Presentation on theme: "Treatment of Trauma in the Schools"— Presentation transcript:
1Treatment of Trauma in the Schools Ally Burr-Harris, Ph.D.Center for Trauma RecoveryChild Traumatic Stress ProgramUniversity of Missouri – St. LouisRevised 11/8/04
2Greater St. Louis Child Traumatic Stress Program Free trauma-related assessment and treatment of childrenCognitive-behavioral, family systems treatment orientationConsultation/training for professionalsSchool-based group therapy for children/adolescents exposed to violenceNational Child Traumatic Stress Network (NCTSN)Other common disorders treated at clinic: depression, ODD/CD, “anger problems,” attachment disorder, and to lesser extent other anxiety disorder.May also offer DV group for kids/adolescents at clinic if enough interest
3Types of Traumas Natural disasters Kidnapping School violence Community violenceTerrorism/warHomicidePhysical abuseSexual abuseDomestic violenceMedical proceduresVictim of crimeAccidentsSuicideExtreme neglect or deprivation
4Protective Factors for Post-Trauma Adjustment Strong academic and social skillsActive coping, self-confidenceSocial supportFamily cohesion, adaptability, hardinessHigh neighborhood/school qualityStrong religious beliefs, cultural identityEffective coping and support by parents
5Risk Factors for Post-Trauma Adjustment Problems Severity of traumaExtent of exposureHistory of other multiple stressorsProximity of traumaPreexisting psychopathologyInterpersonal violencePersonal significance of traumaSeparation from caregiverExtent of disruption in support systemsLack of material/social resourcesParent psychopathology; parent distressGenetic predispositionChronic, ongoing traumatic events with long-term disruptions in the social environment cause more psychopathology (e.g., removal from home b/c of abuse).\The single best predictor of positive outcome for children surviving a traumatic event is effective trauma-related coping by parents.
6Trauma Symptoms in Preschool Children Regressive behaviorsSeparation fearsEating and sleeping disturbancesPhysical aches and painsCrying/irritabilityAppearing “frozen” or moving aimlesslyPerseverative, ritualistic playReenactment of trauma themesFearful avoidance and phobic reactionsMagical thinking related to traumaYC: fears/avoidance/preoccupations may or may not have obvious link to traumaRegression examples: toileting accidents, refusal to sleep alone, thumbsucking, clinging, babytalking
7Trauma Symptoms in School-Age Children Sadness, crying irritability, aggressionNightmaresTrauma themes in play/art/conversationSchool avoidance, failurePhysical complaintsConcentration problemsRegressive behaviorEating/sleeping changesAttention-seeking behaviorWithdrawal
8Trauma Symptoms in Adolescents Similar to adult response to traumaFeelings of shame/guiltIncreased risk-taking behaviorsWithdrawal from peers/familyPseudomature behaviorsSubstance abuseDelinquent behaviorsChange in school performanceSelf-destructive behaviors
9School Assessment of Trauma Symptoms UCLA PTSD Index -Revised (Steinberg, Pynoos, Rodriguez, 2002) - screens for trauma exposure and trauma symptomsYouth (school-age) version, parent versionTrauma Symptom Checklist for Children (TSCC, TSC/YC; Briere, 1995) - assesses for PTSD and other trauma symptoms such as depression, anger problems, etc.CBCL would also assess broad range psychological problems that can co-occur with trauma.Clinical interview that includes trauma history and developmental history.
