaviors, risky sexual behaviors) Other problems (future victimization, relationship difficulties, academic

performance, occupational achievement, ) Comorbid problems

The Childhood Trauma Challenge

Characteristic PopulationAmerican youth population 0-17 years 74,108,000a

~75% experience potentially traumatic events 55,581,000~30% of these develop clinically significant

trauma-related problems needing tx16,674,300

(22.5%)

a2012 data retrieved 2/23/15 from http://www.census.gov/population/age/data/2012comp.html.

Are we prepared to meet this treatment need?

Effective Interventions Are Needed

Trauma-Focused Cognitive-Behavioral TherapyCognitive-Behavioral Intervention for Trauma in SchoolsAlternatives for FamiliesCognitive Processing TherapyProlonged Exposure TherapyChild-Parent PsychotherapySafeCareThe Incredible YearsParent Child Interaction TherapyCBT for Children with Sexual Behavior ProblemsFunctional Family TherapyDialectic Behavior TherapyMultidimensional Treatment Foster CareMultisystemic TherapyTriple P

Effective, Evidence-Based Treatments are Available!

Why TF-CBT? Strong empirical support for efficacy. 20+ randomized controlled trials supporting its efficacy

conducted on 6 continents with diverse populations, providers and delivery systems.

Highest rating in the National Registry of Evidence-based Programs and Practices, CrimeSolutions.gov, the California Evidence-Based Clearinghouse for Child Welfare, OVC Guidelines Report.

Named a “Best Practice” for cases of child abuse in the Kauffman Best Practices Report

Successfully implemented nationally and many countries outside the U.S.

Excellent outcomes in community agencies. Impact generalizes to a variety of problems. Teaches basic skills necessary in many EBTs. Educational and implementation resources available

What is TF-CBT?

“TF-CBT is a components-based hybrid approach that integrates trauma-sensitive interventions, cognitive-behavioral principles, as well as aspects of attachment, developmental neurobiology, family, empowerment, and humanistic theoretical models in order to optimally address the needs of children and families impacted by traumatic experience(s).” (p. 41)

-Cohen, Mannarino & Deblinger (2017)

What is TF-CBT?

Key characteristics Relatively brief (12-16 sessions) Components and phase-based (beginning, middle, end) Child and caregiver involvement in all components Based on CBT, exposure, and parenting principles Goals are to:

• Build and use coping knowledge and skills• Build caregiver support• Gradual exposure to memories of traumatic events• Process unhelpful thoughts and emotions• Plan for the future.

Treatment Targets of TF-CBT

Symptoms of Posttraumatic stress disorder (PTSD) Depression Anxiety

Other common trauma-related difficulties Fear Guilt, Self-blame Shame, Stigmatization Moderate behavior difficulties related to traumatic stress

Delivery Structure• Weekly or 2x/week

sessionso 60-90 minutes

o Time with child

o Time with caregiver

o Time together

• Practice at home• 8-24 session duration• 12-16 sessions typical• Follow tx components

PscyhoeducationRelaxationAffective ModulationCognitive Coping

Trauma Narrativeand Processing

In vivoConjoint sessionsEnhancing safety

Trauma Narrative

Phase

Integration/ Consolidation

Phase

StabilizationPhase

Pare

ntin

g Sk

ills

Gra

dual

Exp

osur

e

Tim

e: 1

2-16

Ses

sions

1/3

1/3

1/3

TF-CBT Pacing

TF-CBTWeb

www.musc.edu/tfcbt

CTGWeb

Online Resources for TF-CBT

www.musc.edu/ctg

www.musc.edu/tfcbtconsult

TF-CBTConsult

Few Children Receive Evidence Supported Interventions

Victimization Type Experienced

Saw a counselor Past Year

Saw a counselorLifetime

Physical assault 9.4% 14.0%Sexual victimization 13.9% 18.1%Maltreatment by a caregiver

13.3% 16.0%

Witnessed violence 6.5% 10.3%Finkelhor, D. (2014). Treatment data from the National Survey of Children Exposed to Violence II, personal communication.

