Transcript Treatment of Trauma in Children and Young People Lightning

Assessment and Treatment of
Trauma in Children and Young
People
Robyn Lamb
March 09
Domains of Impairment in Children
exposed to Complex Trauma
• Attachment
• Biology
• Affect Regulation
• Dissociation
• Behavioural control
• Cognition
• Self concept
Initial contact
Child Sexual Assault Service
• Psychosocial Assessment
• Medical Assessment general / forensic
• 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?
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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
• 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)
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
• Incorporates assessment data, clinical
interview, and observation to create a
Unique Client Picture
• Includes specific components of traumaspecific treatment described by the
Trauma Wheel
• 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
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assessment, triage, and clinical decisions.
Found increasingly useful within the medical field.
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 2005.
TAP includes a pathway that directs triage,
assessment, referrals, and clinical interventions.
*Chadwick’s Philosophy of
Trauma Treatment
• 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.
*3 Components of TAP
1. Assessment
Creating a Unique Client Picture
2. Triage
3. Treatment
*Unique Client Picture
• Clinical Interviews
• Behavioral Observation
• Standardized Measures
*Standardize your Assessment Choices
What measures exist to help you know your client?
Domain
Informants
Child
Caretaker
Clinician
Trauma History
UCLA PTSD Index
Caretaker TraumaTSI
Clinical Interview
Symptom Presentation
Trauma Symptoms
TSCC, UCLA PTSD
Index
Trauma Symptoms
CSBI, CDC, UCLA
PTSD Index
Other Symptoms:
CBCL
Clinical
Interview/Observation
Other Symptoms:
YSR, CDI, BAIC
* 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 History
Clinical 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 treatments are you as a therapist
able to provide?
• Funding?
• Client Issues?
…Reality!!!!!
*How to make sense of
assessment results (cont.):
• 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
• 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
• Which family members need to be
included in treatment? What are
the dynamics in the family?
• Family and client buy in
• 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:
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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)
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Use specific procedures, not much “free-styling”
Goal directed
Skill-building oriented
Use of practice and feedback methods
 Role play
 Homework
*The Trauma Wheel
Relationship Building
Addressing
Maladaptive
Cognitions
Skill Building
&
Psychoeducation
Affect
Regulation
Child
Development
Trauma
Integration
Culture
Systemic
Dynamics
Multiple modalities for treatment
• Play, Art, Craft, Sand tray
• Psychotherapy
• Expressive therapy
*Affect Regulation: Assumptions
• Expressing feelings and emotions is
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important.
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.
Relationship Building
Cognitive
Attributions &
Distortions
Emotional
Processing
Systemic
Integration
Psychoeducation
& Skill Building
Trauma
Processing
*Affect Regulation: Tasks
• Feeling identification and labeling
• Express feelings congruent with
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feelings you are identifying
Experience and communicate
feelings
Appropriately manage range of
emotions
Develop positive self-feelings
Resolution of troubling emotions
Relationship Building
Cognitive
Attributions &
Distortions
Emotional
Processing
Systemic
Integration
Psychoeducation
& Skill Building
Trauma
Processing
Feelings
Feelings
*Skill Building and Psychoeducation:
Assumptions
• The child and family lack the
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skills to effectively cope with
trauma reactions of the child
An increase in information and
skills will increase knowledge and
adaptive functioning.
Increase in knowledge will
decrease uncertainty and
increase normalization.
Relationship Building
Cognitive
Attributions &
Distortions
Emotional
Processing
Systemic
Integration
Psychoeducation
& Skill Building
Trauma
Processing
*Skill Building and Psychoeducation:
Tasks
• Behavior management techniques
• Enhancement of positive
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behaviors/social skills
Relaxation techniques
Psychoeducation
– Dynamics of abuse
– Healthy relationships
– Age-appropriate development
Communication and problem-solving
Development of safety plans
Relationship Building
Cognitive
Attributions &
Distortions
Emotional
Processing
Systemic
Integration
Psychoeducation
& Skill Building
Trauma
Processing