11CBT Treatment Objectives Break associations between negative feelings and trauma cuesIncrease tolerance of trauma thoughts and memoriesDecrease reliance on maladaptive copingFacilitate processing of traumaCorrect trauma-related distortionsModel (therapist, parent) effective copingReinforce (therapist, parent) positive coping and respond effectively to behavior problems
12Appropriate Clients Functioning at 3 years or higher PTSD symptoms Trauma-related confusion or misconceptionsSubstantiated abuse/traumaParents (nonoffending) supportive of treatment
13Inappropriate Clients Psychotic symptomsSubstance dependence/abuseSuicidal intent, high self-harm riskQuestionable validity of abuse/traumaExtremely resistant after “best sell”High intensity trauma ongoing
14Outpatient Individual TF-CBT Short-term (Average= 3 assessment sessions plus 12 treatment sessions)Divided individual sessions for child and parent initiallyJoint sessions begin once parent’s symptoms have decreased and coping skills are improved
15School-Based TF-CBT Screen for trauma exposure/symptoms Assess for treatment appropriateness10 to 12 individual sessions with parental involvement strongly encouraged for elementary age10 to 12 week group therapy with option of 2 individual sessions and 2 parent feedback sessions if possible
16Trauma-Focused CBT: Components PsychoeducationEnsuring Environmental SafetyStress Inoculation Training (coping skills)Gradual ExposureAffective and Cognitive ProcessingSafety SkillsParental InvolvementBehavior Management Skills TrainingFamily Sessions
17Psychoeducation Common reactions to trauma (parent, child) PTSD in childrenAccurate trauma-related informationSelf-care after trauma; supporting childPurpose, rationale, estimated length, typical course of treatmentSplinter or wound analogyEnsuring safetyHealthy discipline; Healthy sexualityAppropriate developmental expectations
18Stress Inoculation Training (SIT) Techniques for reducing physiological stress reactions in response to trauma remindersLife Saver vs. Swim Lesson analogyDeep breathing=belly breathing, rises upon inhalation, in through nose, out through mouth, redirect focus to breathing or else have child focus on five counts in, five counts out.Thought-stopping-verbal command, physical cue; thought replacement via mental image (can use multisensory detailed art here) -- replace with perfect momentCognitive coping: learned optimism (Seligman, 1990) or positive self-talk.With parents: you can use paradoxical intention (prescribed worrying followed by thought stopping).Use lifesaver when drowning analogy
19SIT Techniques Deep breathing Mindfulness, visual imagery Belly breathing, pinwheelMindfulness, visual imagery“Safe place”Progressive muscle relaxationTin soldier/Raggedy AnnRaw/Cooked noodleDevelopmentally appropriate scriptOllendick, T. H., & Cerny, J. (1981). Clinical behavior therapy with children. New York: Plenum Press.
20SIT Techniques (cont.) PMR examples Ollendick, T. H., & Cerny (1981). Clinical behavior therapy with children. New York: Plenum Press.Koeppen, A.S. (1974). Relaxation training for children. Elementary School Guidance and Counseling, 9,Forman (1993). Learning to Relax
21SIT Techniques (cont.) Thought-stopping/replacement Stop sign, Change your channelCognitive coping skills (positive focus)Mantra coaching“I’m safe now…I can do this…He’s locked up now…It wasn’t my fault…”
22Gradual Exposure (GE)Purpose is to gradually expose child to thoughts, memories, and other reminders of the trauma until child can tolerate those memories without significant emotional distress and no longer needs to avoid them.Techniques used to disconnect cues of traumatic event from overwhelming negative emotions.Wound-washing analogy; dangers of maintaining avoidance of cues and of cues generalizing can be explained with swimming fear analogy.Phil Saigh - flooding, Esther Deblinger - GERepeated exposure may only be necessary if PTSD case-Predict ransient worsening followed by sx reduction.-Explain to parent that generalization of fear and avoidance behaviors can interfere with development-Can sometimes lead into GE through psychoeducation about type of traumaand through others’ books about similar trauma experiences
23Gradual ExposureHierarchical exposure starting from moderate distress (e.g., facts about trauma) and working toward extreme distress (e.g., worst moment)Modalities: play, art, visualization, narratives, drama, in vivo exposure (for feared but safe situations)Reduce arousal through reprocessing and elaboration across sessionsCan use SIT skills during exposure phase
24Exposure ExamplesWriting anonymous book about trauma; advising others who face similar situationsPlaying out trauma with toys and gradually incorporating positive resolutionDrawing pictures of trauma images and later shredding themGetting rid of upsetting thoughts or images (thought funeral)Writing rap song about impact of traumaSharing trauma narrativeThird person narrative may be safer
25Affective and Cognitive Processing (CP) Feeling Identification and ExpressionFeeling charades; Polaroid feeling chart; Feeling identification raceCognitive TriangleThoughts, Feelings, BehaviorsPractice generating helpful thoughtsTrain gameFeeling exercises: charades, feeling chart with polaroids, feeling raceTFBR Example: Kid bumps into you in the hall and keeps going.
26Affective and Cognitive Processing (cont.) Identify trauma-related inaccurate or unhelpful thoughts using open-ended inquiry, impact statement, narrative, observation, or self-report measuresWhy do you think this happened to you?What caused it?How trusting were you of other people?How about now?Why do bad things happen to good people?What would keep it from happening again?