Bringing Evidence Supported Treatmentsto South Carolina Children and Families

Coordinating CentersDee Norton Child Advocacy Center

Charleston, SCNational Crime Victims Research and

Treatment CenterMedical University of South Carolina

www.musc.edu/projectbestProject BEST is funded by The Duke Endowment and participating agencies.

Mission of Project BEST

To ensure that all abused children and their familiesin every community in South Carolina receiveappropriate, evidence supported mental healthassessment and psychosocial treatment services.

• Build the capacity of every community to deliver Evidence Supported Interventions.

• Establish collaboration so that every child gets Evidence Supported Interventions.

Building Evidence-Based Trauma Treatment Service Capacity

So, exactly how do we build these services in our communities?

Mental Health

ChildWelfare

JuvenileJustice

CACs

PrivatePractitioners

Medical

Schools

LawEnforcement

FamilyCourt

RapeCrisis

DomesticViolence

Drug &Alcohol

MentorPrograms

Probation

GALs CriminalCourt

Medicaid

Drug &Alcohol

MCOs

Victim’sCompensation

AlternativeCare

ParentingPrograms

Sex OffenderTreatment

pRTFs

GroupHomes

VictimAdvocates

FosterHomes

In-HomeServices

BmodServices

Why do victimized children not receive effective trauma treatment?

Many abused children are not identified. Lack of EBT service capacity.

Not enough therapists trained in EBTs. Lack of consistent use of the EBT after training. Limited reach of current service delivery systems.

Children and families not referred to trained therapists. Brokers of mental health services unaware of EBTs. Generic service plans that do not include EBTs. Lack of case management skills related to EBTs.

Lack of collaboration between service providers. Poor initial engagement in treatment. Sporadic attendance. High premature dropout rates.

Lack of focus on treatment outcomes.

Community as the Target

Saunders & Hanson (2014)

ReferralChild Welfare

Juvenile Justice

VictimAdvocates

GuardianAd Litem

Rape Crisis Center

Bro

kers

MH

Providers

PublicMentalHealth

NonprofitMH

Services

MCO Providers

Private PractitionersSchools

MedicalMedical

Relevant Service Systems

Break out of ourservice and training silos!

Child welfare

Mentalhealth

Juv

enil

eJu

stiC

e

Ga

l

N=1,613 children within 75 child welfare agencies over 36 months Examined Interorganizational Relationships (IORs)

• Number of coordination approaches between each child welfare agency and mental health service providers

• Tested relationships between IORs, Service Use, and Outcomes Greater intensity of IORs more service use for children

greater mental health improvement. Conclusion:

Encourage more and different types of organizational ties between child welfare and mental health service systems.

Bai, Y., Wells, R., Hillemeier, M.M. (2009). Coordination between child welfare agencies and mental health service providers, children’s service use, and outcomes. Child Abuse & Neglect, 33, 372-381.

National Survey of Child and Adolescent Well-Being

Coordination Improves Outcomes

Community-Based Learning CollaborativeCommunity Change Team

ClinicalSenior

Leaders

ClinicalSupervisors

Therapists Brokers

BrokerSupervisors

BrokerSenior

Leaders

Families

Goals of a

Community-Based Learning Collaborative

Promote collective, shared community responsibility for abused and traumatized children and their families across agencies.

Develop a linked, collaborative, learning community. Build the capacity of communities to deliver EBTs, not just one agency or

set of providers. Build the “supply” of trained, knowledgeable, and skilled therapists who

use EBTs properly. Build “demand” for EBTs among trained, knowledgeable and skilled

brokers who understand EBTs and use Evidence-Based Treatment Planning and Case Management for Treatment Success.

Build cooperative, collaborative, sustainable relationships between brokers and therapists and agencies within the community.

Promote organizational and community change as well as individual learning and practice change. Institutionalize EBTs.

Cultivate local expertise and commitment to EBTs.

