1. Treating Childhood Trauma: An Overview of Trauma-Focused Cognitive Behavioral Therapy Presentation material utilized with permission from Drs. Joy Pemberton & Ben Sigel Sufna John, PhD

2. Objectives Learn how Trauma-Focused Cognitive- Behavioral Therapy (TF-CBT) is being disseminated in Arkansas. Learn to recognize the symptoms of child traumatic stress. Understand how to use TF-CBT in the treatment of trauma-exposed children.

3. Arkansas Building Effective Services for Trauma (AR BEST)

4. IN THE SPRING OF 2009… The Arkansas State Legislature approved funding to improve screening, monitoring and continuity of care for children experiencing physical or sexual abuse in Arkansas to address the psychological impact of their trauma.

5. TF-CBT Training On-line training in TF-CBT (http://tfcbt.musc.edu/) Live, two-day introductory conference in central Arkansas led by Anthony Mannarino, Ph.D. 14 bi-monthly phone consultation calls – Participate in 12 of 14 calls – Provide 2 case presentations with results from standardized trauma symptom measures This is all provided at no cost to Arkansas clinicians! Sigel et al., 2012

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8. The Numbers 1060 providers from all across Arkansas have completed the web-based and two-day training. 366 have completed the ongoing consultation calls. In 2013, 859 children were registered. – The majority are Caucasian females with a history of sexual abuse. – At intake, the majority of children are experiencing serious behavior problems or significant symptoms of Post-Traumatic Stress Disorder (PTSD).

9. Childhood Traumatic Stress

10. Types of Childhood Trauma Child abuse – Physical – Sexual – Emotional Victim/Witness of Violence – Domestic – Community – School Accidents (e.g., motor vehicle) Disasters War/Terrorism and Refugee Medical (e.g., transplant) Traumatic Grief

11. What Is Child Traumatic Stress? Child traumatic stress refers to the physical and emotional responses of a child to events that threaten the life or physical integrity of the child or of someone critically important to the child (such as a parent or sibling). Traumatic events overwhelm a child’s capacity to cope and elicit feelings of terror, powerlessness, and out-of-control physiological arousal.

12. Types of Traumatic Stress Acute trauma is a single traumatic event that is limited in time. Examples include: –Serious accidents –Community violence –Natural disasters (earthquakes, wildfires, floods) –Sudden or violent loss of a loved one; separations from parent/siblings –Physical or sexual assault (e.g., being shot or raped)

13. Chronic trauma refers to the experience of multiple traumatic events. – These may be multiple and varied events—such as a child who is exposed to domestic violence, is involved in a serious car accident, and then becomes a victim of community violence—or longstanding trauma such as physical abuse, neglect, or war. – The effects of chronic trauma are often cumulative, as each event serves to remind the child of prior trauma and reinforce its negative impact. Types of Traumatic Stress

14. Complex trauma describes both exposure to chronic trauma—usually caused by adults entrusted with the child’s care—and the impact of such exposure on the child. – Children who experienced complex trauma have endured multiple interpersonal traumatic events from a very young age. – Complex trauma has profound effects on nearly every aspect of a child’s development and functioning. – Possible lifelong course if no intervention* (BPD vs. Complex trauma) Source: Cook et al. (2005). Psychiatr Ann,35(5):390-398. Types of Traumatic Stress

15. Effects of Trauma Exposure Attachment. Traumatized children feel that the world is uncertain and unpredictable. They can become socially isolated and can have difficulty relating to and empathizing with others. Biology. Traumatized children may experience problems with movement and sensation, including hypersensitivity to physical contact and insensitivity to pain. They may exhibit unexplained physical symptoms and increased medical problems. Mood regulation. Children exposed to trauma can have difficulty regulating their emotions as well as difficulty knowing and describing their feelings and internal states.

16. Effects of Trauma Exposure Behavioral control. Traumatized children can show poor impulse control, self-destructive behavior, and aggression towards others. Cognition. Traumatized children can have problems focusing on and completing tasks, or planning for and anticipating future events. Some exhibit learning difficulties and problems with language development. Self-concept. Traumatized children frequently suffer from disturbed body image, low self-esteem, shame, and guilt.

