Assessment and Treatment of Trauma in Children and Young People Robyn Lamb March 09

Domains of Impairment in Children exposed to Complex Trauma Attachment Attachment Biology Biology Affect Regulation Affect Regulation Dissociation Dissociation Behavioural control Behavioural control Cognition Cognition Self concept Self concept

Initial contact Child Sexual Assault Service Psychosocial Assessment Psychosocial Assessment Medical Assessment general / forensic Medical Assessment general / forensic What does the child/family need? What does the child/family need? –Safety? –Stabilization? –Concrete services [referrals, legal information/assistance with reporting, liaison with CPS and other systems] What helps for those needs? What helps for those needs? –Crisis response –Advocacy –Case management –Psychoeducation

Hierarchy of needs Safety and basic physical and wellbeing MASLOW’S HIERARCHY Diagram of Maslow's hierarchy of needs. 1. Physiological (Biological needs) 2. Safety 3. Love/Belonging 4. Status (Esteem) 5. Actualization

Assess before treating so that intervention can be matched to need Multidimensional approach Areas of competence and vulnerability are assessed in overlapping biological, emotional, social and cognitive domains Areas of competence and vulnerability are assessed in overlapping biological, emotional, social and cognitive domains Individual functioning is considered in the context of the child’s relationships and the family’s ecological niche Individual functioning is considered in the context of the child’s relationships and the family’s ecological niche

Assessment-Based Treatment for Traumatized Children: Using the Trauma Assessment Pathway Model (TAP) Assessment-Based Treatment for Traumatized Children: Using the Trauma Assessment Pathway Model (TAP) Al Killen Harvey Rady Childrens Hospital Chadwick Center Programs San Diego Trauma Counseling Forensic and Medical Services Family Support Professional Education Research Linkage Child & Adolescent Services Research Center (funded by the NIMH) It is with the generous permission of Al Killen Harvey, Chadwick Centre that *Slides have been reproduced in this presentation

*TAP Model Overview A treatment manual for traumatized children ages 2 to 18 years A treatment manual for traumatized children ages 2 to 18 years Incorporates assessment data, clinical interview, and observation to create a Unique Client Picture Incorporates assessment data, clinical interview, and observation to create a Unique Client Picture Includes specific components of trauma- specific treatment described by the Trauma Wheel Includes specific components of trauma- specific treatment described by the Trauma Wheel Draft completed and undergoing revisions Draft completed and undergoing revisions

*What Is Assessment Based Treatment (ABT)? Development of clinical assessment-based treatment refers to the “development of an integrated plan of prioritized interventions, that is based on the diagnosis and psychosocial assessment of the client, to address mental, emotional, behavioral, developmental and addictive disorders, impairments and disabilities, reactions to illnesses, injuries, and social problems.” (Social work, consolidated laws, effective Sept. 1, 2004)

*Clinical Pathways A sequence or path that clinicians follow in making assessment, triage, and clinical decisions. A sequence or path that clinicians follow in making assessment, triage, and clinical decisions. Found increasingly useful within the medical field. Found increasingly useful within the medical field. Evaluation of UCLA’s Asthma Pathway showed substantial cost effectiveness and adherence to medical standards (Chest, 1998) Evaluation of UCLA’s Asthma Pathway showed substantial cost effectiveness and adherence to medical standards (Chest, 1998) Rady Children’s Hospital developed over 40 pathways, starting with Asthma in 1994, domestic violence in 2001, and TAP in Rady Children’s Hospital developed over 40 pathways, starting with Asthma in 1994, domestic violence in 2001, and TAP in TAP includes a pathway that directs triage, assessment, referrals, and clinical interventions. TAP includes a pathway that directs triage, assessment, referrals, and clinical interventions.

The therapeutic goal is to resolve the impact of a single or series of traumatic experiences to the child and their family. The therapeutic goal is to resolve the impact of a single or series of traumatic experiences to the child and their family. Therapeutic decisions emerge from clinical and standardized assessment. Therapeutic decisions emerge from clinical and standardized assessment. *Chadwick’s Philosophy of Trauma Treatment

*3 Components of TAP 1. Assessment Creating a Unique Client Picture 2. Triage 3. Treatment

*Unique Client Picture Clinical Interviews Clinical Interviews Behavioral Observation Behavioral Observation Standardized Measures Standardized Measures

