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Treatment of Trauma in the Schools

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1 Treatment of Trauma in the Schools
Ally Burr-Harris, Ph.D. Center for Trauma Recovery Child Traumatic Stress Program University of Missouri – St. Louis Revised 11/8/04

2 Greater St. Louis Child Traumatic Stress Program
Free trauma-related assessment and treatment of children Cognitive-behavioral, family systems treatment orientation Consultation/training for professionals School-based group therapy for children/adolescents exposed to violence National 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

3 Types of Traumas Natural disasters Kidnapping School violence
Community violence Terrorism/war Homicide Physical abuse Sexual abuse Domestic violence Medical procedures Victim of crime Accidents Suicide Extreme neglect or deprivation

4 Protective Factors for Post-Trauma Adjustment
Strong academic and social skills Active coping, self-confidence Social support Family cohesion, adaptability, hardiness High neighborhood/school quality Strong religious beliefs, cultural identity Effective coping and support by parents

5 Risk Factors for Post-Trauma Adjustment Problems
Severity of trauma Extent of exposure History of other multiple stressors Proximity of trauma Preexisting psychopathology Interpersonal violence Personal significance of trauma Separation from caregiver Extent of disruption in support systems Lack of material/social resources Parent psychopathology; parent distress Genetic predisposition Chronic, 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.

6 Trauma Symptoms in Preschool Children
Regressive behaviors Separation fears Eating and sleeping disturbances Physical aches and pains Crying/irritability Appearing “frozen” or moving aimlessly Perseverative, ritualistic play Reenactment of trauma themes Fearful avoidance and phobic reactions Magical thinking related to trauma YC: fears/avoidance/preoccupations may or may not have obvious link to trauma Regression examples: toileting accidents, refusal to sleep alone, thumbsucking, clinging, babytalking

7 Trauma Symptoms in School-Age Children
Sadness, crying irritability, aggression Nightmares Trauma themes in play/art/conversation School avoidance, failure Physical complaints Concentration problems Regressive behavior Eating/sleeping changes Attention-seeking behavior Withdrawal

8 Trauma Symptoms in Adolescents
Similar to adult response to trauma Feelings of shame/guilt Increased risk-taking behaviors Withdrawal from peers/family Pseudomature behaviors Substance abuse Delinquent behaviors Change in school performance Self-destructive behaviors

9 School Assessment of Trauma Symptoms
UCLA PTSD Index -Revised (Steinberg, Pynoos, Rodriguez, 2002) - screens for trauma exposure and trauma symptoms Youth (school-age) version, parent version Trauma 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.

10 Common Trauma-Related Diagnoses
Adjustment Disorder Acute Stress Disorder Posttraumatic Stress Disorder (PTSD) Depression (Dysthymic Disorder, MDD) Behavior Disorder (ADHD, ODD, Conduct Disorder) Anxiety Disorder (GAD, Panic Disorder, Specific Phobia) Reactive Attachment Disorder (RAD) Bereavement

11 CBT Treatment Objectives
Break associations between negative feelings and trauma cues Increase tolerance of trauma thoughts and memories Decrease reliance on maladaptive coping Facilitate processing of trauma Correct trauma-related distortions Model (therapist, parent) effective coping Reinforce (therapist, parent) positive coping and respond effectively to behavior problems

12 Appropriate Clients Functioning at 3 years or higher PTSD symptoms
Trauma-related confusion or misconceptions Substantiated abuse/trauma Parents (nonoffending) supportive of treatment

13 Inappropriate Clients
Psychotic symptoms Substance dependence/abuse Suicidal intent, high self-harm risk Questionable validity of abuse/trauma Extremely resistant after “best sell” High intensity trauma ongoing

14 Outpatient Individual TF-CBT
Short-term (Average= 3 assessment sessions plus 12 treatment sessions) Divided individual sessions for child and parent initially Joint sessions begin once parent’s symptoms have decreased and coping skills are improved

15 School-Based TF-CBT Screen for trauma exposure/symptoms
Assess for treatment appropriateness 10 to 12 individual sessions with parental involvement strongly encouraged for elementary age 10 to 12 week group therapy with option of 2 individual sessions and 2 parent feedback sessions if possible

16 Trauma-Focused CBT: Components
Psychoeducation Ensuring Environmental Safety Stress Inoculation Training (coping skills) Gradual Exposure Affective and Cognitive Processing Safety Skills Parental Involvement Behavior Management Skills Training Family Sessions