17. Childhood Trauma and PTSD – Intrusion (e.g. nightmares, intrusive memories, dissociative reactions, distress at exposure to internal/external cues) – Avoidance (thoughts, feelings, places, and people associated with the trauma) – Negative alternations in cognition/mood (e.g. negative beliefs about oneself or the world, negative emotional state, anhedonia, detachment from others) – Alterations in arousal/reactivity (e.g. irritability, self- destructive behavior, hypervigilance, difficulties with concentration, sleep disturbance) Source: American Psychiatric Association. (2013). DSM-V ( 5th ed.). Washington DC: APA.

18. Childhood Trauma and PTSD In children under the age of 6, the key symptoms remain the same, but the total number of symptoms that are necessary within each category vary. DSM-V also provides specific examples of how symptoms may vary in presentation by age. Source: American Psychiatric Association. (2013). DSM-V ( 5th ed.). Washington DC: APA.

19. 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

20. Research On TF-CBT TF-CBT is the most rigorously tested treatment for traumatized children – 13 RCTs 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

21. TF-CBT Appropriate for… Children with known trauma history – Single or multiple, any type Children with prominent trauma symptoms – PTSD, depression, anxiety, with or without behavioral problems Children with severe behavior problems may need additional or alternative interventions Non-offending parental/caretaker involvement is optimal – However, PTSD improves even in the absence of caretaker involvement

22. TF-CBT Appropriate for… Treatment settings: clinic, school, residential, home, inpatient Groups including: – Children in foster care – Children with exposure to chronic trauma – Children with symptoms other than PTSD – Children aged 3 to 17 – Children with PDD who function at higher level – Children of different cultural groups including Latino, African-American, and Native-American

23. 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 (roughly 50% each) 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

24. 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

25. Psychoeducation and Parenting Skills Parenting: Help parents learn skills to manage child behaviors and/or difficult emotions – May continue throughout course of treatment Psychoeducation: Provide information about trauma and common trauma reactions – Begins gradual exposure

26. “PRAC Skills” Relaxation: Explain and teach techniques to physically calm the body Affect Modulation: Help child increase comfort with and ability to manage emotions Cognitive Coping: Educate child about the importance of thoughts and ways to manage inaccurate/unhelpful thoughts (not necessarily related to the trauma) Mastery is not required before moving on Gradual exposure continues

27. Trauma Narrative and Processing Trauma Narrative: Create a narrative about the child’s traumatic experience – Continues naturally from previous gradual exposure – Includes child’s emotional and cognitive responses to event(s) – Therapist shares each draft with parent (if applicable) Cognitive Processing: Help child identify and work to change inaccurate/unhelpful thoughts related to the trauma PRAC Skills used throughout to help child manage responses

28. In Vivo Mastery of Trauma Reminders and Conjoint Child-Parent Sessions In Vivo Mastery of Trauma Reminders: Plan and carry out exposure to avoided situations Conjoint Child-Parent Sessions: Hold joint sessions with child and parent for sharing trauma narrative and/or other purposes – Usually occurs once child has completed narrative – Parent is already “prepped” by therapist to hear narrative from child and respond appropriately

29. Enhancing Future Safety and Development Teach skills that will help child create safe situations and/or manage unsafe situations in the future This component is usually addressed throughout treatment. – Recognizing trauma triggers and managing responses E.g., plan for continuing use of PRAC skills – Recognizing unsafe situations and avoiding/exiting them if possible E.g., “No-Go-Tell”

30. Michael

31. Background 8 years old African American Male Lives with legal guardians and younger brother since the age of 6 months. Guardianship was granted at the age of 3 years. Removed from the home of his biological parents due to parental substance abuse, witnessing domestic violence, and neglect.

32. Traumatic Event Suffered severe burns, requiring skin grafting and compression garments, in a fire in his home Younger sibling escaped unharmed.

