Integrating tf -CBT and Sexual offense specific treatments for Teens

1. Integrating tf-CBT and Sexual offense specific treatments for Teens By Adam H. Benton, PhD

2. (TF-CBT)Trauma-Focused Cognitive-Behavior Therapy • Traumatic Stress in Children • Assessment of Trauma Symptoms • Development and Research On TF-CBT • Treatment Using TF-CBT Components • Trauma-Informed Care in Juvenile Justice and Residential Settings • The AR BEST Program

3. What is Child Traumatic Stress? Child Maltreatment Domestic Violence Natural Disasters Community and School Violence Medical Trauma Traumatic Loss Terrorism War-Zone Trauma

4. How Big is the Problem?The Epidemiology of Child Traumatic Stress General population studies Disaster studies • Terrorism • Natural disasters Child maltreatment studies

5. General Population Studies of Child Traumatic Stress National Survey of Adolescents(Kilpatrick & Saunders, 1997) • Representative US sample: 12-17 yrs • Serious physical assault: 5 million • Sexual assault: 1.8 million Youths in Urban America study(Breslau et al., 2004) • Mid-Atlantic US city • Baseline 6 yrs; follow-up 20-22 yrs • 82.5% one or more lifetime traumatic events: 87.2% males, 78.4% females • Exposure to violent assault • Increase after 15 years, peaked @ 16-17 yrs • Major decrease by age 21

6. General Population Studies of Child Traumatic Stress Developmental Victimization Study(Finklehor et al., 2005) • Representative US sample: 2-17 yrs • 1 in 8 experienced a form of child maltreatment • 1 in 3 witnessed violence The Great Smoky Mountains Study(Copeland, et al., 2007) • A majority of children (67.8%) were exposed to one or more traumatic events by age 16. • Children exposed to trauma had almost double the rates of psychiatric disorders of those not exposed.

7. Disaster Studies New York City, NY Department of Education Study(Hoven et al., 2005) • At 6 months post World Trade Center attack, the prevalence of: • PTSD was 10.6% • agoraphobia was 14.8% • conduct disorder was 12.8% • separation anxiety was 12.3% • alcohol problems was 4.5% • Over 60% experienced at least one major traumatic event prior to the attacks. Gulf Coast Child & Family Health Study(Abramson et al., 2007) • At 2 years after Hurricane Katrina. • 46,000 children were displaced • 51% of displaced children had at least 1 risk factor for poor long term outcomes

9. Child Maltreatment Prevalence2007

10. Posttraumatic Stress Disorder C. Persistent Avoidance (3+) Exposure Experienced or witnessed…actual or threatened injury or death Responded with intense fear, helplessness, or horror B. Reexperiencing Intrusive recollections Recurrent dreams Acting or feeling as if the event were recurring Intense distress triggered by internal or external cues Physiological reactivity Avoiding thoughts, feelings etc Places, activities, or people Inability to recall events Diminished interests in significant activities Detachment or estrangement from others Restricted affect Foreshortened future

11. Posttraumatic Stress Disorder D. Persistent Increased Arousal (2+) Duration of 1 month or more Clinical impairment Difficulty sleeping Irritability Difficulty concentrating Hypervigilance Exaggerated startle response

12. What is the impact of Child Traumatic Stress? • Capacity to regulate emotion and attention • Social development • Cognitive development: IQ and language • Academic performance • Substance use/abuse • Numbness, desensitization to threat • Re-victimization • Recklessness and reenacting behavior • Posttraumatic stress and other disorders (depression, anxiety, phobia, panic) • Developmental Trauma Disorder • Health effects

13. Traumatic Stress Symptoms in Children Compared to adults… • Less numbing and difficulty recognizing avoidance • More overt aggression, destructiveness, and reenactment (also in play and drawings) • Older children – foreshortened future • Over the age of 10 – react more like adults Dyregrov & Yule, 2005

14. Effect of increasing trauma exposures on cumulative rates of psychiatric diagnoses by age 16 years (Copeland et al., 2007)

16. Incidence of PTSD in Children 6% life-time prevalence in older adolescents Natural Disasters 30-50% moderate symptoms 5-10% full criteria Traffic Accidents 29% at 4 wks 36% at 6 wks 6 – 25% at 12-15 wks 14% at 9 months Exposure to war 25 – 70% Diseases or hospitalization X < 15% Sexual and Physical Abuse 11 – 20% Symptoms often remain for years without treatment (15-29% still meet criteria 5- 33 years later) Dyregrov & Yule, 2005