27Common Trauma-Related Cognitive Distortions Self-blameGuilt, survivor guiltShame/embarrassment b/c of trauma or symptomsHero fantasies related to traumaOvergeneralization of danger/riskMinimization of traumaOmen formationForeshortened futureMagical thinkingRevenge fantasies
28Affective and Cognitive Processing (cont.) Model helpful thoughtsCorrect distortionsYounger children: Insert mantrasColoring book exampleNarrative: “It’s not your fault”Older children: Help to reprocess
29Methods for Challenging Distortions Identify feelings, behaviors, outcomes related to negative thought and generate more helpful thought insteadOne-down Columbo style approachMirror distortions in the extreme and push child to amend distortionProgressive logical questioningCartoon bubblesRole plays, talk shows, peer counselingBooks/narrativesOne-down columbo style when trying to get them to buy into concept
30Safety Skills Recognize dangerous situations Good touch/bad touch (SA cases)Problem-solving skillsSupport-seeking skillsCalming skills if risk of self-injuryPresent carefully so as not to blameDevelop safety planUse tornado drill analogy to reduce chances of self-blame.
31Parental Involvement in Individual Treatment Assessment feedbackPsychoeducationParallel work in areas of SIT, GE, and CPParenting Skills Building, Behavior Mgmt.Joint parent-child sessionsContinuation of GE and CP jointlyParent models positive coping with traumaParent assumes role of therapist as child’s supporter related to traumaIncluding parent in treatment produces significantly more improvement in externalizing and depressive symptoms of child even if child is not in treatment. Also leads to parents improved ability to support child around trauma (Deblinger, 1996)Parenting skills:appropriate developmental expectations; Praise; active ignoring, correct use of time out, communication/negotiation/problem-solving; contingency reinforcement schedules (I.e., behavior charts), predicting and planning ahead for problems, setting up rules/privileges/consequences with teens. Nurturing/supporting children at different stages.
32Helping Parents of Traumatized Children Communicate with parents frequently about childEncourage parents to listen to child closelyEncourage parents to set aside special time for childRecommend maintenance of normal routineEncourage parents to remain calm and to get help for themselves if neededNormalize child’s emotional/behavioral difficulties after traumaModel soothing behaviors with childAssist in developing plan for behavior management
33Guidelines for Parents Comforting Traumatized Childrenreinforce ideas of safety and securityallow child to be more dependent temporarily if neededfollow child’s lead (hugs, listening, supporting)use typical soothing behaviorsuse security items and goodbye rituals to ease separation with younger childrendistract with pleasurable, normally occurring activitieslet child know you care
34Guidelines for Parents Discussing Trauma with ChildEncourage child to express feelings about trauma but don’t pressureRemain calm when answering questions and use simple, direct termsDon’t soften information for childHelp child develop realistic understanding of what happenedGently correct trauma-related distortionsBe willing to repeat yourselfNormalize “bad” feelings
35Guidelines for Parents Controlling Child’s EnvironmentMaintain normal routinesAvoid exposing child to further trauma or to unnecessary trauma reminders (e.g., media)Minimize contact with others who upset childGuide others in supporting child
36Guidelines for Parents Listening skillsChildren need to have their feelings accepted and respectedListen quietly and attentivelyAcknowledge their feelings with a word or twoGive their feelings a nameGive them their wishes in fantasyShow empathyHow to Talk So Kids Will Listenand Listen So Kids Will TalkBy Adele and Faber
37Guidelines for Parents Listening No-No’sDenial of feelingsPhilosophical responseAdviceToo many questionsDefense of the other personPityAmateur psychoanalysisHow to Talk So Kids Will Listenand Listen So Kids Will TalkBy Adele and Faber
38Behavior Management Caregiver interventions Anger control skills with childSkills training (problem-solving, social skills, communication)Specific behavior plans (sleep problems, sexual behavior problems)Intervene in relevant systems
39Caregiver Interventions for Behavior Management Create predictability for childMake expectations clearReasonable developmental expectationsDon’t personalize child’s behaviorAvoid power struggles“Emotionally unplug” when disciplining; “Emotionally plug in” when rewarding123 Magic
40Caregiver Interventions for Behavior Management Identify triggers that upset child and plan aheadExpect angry outburstsAddress aggressive/self-destructive behaviors quickly and firmlyModel self-controlBe patient and calm
