The Child and Family Traumatic Stress Intervention: Implementing an Evidence-Based Early/Acute Intervention in Child Advocacy Centers

PRESENTERS Steven Marans, MSW, Ph.D. ‒ Harris Professor of Child Psychiatry and Professor of Psychiatry ‒ Director, Childhood Violent Trauma Center, Yale Child Study Center ‒ Yale University School of Medicine Carrie Epstein, LCSW-R ‒ Assistant Professor ‒ Director of Clinical Services and Training, Childhood Violent Trauma Center, Yale Child Study Center ‒ Yale University School of Medicine ‒ Consultant, Safe Horizon, Inc. Nancy Arnow, LMSW ‒ Vice President ‒ Child Advocacy Centers and Mental Health Treatment Programs ‒ Safe Horizon, Inc.

CFTSI: What Is It? Brief (4-8 session) evidence-based early intervention model for children following a range of potentially traumatic events (PTE) – –After exposure – –After disclosure of earlier sexual or physical abuse Children aged 7-18 years old

Goals of CFTSI CFTSI aims to: Reduce traumatic stress symptoms and prevent chronic PTSD Improve screening and initial assessment of children impacted by traumatic stress Assess child’s need for longer-term treatment

Mechanisms of CFTSI CFTSI works by: Increasing communication between caregiver and child about child’s traumatic stress reactions Providing skills to family to help cope with traumatic stress reactions Assessing concrete external stressors (e.g. housing issues, systems negotiation, safety planning, etc.)

CFTSI: Filling a Gap in Available Interventions CFTSI: Fills a gap between acute responses/crisis intervention and evidence-based, longer-term treatments designed to address traumatic stress symptoms and disorders that have become established

Capitalizing on Protective Factors Family and social support are best predictors for good post-trauma outcomes –Primary caregiver/s are central to CFTSI Improves support through improving communication: –Helps child communicate about reactions and feelings more effectively –Increases caregiver’s awareness and understanding of child’s experience CFTSI provides skills to help children and families cope with and master trauma reactions

Recovery through Regaining a Sense of Control CFTSI: Replaces chaotic post-traumatic experience with: –Structure –Words –Opportunity to be heard by caregiver Uses standardized assessment instruments to: –Structure discussion about symptoms –Increase symptom recognition and communication about them Provides skills and behavioral interventions Increases control through symptom reduction

The CFTSI Model

CFTSI: What and How? Session 1 – Meeting with Caregiver Provide psychoeducation about trauma and trauma symptoms Assess caregiver’s and child’s trauma symptoms Address case management and care coordination issues Session 2, Part A: Meeting with Child Provide psychoeducation about trauma and trauma symptoms Assess child’s symptoms Session 2, Part B: Family Meeting - Key part of intervention Begin discussion by comparing caregiver and child’s reports about trauma symptoms Identify the specific trauma reactions to be the focus of behavioral interventions and introduce coping skills

CFTSI: What and How? Session 3: Family Meeting Praise and support communication attempts Re-administer measures to assess levels of distress and increased awareness Practice coping skills(s), support efforts Session 4: Family Meeting/Case Disposition Follow same format as Session 3 Review progress made and identify any additional case management or treatment needs Possible Additional Sessions May require 1 or 2 additional individual sessions with caregiver(s) or child due to a range of issues

CFTSI: An Evidence-based Model Listed in: NCTSN list of evidence-based treatments California Evidence-based Clearinghouse for Child Welfare NREPP (National Registry of Evidence-based Programs and Practices (soon)

Randomized Control Trial: Results CFTSI versus 4-session psychoeducation/supportive comparison intervention Sample size = 112 Participants recruited from: –Forensic Sexual Abuse Program –Pediatric Emergency Department –New Haven Department of Police Service Funded by SAMHSA

Sample Demographics (Sample Size = 106) Intervention  N=53 24 Boys 24 Boys 29 Girls 29 Girls Mean Age=12; SD=2.8 Mean Age=12; SD=2.8 Mean # Traumas=6.1; SD=2.7 Mean # Traumas=6.1; SD=2.7 Comparison  N=53 21Boys 32 Girls Mean Age=12; SD=2.7 Mean # Traumas=6.6; SD=2.4

Nature of Trauma

Children Who Received CFTSI Were 73% Less Likely to Meet Partial or Full Criteria for PTSD * *p<.05

Adapting CFTSI for Child Advocacy Centers (CACs) Implementation of CFTSI with sexually and physically abused children seen in CACs Initial collaboration with Safe Horizon in New York City Further dissemination to additional CACs nationally

Overview of Safe Horizon Safe Horizon is the nation’s leading victim assistance organization, moving thousands of victims of violence and abuse from crisis to confidence each year Our mission is to provide support, prevent violence, and promote justice for victims of crime and abuse, their families and communities We have 35 years of experience in expert service delivery

Safe Horizon’s Child Advocacy Centers Safe Horizon is the only organization in the country to operate four and soon to be five fully co-located, nationally accredited CACs in an urban setting Each year, our CACs investigate and respond to over 4,000 cases of sexual abuse and/or severe physical abuse

Where We Were: Environmental Factors: – –148% increase in CAC volume following a tragic, highly publicized child fatality – –Flat and diminishing CAC funding Organizational Factors: – –Strategic Plan: Move to standardize service delivery and implement evidence-based practices whenever possible – –CAC Vision: To provide immediate, expert victim advocacy & therapeutic services to every child victim and impacted family walking through the doors of our CACs CAC Practice: – –Eclectic CAC services in response to complex and multiple needs of clients

Safe Horizon-Yale Partnership: National search for a trauma-focused, brief, evidence-based treatment Development of a flow chart illustrating how a potential CFTSI case progresses through a CAC Development of inclusion/exclusion criteria Development of scripts for introducing CFTSI to families Translation of CFTSI into Spanish Creation of audio versions of informational handouts

Where We Are Now: Have successfully adapted and sustained CFTSI at our four CACs for over 5 years Have completed over 730 CFTSI cases – –Children feel better; Caregivers have learned skills to help their children feel better – –Staff feel more effective & reduced burnout – –MDT partners feel more hopeful – –Funders are very interested in reduction of trauma symptoms- importance of data!

Sustaining CFTSI Over Time: Importance of data-evaluation results Strong organizational leadership & agency-wide support Recruitment changes & Ongoing training Expert Monthly Consultation Calls – –Rotating case presentations with all CFTSI providers & leadership – –With Clinical Directors Monthly tracking of key CFTSI metrics

Evaluation of CFTSI in CAC Setting

Evaluation Results Results from 12-month evaluation conducted in Safe Horizon’s Child Advocacy Centers Sample Size = 134 Trauma type: sexual and physical abuse Statistically significant reductions in symptoms (p<.001) Symptom severity goes from clinically significant levels to below clinical levels

Change in PTSD Symptoms Following CFTSI (N=134)

Caregiver Satisfaction Survey Completed with caregivers following final CFTSI session N=63

If you had a friend dealing with a similar situation, would you suggest that s/he try CFTSI?

Did you learn about trauma and how it may affect your child and family?

Did you and your child learn about ways/skills to help your child feel better and make the problems and/or reactions your child was having happen less often?

Future Directions

CFTSI Treatment Applications Current: –CAC setting –Children in foster care In development: –Domestic violence shelter setting –Young children (aged 3-6 years) –Physically injured children –Military families

CFTSI: Dissemination and Spread National trainings Learning collaboratives Train-the-Trainer program

Implementation of CFTSI in a CAC Setting: A Brief Case Presentation