*Standardize your Assessment Choices What measures exist to help you know your client? DomainInformants ChildCaretakerClinician Trauma HistoryUCLA PTSD IndexCaretaker Trauma- TSI Clinical Interview Symptom PresentationTrauma Symptoms TSCC, UCLA PTSD Index Other Symptoms: YSR, CDI, BAIC Trauma Symptoms CSBI, CDC, UCLA PTSD Index Other Symptoms: CBCL Clinical Interview/Observation * Teacher can complete TRF Relevant Contextual History Family Dynamics FAM-III, FRI, FACES Peers YSR Family Dynamics FAM-III, FRI Parenting: PSI Peers CBCL Clinical Interview/Observation Developmental HistoryClinical Interview IQ: WISC,KBIT, Stanford Binet Clinical Interview ITSEA, BITSEA, ASQ Clinical Interview/ Observation Denver, Bayleys

*Assessment Pathway Process 1. Core measures administered 2. Problem areas identified 3. Other measures are administered to probe more deeply

*Guiding Therapists via Assessment Pathways integrated into assessment measures

*Treatment Triage What are the treatments that you have available at your site? What are the treatments that you have available at your site? What treatments are you as a therapist able to provide? What treatments are you as a therapist able to provide? Funding? Funding? Client Issues? Client Issues? …Reality!!!!! …Reality!!!!!

*How to make sense of assessment results (cont.): Involve the parents and children in your interpretive process Involve the parents and children in your interpretive process Integrate results with clinical impressions & think about how the results can be used to plan treatment Integrate results with clinical impressions & think about how the results can be used to plan treatment Don’t discount your clinical judgment!! Don’t discount your clinical judgment!!

* Problem Solving: What Happens When the Measures & Clinician Don’t Agree?

*How do you discuss feedback with your clients?

Critical Items

*How to form your clinical hypothesis Consider all assessment feedback Consider all assessment feedback Which family members need to be included in treatment? What are the dynamics in the family? Which family members need to be included in treatment? What are the dynamics in the family? Family and client buy in Family and client buy in Consider the cause of distress Consider the cause of distress

*Treatment Triage Select the treatment modality that is best for your client based upon the unique client picture and the evidence-based practices available: Select the treatment modality that is best for your client based upon the unique client picture and the evidence-based practices available: –Trauma-Focused CBT –TAP Model –PCIT –Abuse-Focused CBT –Lieberman et al.’s Models for young children –UCLA Trauma/Grief Focused Group Model

*Treatment through the TAP Model Using the Trauma Wheel & the Clinical Pathway

Characteristics of Treatments with good evidentiary support Tend to be behavioral or cognitive-behavioral (eg TFCBT); or use tailored responses (Ref Eliana Gil) Tend to be behavioral or cognitive-behavioral (eg TFCBT); or use tailored responses (Ref Eliana Gil) Use specific procedures, not much “free-styling” Use specific procedures, not much “free-styling” Goal directed Goal directed Skill-building oriented Skill-building oriented Use of practice and feedback methods Use of practice and feedback methods Role play Role play Homework Homework

Trauma Integration Systemic Dynamics Skill Building & Psychoeducation Addressing Maladaptive Cognitions Affect Regulation Relationship Building Culture Child Development *The Trauma Wheel

Multiple modalities for treatment Play, Art, Craft, Sand tray Psychotherapy Expressive therapy

*Affect Regulation: Assumptions Expressing feelings and emotions is important. Expressing feelings and emotions is important. Symptoms are associated with underlying feelings and impacts behavior and social relationships. Symptoms are associated with underlying feelings and impacts behavior and social relationships. There is a need to validate, understand, and experience feelings before resolution of those feelings can occur. There is a need to validate, understand, and experience feelings before resolution of those feelings can occur.

*Affect Regulation: Tasks Feeling identification and labeling Feeling identification and labeling Express feelings congruent with feelings you are identifying Express feelings congruent with feelings you are identifying Experience and communicate feelings Experience and communicate feelings Appropriately manage range of emotions Appropriately manage range of emotions Develop positive self-feelings Develop positive self-feelings Resolution of troubling emotions Resolution of troubling emotions

Feelings

*Skill Building and Psychoeducation: Assumptions The child and family lack the skills to effectively cope with trauma reactions of the child The child and family lack the skills to effectively cope with trauma reactions of the child An increase in information and skills will increase knowledge and adaptive functioning. An increase in information and skills will increase knowledge and adaptive functioning. Increase in knowledge will decrease uncertainty and increase normalization. Increase in knowledge will decrease uncertainty and increase normalization.

*Skill Building and Psychoeducation: Tasks Behavior management techniques Behavior management techniques Enhancement of positive behaviors/social skills Enhancement of positive behaviors/social skills Relaxation techniques Relaxation techniques Psychoeducation Psychoeducation – Dynamics of abuse –Healthy relationships –Age-appropriate development Communication and problem-solving Communication and problem-solving Development of safety plans Development of safety plans