Key Elements of a Community-Based Learning Collaborative

Development of a Community Change Team Therapists, clinical supervisors, clinical senior leaders Brokers, broker supervisors, broker senior leaders Shared community responsibility and leadership Collaboration and coordination

Multiple training approaches and events over time Adult learning principles and active learning techniques Online learning, use of technology Expert consultation Resource library

Action periods to implement the new practices with expert consultation Practice new approaches with expert consultation Expose barriers to implementation and sustainability, find solutions

Promote collaboration and shared community responsibility Service coordination, communication, team-building, collective responsibility.

Measure and monitor community, practitioner and client outcomes

5 9

Pre-Work LS1 LS2Action Period

Action Period

4+

Community-Based Learning Collaborative Timeline

12

Clinical Supervisors

1-day

Orient.SL Train.

Comm.Prep

0CBLC Month

Requirements• Readings• Online training courses• Two 2-day learning sessions• 2 TF-CBT training cases (clinicians)• Implement EBTP & CMSTS (brokers)• Coordination, solve barriers (senior leaders)• Consultation call groups• Metrics

Senior Leader Track

LeadershipSupport

CBLC Curriculum Areas

Clinical Track

TF-CBT

Broker Track

EBTPCMTS

Common Material and ActivitiesClinicians, Brokers, Senior Leaders

Service Coordination Community Collaboration

Family Engagement

Team Building

JointCommunity

Responsibility

Project BEST Coverage

Shortcut to Show Desktop.lnk

Pee Dee CBLCDurant Children’s

Center

Coastal CBLC

Children’sRecovery

Center

DorchesterChildren’s

Center

DNLCCNCVC

Upstate CBLC

Julie ValentineCenter

FoothillsAlliance

Pioneer CBLC Edisto CBLCEdisto Children’s

Center

North Central CBLC

Palmetto CASA-CAC

Lower State LC

Midlands CBLCCAC of Aiken Cty.

Dickerson Center for Children

CARE House of the Pee

Dee

Safe Passage

Project BEST Community-Based and Clinical Learning Collaboratives

TF-CBT AF-CBTPB

Phase CBLCClinical

LCTF

Total CBLCClinical

LCAF

Total Total1 3 2 5 0 0 0 52 4 2 6 0 0 0 63 6 0 6 0 0 0 64 1 2 3 2 0 2 5

Total 14 6 20 2 0 2 22

2007-2017

Project BESTTF-CBT Participants

1542 South Carolina professionals have participated 2165 TF-CBT child clinical training cases479* Therapists completed TF-CBT training requirements169 Brokers completed all training requirements134 Senior leaders completed all training requirements782 Fully trained, multidisciplinary professionals

All 46 South Carolina counties are served by trained TF-CBT therapists.

*Additional 119 therapists are currently in training.

SCTPI Results

Metric PercentParticipants completing all CBLC requirements 66%TF-CBT training cases completing all treatment components

55%

Agency children-Received traumatic events evaluation 65 - 76%Agency children-Received trauma symptoms evaluation 62 - 76%Traumatized community children completing trauma treatment

33 - 45%

SCTPI Results

Scale d*Organizational support for TF-CBT implementation 0.48Therapists -- TF-CBT clinical skills 1.02Therapists -- TF-CBT practices 0.84Brokers -- Trauma information 0.92Brokers -- TF-CBT information 1.38Brokers -- Family engagement skills 1.54Brokers -- Evidence-based treatment planning skills 1.73Brokers -- Trauma practices 0.89Community collaboration 0.37Treatment barriers reduction 0.61

*Cohen’s d effect size

Recent RCT Results: Cohen et al. (2011) pre-post child UCLA total: d = 0.64Deblinger et al. (2011) mean pre-post for child outcomes: d = 0.94

Reexperiencing* Avoidance* Hyperarousal* Total Score*

Pre Post Pre Post Pre Post Pre Post

Mean 7.9 3.5 9.6 4.1 8.3 4.2 25.8 11.8

SD 3.8 3.2 4.8 3.9 3.7 3.5 10.3 9.4

D 1.17 1.15 1.11 1.36

N =537. All pre-post comparisons, p<.0001

Child CPSS Scores Pre- and Post-treatment

SCTPI Training Cases

Outcome Matrix for Child CPSS

0%

20%

40%

60%

80%

100%

85.5

8.95.6

Got Worse

Stayed Same

Improved

N=547

d > 0.20*

*Crosby et al. (2003)