17. Predictors of PTSD Reactions in Children • Level of Exposure • Lack of social support • Female gender • Previous trauma exposure • Prior psychiatric problems • Strong acute response • Family history of mental illness • Cognitive variables • Negative appraisal • Unfairness • Rumination • Thought suppression • Confusion during the event

18. Trauma & the Brain Vertical Organization Cortex: the thinking brain; Prefrontal cortex- reasoning, executive functions, decision making, social control, impulse control, personality Limbic: Amygdala evaluates threats; Hippocampus encodes memories and facilitates conscious memory; Thalamus –relay station; Hyposthalamus- homeostasis, brain-body exchange of info Brain Stem: Cardiovascular, arousal, some reflexes

19. Trauma & the brain Hemispheric Organization Right Hemisphere Non-verbal communication Imagery, visual spatial info General, big picture perspectives Negative emotions Withdraw and avoid Left Hemisphere Analytic thinking Language, words and numbers Detail perspectives Positive emotions Motivation to approach tasks

20. Neurobiology of Trauma • Limbic Irritability • Increase activation of the Amygdala- hypervigilence, scanning for threat cues, over interpreting innocuous cues as significantly threatening • Difficulty regulating emotions and emotionally charged situations • Decreased activation of speech centers….expressive/receptive language difficulties • Social and relational problems related to reading social cues • Attention problems due to hyper-focused on perceived threat and missing dismissing non-threatening information

21. Neurobiology of Trauma • Hippocampus • Smaller hippocampal volume due to persistent threat: reduced short-term memory, verbal memory, dissociation, and context dependent memory • Lack of development of left hippocampus area, contributes to language difficulties • Deficient Left Hemisphere Development • Difficulty analyzing and understanding their own and others behavior • Decreased verbal skills • Pathological responses involving anger, fear avoidance, withdrawal, and depression • Decreased adaptive coping responses

22. Neurobiology of Trauma • Cerebellar Vermis • Difficulty with emotional stability, controlling activation, • Observed by physiological soothing, such as rocking, swinging, when experiencing trauma trigger.

23. Trauma & Attachment • Secure- responds specifically to situations, flexible, adaptive • Avoidant- Over-modulate…limited, rigid with emotions, less specific responses, less flexible and responsive to context • Anxious- under-modulate, respond more quickly and greater intensity to fear eliciting stimuli, responses bypass cortex. poor coping, less specific appraisals, less flexible in response to context “Studies have shown that tram experiences impact significantly the level of neural integration in the brain…..leading to neurological obstacles to creating and sustaining secure relationships.” (Creeden 2009, citing Teicher et al., 2002)

24. Trauma & Implications for treatment • “Neglect and chronic states of mis-attunement lead to an over-prunning of synapses in the prefrontal cortex, leaving individuals with an impaired capacity to modulate and regulate emotion in response to threat.” (Creeden 2009, from Lott 2003) • Children and teens with chronic trauma histories have problems with arousal in general, rather than with sexual arousal specifically. • Treatment providers should consider a focus on broad-based arousal control and regulation, rather than solely sexual arousal. • Clients with language deficits may benefit less from our typical language dependent styles of counseling

25. Trauma & Implications for treatment • Executive Functioning Problems, - ADHD • Impulsivity, disorganization, rigid problem-solving approaches, misreading social cues • Interventions to address these deficits are important to treatment • Our clients trauma experiences are intertwined strongly with their abusive behavior and not just from a social-learning perspective…but through the link to their experience of anxiety, fear, abandonment, anger, shame and other overwhelming affect states. Creeden 2009. • “Not addressing the impact of the client’s own trauma, will simply impede the learning and effective use of skills we are teaching them to control/change their inappropriate and abusive behavior.” Creeden 2009

26. Trauma histories of those in Juvenile Justice system • Several studies estimate that 75-93 percent of youth entering the system have experienced some degree of traumatic victimization. • Males who experience trauma prior to the age of 12….50-79 percent become involved in serious juvenile delinquency • Young boys who engaged in sexual offenses, 95 percent reported some type of trauma exposure, 77.5 percent reported more than one type. More than half reported both physical and sexual abuse • Incarcerate women are more likely than non-incarcerated women to report sexual or physical abuse • Pre-teens and adolescents who participated in homicide offenses have histories of severe childhood maltreatment • Only 20 percent of states provide evidence-based or standardized assessment tools. • Healing Invisible Wounds: Why Investing in Trauma-Informed Care for Children Makes Sense, July 2010. Justice Policy Institute