17 Psychoeducation Common reactions to trauma (parent, child)
PTSD in children Accurate trauma-related information Self-care after trauma; supporting child Purpose, rationale, estimated length, typical course of treatment Splinter or wound analogy Ensuring safety Healthy discipline; Healthy sexuality Appropriate developmental expectations

18 Stress Inoculation Training (SIT)
Techniques for reducing physiological stress reactions in response to trauma reminders Life Saver vs. Swim Lesson analogy Deep 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 moment Cognitive 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

19 SIT Techniques Deep breathing Mindfulness, visual imagery
Belly breathing, pinwheel Mindfulness, visual imagery “Safe place” Progressive muscle relaxation Tin soldier/Raggedy Ann Raw/Cooked noodle Developmentally appropriate script Ollendick, T. H., & Cerny, J. (1981). Clinical behavior therapy with children. New York: Plenum Press.

20 SIT 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

21 SIT Techniques (cont.) Thought-stopping/replacement
Stop sign, Change your channel Cognitive coping skills (positive focus) Mantra coaching “I’m safe now…I can do this…He’s locked up now…It wasn’t my fault…”

22 Gradual 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 - GE Repeated 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 trauma and through others’ books about similar trauma experiences

23 Gradual Exposure Hierarchical 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 sessions Can use SIT skills during exposure phase

24 Exposure Examples Writing anonymous book about trauma; advising others who face similar situations Playing out trauma with toys and gradually incorporating positive resolution Drawing pictures of trauma images and later shredding them Getting rid of upsetting thoughts or images (thought funeral) Writing rap song about impact of trauma Sharing trauma narrative Third person narrative may be safer

25 Affective and Cognitive Processing (CP)
Feeling Identification and Expression Feeling charades; Polaroid feeling chart; Feeling identification race Cognitive Triangle Thoughts, Feelings, Behaviors Practice generating helpful thoughts Train game Feeling exercises: charades, feeling chart with polaroids, feeling race TFBR Example: Kid bumps into you in the hall and keeps going.

26 Affective and Cognitive Processing (cont.)
Identify trauma-related inaccurate or unhelpful thoughts using open-ended inquiry, impact statement, narrative, observation, or self-report measures Why 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?

27 Common Trauma-Related Cognitive Distortions
Self-blame Guilt, survivor guilt Shame/embarrassment b/c of trauma or symptoms Hero fantasies related to trauma Overgeneralization of danger/risk Minimization of trauma Omen formation Foreshortened future Magical thinking Revenge fantasies

28 Affective and Cognitive Processing (cont.)
Model helpful thoughts Correct distortions Younger children: Insert mantras Coloring book example Narrative: “It’s not your fault” Older children: Help to reprocess

29 Methods for Challenging Distortions
Identify feelings, behaviors, outcomes related to negative thought and generate more helpful thought instead One-down Columbo style approach Mirror distortions in the extreme and push child to amend distortion Progressive logical questioning Cartoon bubbles Role plays, talk shows, peer counseling Books/narratives One-down columbo style when trying to get them to buy into concept

30 Safety Skills Recognize dangerous situations
Good touch/bad touch (SA cases) Problem-solving skills Support-seeking skills Calming skills if risk of self-injury Present carefully so as not to blame Develop safety plan Use tornado drill analogy to reduce chances of self-blame.

31 Parental Involvement in Individual Treatment
Assessment feedback Psychoeducation Parallel work in areas of SIT, GE, and CP Parenting Skills Building, Behavior Mgmt. Joint parent-child sessions Continuation of GE and CP jointly Parent models positive coping with trauma Parent assumes role of therapist as child’s supporter related to trauma Including 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.

32 Helping Parents of Traumatized Children
Communicate with parents frequently about child Encourage parents to listen to child closely Encourage parents to set aside special time for child Recommend maintenance of normal routine Encourage parents to remain calm and to get help for themselves if needed Normalize child’s emotional/behavioral difficulties after trauma Model soothing behaviors with child Assist in developing plan for behavior management

33 Guidelines for Parents
Comforting Traumatized Children reinforce ideas of safety and security allow child to be more dependent temporarily if needed follow child’s lead (hugs, listening, supporting) use typical soothing behaviors use security items and goodbye rituals to ease separation with younger children distract with pleasurable, normally occurring activities let child know you care

34 Guidelines for Parents
Discussing Trauma with Child Encourage child to express feelings about trauma but don’t pressure Remain calm when answering questions and use simple, direct terms Don’t soften information for child Help child develop realistic understanding of what happened Gently correct trauma-related distortions Be willing to repeat yourself Normalize “bad” feelings