Pre-Post TF-CBT OutcomesCommunity Therapists’ Training Cases

Project Measure Respondent N dProject BEST Phase 1 UCLA Child 346 1.00Project BEST Phase 1 MFQ Child & Parent 188 0.97SCTPI CPSS Child 537 1.36SCTPI CPSS Parent 527 1.03SCTPI MFQ Child & Parent 518 1.08PATS (Florida) CPSS Child 170 1.22

More Children Improve

Community Collaboration

More ChildrenGet EBTs

TreatmentBarriers

Community Collaboration?

Correlation Matrix

Table 6. Associations between pre- and post-CBLC collaboration, barriers, and treatmentcompletion estimates.

VariableCollabor.

PreCollabor.

PostBarriers

PreBarriers

Post% Compl.

Tx Pre

Collaboration-Post .52*** 1.00

Barriers-Pre -.33*** -.23*** 1.00

Barriers-Post -.19** -.25*** .45*** 1.00

% Complete Tx-Pre .53*** .30*** -.31*** -.12T 1.00

% Complete Tx-Post .30*** .41*** -.22*** -.31*** .30***N=270. **p<.01; ***p<.001.

Mediational Analyses

Table 7. Mediation analysis for barriers to treatment -- initial assessment.Model B Beta R R2 ΔR2 F tCollab. -> %Tx 1.74 0.50 0.50 0.25 0.25 181.3*** 13.47***Collab. -> Barr. -0.46 -0.31 -0.31 0.10 0.10 58.0*** -7.61***Barr. -> %Tx -0.67 -0.28 -0.28 0.08 0.08 47.6*** -6.90***Collab. + Barr. -> %Tx

Collaboration 1.58 0.46 0.50 0.25 0.25 181.3*** 11.81***Barriers -0.34 -0.14 -0.52 0.27 0.02 13.6*** -3.69***

N=550. ***p<.001.

Table 8. Mediation analysis for barriers to treatment -- final assessment.Model B Beta R R2 ΔR2 F tCollab. -> %Tx 1.54 0.42 0.42 0.17 .17 62.0*** 7.88***Collab. -> Barr. -0.33 -0.25 -0.25 0.07 0.07 20.4*** -4.52***Barr. -> %Tx -0.88 -0.31 -0.31 0.10 0.10 31.2*** -5.59***Collab. + Barr. -> %Tx

Collaboration 1.34 0.36 0.42 0.17 0.17 62.0*** 6.78***Barriers -0.62 -0.22 -0.47 0.22 0.04 16.6*** -4.08***

N=297. ***p<.001.

More Children Improve

Community Collaboration

TreatmentBarriers

More ChildrenGet EBTs

(-) (-)

(+)

Lessons Learned

Community therapists can… Learn TF-CBT knowledge and clinical skills Do TF-CBT effectively in community mental health service agencies

with their typical patients Get good treatment effects!

Community mental health service agencies can implement and sustain the use of TF-CBT successfully.

Lessons Learned

Doing an EBT is more difficult than treatment as usual. Implementing treatment outcome assessment may be more

difficult than implementing an EBT. The most effective treatment cannot work without patient

engagement .

Lessons Learned

Brokers can learn and implement trauma-informed, evidence-based case management practices.

Therapists like working with trained brokers. A trained broker will fill up a trained therapist quickly.

Sustainment Challenges

Maintaining TF-CBT capacity. Maintaining adequate treatment fidelity. High staff turnover rates. Efficient mechanisms for training new hires. Building treatment capacity further in some parts of the state. Identifying more abused and traumatized children.

Leadership is the Critical Element!

Visionary & Transformational

Supportive Problem-solving Accountable Committed to

outcomes Collaborative Community-focused

Ben Saunderssaunders@musc.edu

Contact Information