41Caregiver Interventions for Behavior Management Consistent limit-settingPredict increase in negative behaviorReward positive behaviorPRIDE skills (from PCIT)Naturally occurring reinforcersJump start material reinforcers when necessaryIgnore negative behaviorGive effective instructionsTime-out, removal of privilegesTraffic ticket analogy - consistent limit-settingBroken soda machine analogy - predict increase in negative behavior
42Anger Control SkillsIdentify triggers or high-risk situations and plan aheadRed button exerciseIncrease awareness of physiological and cognitive componentsTeach/rehearse management strategiesCounting, breathingRelaxation (turtle technique)Leave situation, SCARExerciseThought-stopping; replace with mantra
43Problem-Solving Skills Name problemPractice perspective-takingGenerate total possible solutions (w/out evaluation)Evaluate and discard non-feasible solutionsChoose solution (within child’s control)Try it outCheck back and reevaluate
44Managing Sexual Behavior Problems Help parents communicate openly and clearly about appropriate/inappropriate sexual behaviorExamine behavioral patterns and identify motivators/positive reinforcers of behaviorAlter parental responses by establishing negative consequence for behaviorIdentify and shape positive replacement behaviors so child can achieve desired consequence appropriatelyMotives: sexual arousal, social acceptance, curiosity, reenactment of trauma b/c of confusion
45Managing Sleep Problems Establish consistent bedtime routines and schedulesGradually transition child back to own bed and fade out “check-ins;” fade out rewards for successful nights.Relaxation tape or exercisesRestructuring nightmares to bring resolutionVisual imagery of peaceful place
46Traumatic Bereavement PTSD in the case of traumatic loss often impedes the grieving process. The person focuses on the traumatic death rather than the loss.After exposure, additional treatment components include recognition/acceptance of the loss, positive reminiscing, coping with future loss reminders, and addressing conflicting thoughts about the deceased.Take into account spiritual/cultural framework when making sense of loss.
47Group CBT of PTSD in Children and Adolescents Same components as Individual CBTMembers need to have similar level/type of trauma exposureProvides opportunity for social skills-building, peer feedback, and stigma reductionAdvantageous if large-scale trauma or school setting with high violence rateSchool-wide trauma exposure/symptom screening yields best referralsModules include traumatic bereavement
48School TF-CBT group outline How violence affects youthsSelf assessment of symptomsPsychoeducationRecognizing/managing feelingsPositive coping strategies (SIT)Coping with trauma cuesChallenging hurtful thoughtsHow the violence affected me - GEIndividual session, group sessionsChallenging stuckpoints - CPTraumatic bereavement, positive reminiscing
49School TF-CBT Group Outline Continued Changing problem behaviorsSupport-seekingAnger management, emotional controlCommunication skills, problem-solvingBuilding healthy relationshipsFeeling good about myselfPositive self-esteemGoal-settingGroup closure
50Empirical Support for PTSD Treatment in children TF-CBT (individual, group) - 13 randomized trials, mostly with SA samples - treatment effects for PTSD, depression, behavior problems, social competence, parental distress, and parental supportSchool-based TF-CBT (treatment effects for GPA, PTSD, school attendance and behavior)CBT > Nondirective Supportive TherapyParent involvement in CBT improved child’s symptoms, even when child not involved in txSIT, EMDRPCIT, MST
51TF-CBT ReferencesDeblinger, E., Heflin, A. H. (1996). Treating Sexually Abused Children and Their Nonoffending Parents: A Cognitive Behavioral Approach. Sage Publications, Inc. Thousand Oaks, CA.Cohen, J. A., Mannarino, A. P., Deblinger, E. (2001). Child and Parent Trauma-Focused Cognitive Behavioral Therapy: Treatment Manual. Allegheny General Hospital, Center for Traumatic Stress in Children and Adolescents.Also have Cohen and Mannarino manual which can be utilized for elem. School-age TFCBT groups.
52School-Based TF-CBT References Burr-Harris, A. (Sept, 2004). School-Based Trauma-Focused Cognitive-Behavioral Group Therapy Manual (7th -12th grades). Greater St. Louis Child Traumatic Stress Program, University of Missouri-St. LouisLayne, C. M., Saltzman, W. R., Pynoos, R. S. (2002). Trauma/Grief-Focused Group Psychotherapy Program. UCLA Trauma Psychiatry Service.Jaycox, L. (2004). Cognitive Behavioral Intervention for Trauma in Schools. Longmont, Co: Sopris West Educ. Services. (ages 11-15).