27. The system can be traumatic • Long-term separation from parents and family • Violence among peers • In 2007, 10 deaths in JJ facilities • 10.7 percent report sexual contact by staff • Physical and emotional abuse by staff and peers • With youth who have experienced trauma and have PTSD or mental illness, treatment is more effective than incarceration at reducing recidivism • Healing Invisible Wounds: Why Investing in Trauma-Informed Care for Children Makes Sense, July 2010. Justice Policy Institute

28. Assessment of Trauma Symptoms • “The development of the abused or neglected child seldom follows a predictable course, because child maltreatment is characterized by many other negative socialization forces, such as family instability, parental inconsistency, and socioeconomic disadvantage.” Wolf & McEachran, In Mash & Terdal, 1997)

29. Assessment Process • Assess existing risk and safety • Identify general strengths and problems areas for family (marital problems, Family Stressors, etc.) • Identify parental needs (support, child rearing, etc) • Identify child needs (behavior, cognitive, social, mental health symptoms, etc) • Reporting issues

30. Assessment Process • Cognitive problems: Maladaptive patterns of thinking about self, others and situations, including distortions and unhelpful thoughts, like self-blame or rumination about the trauma • Relationship problems: Difficulties getting along with peers, poor problem-solving or social skills, hypersensitivity in interpersonal interactions, maladaptive strategies for making friends, impaired ability to trust. • Affective problems: Sadness, anxiety, fear, anger, poor ability to tolerate or regulate negative affective states, inability to self-soothe.

31. Assessment Process • Family problems: Parenting skills deficits, poor parent-child communication, disturbances in parent-child attachment, disruption in family relationships or functioning due to abuse. • Traumatic behavior problems: Avoidance of trauma reminders; trauma-related, sexualized, aggressive, or oppositional behaviors; unsafe behaviors • Somatic problems: Sleep difficulties, physiological hyperarousal and hypervigilance toward possible trauma cues, physical tension, somatic symptoms. Cohen, Mannarino, & Deblinger, 2006

32. Assessment Instruments • Family Adjustment • Family Adaptability , Cohesion and Expression Scale • Family Environment Scale • Cognitive / Learning Ability • WISC, WPPSI, Stanford Binet, KBIT, WASI • WIAT, Woodcock-Johnson, WRAT, • Social Functioning • Harter Self-Perception Profile for Children • Harter Social Support Scale for Children • Adolescent Interpersonal Competency Questionnaire • Children’s Attributional Style Questionnaire • Emotional /Behavioral • Child Behavior Checklist • Behavior Assessment Scale for Children • Roberts Apperception Test – 2 • Child Depression Inventory • Manifest Anxiety Scale for Children • Strengths & Difficulties Questionnaire • Traumatic Stress Symptoms • UCLA Posttraumatic Stress Index • Trauma Symptom Checklist for Children • Child PTSD Screen • Child Report of Posttraumatic Symptoms • Children’s Impact of Traumatic Events Scale • Child Dissociative Checklist • Traumatic Events Screening Inventory

33. Sample Assessment Battery for Teens • Screener • Behavior Assessment System for Children, Second Edition • Strengths and Difficulties Questionairewww.SDQinfo.org • Traumatic Events Screener • Childhood Trust Events Survey http://www.drjenna.net/checklists/ptsd/childhood_trust_events_survey_child.pdf • PTSD Specific Measure • UCLA PTSD Reaction Index • Video Training: http://www.nctsnet.org/products/administration-and-scoring-ucla-ptsd-reaction-index-dsm-iv

34. Using Assessment to Guide tx UCLA PTSD Index • Overall Score • Cut-off = 37+ Strong Specificity / Sensitivity of Meeting Criteria for PTSD • 30-37 needs treatment • Clusters may indicate specific treatment interventions to focus on • Re-experiencing - Cognitive • Avoidance - Exposure • Increased Arousal – Affect regulation / relaxation

35. Development of TF-CBT Judith A. Cohen, M.D. Anthony P. Mannarino, Ph.D. Allegheny General Hospital, Pittsburgh, PA Center for Traumatic Stress in Children and Adolescents Esther Deblinger Ph.D. New Jersey Child Abuse Research Education and Services Institute

