Understanding and Treating Children with Complex Traumatic Stress: A Brief Overview of CCTC’s Treatment Approach Kristen A. Caprara, Psy.D. Director of Trauma Services, Montgomery County and Sean Halloran, Ph.D. Division Director, Montgomery County Services

Trauma Assistance Program/Sexual Trauma Treatment Program General Information About the Children We Treat: Ages 18 months through 18 years, and their caregivers Experienced a recent traumatic event Currently reside in a safe environment Resident of Montgomery or Philadelphia County Most of the Children We Serve: Are covered by Magellan or Community Behavioral Health (CBH) Are from low-income, multi-problem families with multiple system involvement Have a history of multiple traumas

Types of Traumas that Bring Clients into Treatment Physical Abuse Sexual Abuse Domestic Violence Suicide School/Community Violence (e.g., drive-by shootings) Medical Trauma Homicide House Fires Accidents (e.g., car accidents, being hit by a motor vehicle) Home invasions Kidnapping

Trauma Screening Starts with the initial phone call to ensure that the child is appropriate for TSP Referral resource completes an Application for Services that asks about the current trauma and history of past traumas The child is assigned to a trauma clinician that will complete a comprehensive intake evaluation and also provide the subsequent treatment

Trauma-Focused Intake Assessment Comprehensive Clinical Interview Detailed review of attachment and history of moves/placements Comprehensive assessment of multiple traumas faced by families Systems involvement Familial medical and mental health history Assessment Measures Child Behavior Checklist for Children (CBCL) Ages 1.5-5 or 6-18 Teacher Report Form Trauma Symptoms Checklist for Young Children (TSCYC) (ages 3 – 7) Trauma Symptoms Checklist for Children (TSCC) (ages 8 – 16) Child and Adolescent Needs and Strengths (CANS) Assessment CCTC Medical Developmental History Form Behavioral Observations of the child and family Collateral contacts with other service providers A review of prior medical records/evaluations

Trauma Focused Intake Assessment Treatment Diagnosis Comprehensive and Individually Tailored Treatment Plan Overview of current and past trauma Set of 3 overarching goals that encompass Attachment and relationship building Symptom Reduction and Stabilization Active Parent Involvement and Consistent Participation Goals are individually tailored and based on the needs of the child Goals are reviewed every 15 sessions or 120 days The parent and child are an important part of the treatment team, their feedback and voices are important and should be implemented Detailed and thorough Trauma-Focused Intake Evaluation

Trauma-Focused Treatment Child Parent Psychotherapy (CPP) Core Components/Common Factors Approach

Why look at common factors and core components? Complex trauma histories for both children and their families Experience ongoing traumas/stressors that occur over the course of treatment that make it challenging to follow a linear course of treatment, or provide the treatment with fidelity Multiple systems involvement A longer term treatment approach is needed Trust issues impact the course of treatment The effects of multi-generational trauma Age/developmental issues should be considered

Commonalities between CPP and the Core Components/Common Factors Approach: Respect and focus on attachment and the therapeutic relationship Incorporates trauma-focused “Best Practices”/evidence based interventions Developmentally aware and adaptable Sensitive to culture and gender Systems-oriented Goals are attained through multiple modalities (e.g., direct discussion, play, therapeutic games and activities, art, etc.) Flexible/room for clinical judgment (e.g., the number of sessions for each phase, flow, techniques employed) Adjunctive services available if needed (e.g., psychiatry/psychotropic medication, preschool partial hospitalization program, wraparound services, summer therapeutic enrichment program)

Differences CPP is a specialized treatment used with clients 0 – age 5 Relationship-based intervention focused on attachment and re-building the parent-child relationship post-trauma The child and caregiver are considered the client, all sessions are completed with the dyad Emphasis on teaching skills to both parents and young children Play is the main modality of treatment Core Components/Common Factors Approach is used with clients ages 6 – 18 Focus on some individual work with clients, as well as with family Multiple modalities are used (e.g., direct discussion, relaxation and mindfulness, therapeutic games and activities, art, and play) Emphasis on teaching skills to the child, with the support of their family and in collaboration with other services (e.g., school)

Child Parent Psychotherapy Core Components Self-Reflection Integrate a sociocultural lens Observe Behavior and enter through multiple ports of entry Act as a conduit Familiarity with Relevant Bodies of Knowledge (developmental psychopathology and diagnostic frameworks; infant an early child development; and adult development) Coordinate Care & Collaborate with Other Service Providers Co-Construct a Trauma Framework and Narrative

Core Components/Common Factors Approach Attachment and Therapeutic Relationship Building Psychoeducation Feelings Identification and Expression Affect Regulation Coping Skills/Safety/Self-Protection Skills Relaxation Skills Trauma Processing (e.g., play, trauma workbooks, trauma narratives, etc.) Integration of Trauma and Moving Forward (e.g., meaning making of a traumatic experience, helping families integrate the trauma they have experienced in their lives and move forward in a positive way, and helping families create a new “normal”)

Resources Leiberman, A.F., Ghosh Ippen, C., & Van Horn, P. (2015) Don’t Hit My Mommy: A Manual for Child-Parent Psychotherapy with Young Children Exposed to Violence and Other Trauma. Washington, DC: Zero to Three. The National Child Traumatic Stress Network, www.nctsn.org The Sanctuary Model by Dr. Sandra Bloom, www.sanctuaryweb.com Adverse Childhood Experiences Study, www.acestudy.org