33. Presenting Problems Separation anxiety Fear of the dark/refusal to sleep alone School refusal Nightmares Somatic complaints Frequent tantrums Increased sibling conflict Sadness

34. Traditional Order of TF-CBT 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

35. Modified Order of TF-CBT Psychoeducation and Parenting Skills Relaxation In Vivo Mastery of Trauma Reminders Affect Modulation Cognitive Coping Trauma Narrative and Processing Conjoint Child-Parent Sessions Enhancing Future Safety and Development

36. “About Me” I like to play, I like to draw, I like to play football, I like to kick the ball, I like to run the ball, I like animals, I like flowers, I like my brother, I like my mother, I like my daddy, I like my sister, and I love my baby brother. I live in Arkansas with my mom, dad, brother, sister, and baby brother. It feels comfortable in my house because it makes me feel happy. My dad takes care of me, my mom takes care of me...On a scale of 1 to 10, my life was a 10 before the fire, the best.

37. “In The Fire” We were playing with matches. The bed I was sleeping on caught on fire. I hid and [brother] got out of the fire and he did not wait for me. [brother] got out and I didn’t. He could have waited for me. If he waited for me, I would be happy. But he didn’t, I got mad. I wanted to tackle him. I hid and I had no one to get me out. I was with the fire. Under my knee and on my foot I had an owie, and my hands. I was sad. I didn’t see the fire on my body, I just saw owies. It looked like I got burned. It really hurted. I was hiding and I was scared. I couldn’t hear anything, I just heard the fire. I heard like a scary sound. I couldn’t see anything, I was in the dark.

38. “In The Fire” I had two doctors and they were mean. They put stuff in my nose that made me feel mad. They put something on my foot and I didn’t like it. It was bothering me. I don’t know what they did to my owies. Sometimes they had to clean my owies and I didn’t like it. I didn’t like it when they cleaned my owies because they’re mean. It felt cold when they cleaned my owies, I was cold. I was super mad and super unhappy and super mad when they were cleaning it. The doctors were there and my mom was there. My mom stayed with me.

39. Restructuring I hid and [brother] got out of the fire and he did not wait for me. [brother] got out and I didn’t. He could have waited for me. If he waited for me, I would be happy. But he didn’t, I got mad. I wanted to tackle him. I hid and I had no one to get me out. Restructured: [brother] and I were both scared and we didn’t know what to do. [brother] ran away because he was scared. [brother] got out at first and then I got out second with the firefighters.

40. Restructuring I had two doctors and they were mean. I didn’t like it when they cleaned my owies because they’re mean. Restructured: Even though it hurted, the doctors were trying to protect me and gave me medicine. They wanted to make me feel better.

41. “After The Fire” It was scary and I was tough, like a superhero. My life is happy now. When something scary happens to you, you should pray to God and ask Him to help you feel better. You could talk to your friends and their annoying sisters. Tell people when they hurt you and ask them to stop it. The doctor can fix your owies. You could go to counseling so you won’t be scared. Counseling is scary sometimes, but you should go to counseling because then you could get better and not have nightmares. My counselor thinks that I am the best. It makes her feel happy to see me. Sometimes you won’t want to go to counseling, but you should go anyway, because it will make you feel happier. On a scale of 1 to 10, my life is happier than ever, an 11.

42. Michael’s Parent Report

43. Michael’s Self Report

44. Outcome Improved separation anxiety No reported nightmares Improved self-esteem/lower discomfort in social situations Pride regarding his own resilience Improved tearfulness and temper tantrums

46. Resources TF-CBT Training: http://tfcbt.musc.edu/ National Child Traumatic Stress Network: http://www.nctsn.org/ Cohen, J.A., Mannarino, A.P., & Deblinger, E. (2006). Treating Trauma and Traumatic Grief in Children and Adolescents. New York: The Guilford Press. Cohen, J.A., Mannarino, A.P., & Deblinger, E. (2012). Trauma-Focused CBT for Children and Adolescents: Treatment Applications. New York: The Guilford Press. AR BEST Program: http://arbest.uams.edu/