Trauma-Informed Practice: What Child Welfare …...Trauma-Informed Practice: What Child Welfare...

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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

Transcript of Trauma-Informed Practice: What Child Welfare …...Trauma-Informed Practice: What Child Welfare...

Page 1: Trauma-Informed Practice: What Child Welfare …...Trauma-Informed Practice: What Child Welfare Attorneys Can Do October, 2012 Kimberly Shipman, Ph.D. Kempe Center for Prevention and

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

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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)

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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

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• 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

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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

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Cumulative Impact of Lifetime Victimization-

Trauma on Child Mental Health

Turner, Finkelhor, & Ormrod 2010

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• Fear

• Sadness

• Anger

• Anxiety

• Depression

• Affective Dysregulation

– Physiological arousal

– Emotional distress

– Difficulty self-soothing

Affective Symptoms

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• 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

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• 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

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• PTSD

• Depressive disorders

• Other Anxiety disorders

• Behavior disorders

• ADHD

• Substance use disorders

Comorbidity is common

Trauma exposure and PTSD are often missed

Common diagnoses

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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)

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Assessing Lifetime Trauma Exposure

Steinberg et al., 2004)

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Assessment Example Continued – Trauma Exposure

6

4 Months Ago

Mom’s boyfriend beat her up

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CPSS: PTS

Symptom

Screener Reexp

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• 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

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Mental and Behavioral Health Problems

of Trauma-Exposed Youth

16

Mental and Behavioral Health Needs

Effective Mental Health Services

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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

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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)

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• 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?

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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

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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 ------------------

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So what’s the

problem?

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All sorts of “treatments” are available out there.

Isn’t all “counseling” the same?

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Large Gap Between Scientific Knowledge and

Front-line Practice

Knowledge

Practice

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So as a professional who has ability to identify

kids in need and monitor mental health

services…. What can I do?

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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

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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

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Nurturing Parent Program

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Play Therapy

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Another Resource: http://nrepp.samhsa.gov/

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Ask questions of mental health

providers to identify and monitor

treatment…

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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?

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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

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NCTSN Child Welfare Toolkit

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Trust your instincts and seek a second

opinion….

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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]