36. Research On TF-CBT • TF-CBT is the most rigorously tested treatment for traumatized children – 6 randomized trials • Improved PTSD, depression, anxiety, shame and behavior problems compared to supportive treatments • Improved parental distress, parental support, and parental depression compared to supportive treatment • Successful with diverse ethnic and racial populations

37. What is TF-CBT? A hybrid treatment model that integrates: • Trauma sensitive interventions • Cognitive-behavioral principles • Attachment theory • Developmental neurobiology • Family therapy • Empowerment therapy • Humanistic therapy

38. Core Values CRAFTS Components-based Respectful to Cultural Values Adaptable and Flexible Family Focused Therapeutic Relationship is Central Self-efficacy is Emphasized

39. TF-CBT Treatment Structure • Average 12 – 18 sessions • 1 to 1 ½ hour weekly sessions • Each session is divided into individual child and parent sessions • The length of the child and parent portions may vary by topic • Similar topics in most parent and child sessions • Same therapist for both child and parent(s) • Combined parent-child time in some to many sessions

40. Treatment Using TF-CBT Components • Psychoeducation and Parenting Skills • Relaxation • Affect Modulation • Cognitive Coping • Trauma Narrative and Processing • In Vivo Mastery of Trauma Reminders • Conjoint Child-Parent Sessions • Enhancing Future Safety and Development

41. TF-CBT Components CHILD’S TREATMENT Education Skill Building Exposure/Processing PARENT’S TREATMENT Education Skill Building Exposure/Processing Behavior Management 1996 Deblinger & Heflin JOINT FAMILY SESSIONS

42. Psychoeducation • Begins during first session and continues throughout treatment • Provide information about the specific trauma, common psychosocial reactions to trauma, etc. • Review benefits of early, effective tx • Explain treatment plan and theoretical rationale for skills, exposure and processing

43. Parenting Skills • TF-CBT views parents as central therapeutic agent for change • Establish parent as the person the child turns to for help in times of trouble • Explain the rationale for parent inclusion in treatment • Not because parent is part of the problem but because parent can be the child’s strongest source of healing • Emphasize positive parenting skills, enhance enjoyable child-parent interactions, maximize perception/reality effective parenting

44. Parenting Skills (Praise) • Focus on actively praising the child • Praise a specific behavior • Provide praise ASAP after behavior occurs • Be consistent • Do not qualify your praise • Provide praise with same level of intensity as criticism • “Catch your child being good!”

45. Parenting Skills (Selective Attention) • No reaction to certain negative behaviors • Defiant or angry verbalizations to parent • Nasty faces, rolling eyes, smirking • Mocking, mimicking • Walk away, busy oneself with an activity • Remain calm, dispassionate • Expect a reactions of more provocative behavior • Praise “the opposite”- wanted behavior

46. Parenting Skills (Time Out) • Purpose: Interrupt child’s negative behaviors and allow him/her to regain control • Explain to child • Location: quiet, least stimulating • Once in time out, parent should refrain from comments, and maintain calm demeanor. • Be consistent!

47. Parenting Skills • Time out: Interrupt child’s negative behaviors and allow him/her to regain control • Contingency reinforcement programs: Decrease unwanted behaviors and increase desired behaviors • Other behavior management issues as needed

48. Relaxation/Affective Modulation Feeling Identification • Accurately identify and express a range of different feelings • Board games • Feeling brainstorm • Color My Life or person • Physiological responses to different feelings (spaghetti, robot/ragdoll, etc.) • Can ask directly about feelings experienced during traumatic event. • End on a positive note

49. Relaxation/Affective Modulation • Reduce physiologic manifestations of stress and PTSD • Explain body responses to stress • Shallow breath, muscle tension, headaches • Focused breathing/mindfulness/meditation • Bubble breaths, diaphramatic breathing • Progressive Muscle Relaxation • Physical Activity • Positive Visual Imagery • Anything that helps relax (e.g., art, reading, etc.)

50. Relaxation/Affective Modulation Thought Interruption and Positive Imagery • Use when overwhelmed with trauma reminders • Temporary measure early in treatment • Teaches child control over their thoughts • “Changing the channel” • Saying “go away” or “snap out of it” • Imagining a stop sign • Replace unwanted thought with a positive one