35 Guidelines for Parents
Controlling Child’s Environment Maintain normal routines Avoid exposing child to further trauma or to unnecessary trauma reminders (e.g., media) Minimize contact with others who upset child Guide others in supporting child

36 Guidelines for Parents
Listening skills Children need to have their feelings accepted and respected Listen quietly and attentively Acknowledge their feelings with a word or two Give their feelings a name Give them their wishes in fantasy Show empathy How to Talk So Kids Will Listen and Listen So Kids Will Talk By Adele and Faber

37 Guidelines for Parents
Listening No-No’s Denial of feelings Philosophical response Advice Too many questions Defense of the other person Pity Amateur psychoanalysis How to Talk So Kids Will Listen and Listen So Kids Will Talk By Adele and Faber

38 Behavior Management Caregiver interventions
Anger control skills with child Skills training (problem-solving, social skills, communication) Specific behavior plans (sleep problems, sexual behavior problems) Intervene in relevant systems

39 Caregiver Interventions for Behavior Management
Create predictability for child Make expectations clear Reasonable developmental expectations Don’t personalize child’s behavior Avoid power struggles “Emotionally unplug” when disciplining; “Emotionally plug in” when rewarding 123 Magic

40 Caregiver Interventions for Behavior Management
Identify triggers that upset child and plan ahead Expect angry outbursts Address aggressive/self-destructive behaviors quickly and firmly Model self-control Be patient and calm

41 Caregiver Interventions for Behavior Management
Consistent limit-setting Predict increase in negative behavior Reward positive behavior PRIDE skills (from PCIT) Naturally occurring reinforcers Jump start material reinforcers when necessary Ignore negative behavior Give effective instructions Time-out, removal of privileges Traffic ticket analogy - consistent limit-setting Broken soda machine analogy - predict increase in negative behavior

42 Anger Control Skills Identify triggers or high-risk situations and plan ahead Red button exercise Increase awareness of physiological and cognitive components Teach/rehearse management strategies Counting, breathing Relaxation (turtle technique) Leave situation, SCAR Exercise Thought-stopping; replace with mantra

43 Problem-Solving Skills
Name problem Practice perspective-taking Generate total possible solutions (w/out evaluation) Evaluate and discard non-feasible solutions Choose solution (within child’s control) Try it out Check back and reevaluate

44 Managing Sexual Behavior Problems
Help parents communicate openly and clearly about appropriate/inappropriate sexual behavior Examine behavioral patterns and identify motivators/positive reinforcers of behavior Alter parental responses by establishing negative consequence for behavior Identify and shape positive replacement behaviors so child can achieve desired consequence appropriately Motives: sexual arousal, social acceptance, curiosity, reenactment of trauma b/c of confusion

45 Managing Sleep Problems
Establish consistent bedtime routines and schedules Gradually transition child back to own bed and fade out “check-ins;” fade out rewards for successful nights. Relaxation tape or exercises Restructuring nightmares to bring resolution Visual imagery of peaceful place

46 Traumatic 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.

47 Group CBT of PTSD in Children and Adolescents
Same components as Individual CBT Members need to have similar level/type of trauma exposure Provides opportunity for social skills-building, peer feedback, and stigma reduction Advantageous if large-scale trauma or school setting with high violence rate School-wide trauma exposure/symptom screening yields best referrals Modules include traumatic bereavement

48 School TF-CBT group outline
How violence affects youths Self assessment of symptoms Psychoeducation Recognizing/managing feelings Positive coping strategies (SIT) Coping with trauma cues Challenging hurtful thoughts How the violence affected me - GE Individual session, group sessions Challenging stuckpoints - CP Traumatic bereavement, positive reminiscing

49 School TF-CBT Group Outline Continued
Changing problem behaviors Support-seeking Anger management, emotional control Communication skills, problem-solving Building healthy relationships Feeling good about myself Positive self-esteem Goal-setting Group closure

50 Empirical 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 support School-based TF-CBT (treatment effects for GPA, PTSD, school attendance and behavior) CBT > Nondirective Supportive Therapy Parent involvement in CBT improved child’s symptoms, even when child not involved in tx SIT, EMDR PCIT, MST

51 TF-CBT References Deblinger, 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.

52 School-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. Louis Layne, 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).

53 We’re Done! For additional questions, references, or referrals, contact Ally Burr-Harris, Ph.D. Phone:

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