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Introduction to Trauma-Focused Cognitive-Behavioral Therapy for Children and Adolescents By Adam H. Benton, PhD.

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1 Introduction to Trauma-Focused Cognitive-Behavioral Therapy for Children and Adolescents By Adam H. Benton, PhD

2 TF-CBT Traumatic Stress in Children Assessment of Trauma Symptoms Development and Research On TF-CBT Treatment Using TF-CBT Components The AR BEST Program

3 What is Child Traumatic Stress (CTS) ? Child Maltreatment Domestic Violence Natural Disasters Community and School Violence Medical Trauma Traumatic Loss Terrorism War-Zone Trauma

4 How Big is the Problem? The Epidemiology of Child Traumatic Stress General population studies Disaster studies Terrorism Natural disasters Child maltreatment studies

5 General Population Studies of Child Traumatic Stress National Survey of Adolescents (Kilpatrick & Saunders, 1997) Representative US sample: 12-17 yrs Serious physical assault: 5 million Sexual assault: 1.8 million Youths in Urban America study (Breslau et al., 2004) Mid-Atlantic US city – Baseline 6 yrs; follow-up 20-22 yrs 82.5% one or more lifetime traumatic events: 87.2% males, 78.4% females Exposure to violent assault – Increase after 15 years, peaked @ 16-17 yrs – Major decrease by age 21

6 General Population Studies of Child Traumatic Stress Developmental Victimization Study (Finklehor et al., 2005) Representative US sample: 2-17 yrs 1 in 8 experienced a form of child maltreatment 1 in 3 witnessed violence The Great Smoky Mountains Study (Copeland, et al., 2007) A majority of children (67.8%) were exposed to one or more traumatic events by age 16. Children exposed to trauma had almost double the rates of psychiatric disorders of those not exposed.

7 Disaster Studies New York City, NY Department of Education Study (Hoven et al., 2005) At 6 months post World Trade Center attack, the prevalence of: – PTSD was 10.6% – agoraphobia was 14.8% – conduct disorder was 12.8% – separation anxiety was 12.3% – alcohol problems was 4.5% Over 60% experienced at least one major traumatic event prior to the attacks. Gulf Coast Child & Family Health Study (Abramson et al., 2007) At 2 years after Hurricane Katrina. – 46,000 children were displaced – 51% of displaced children had at least 1 risk factor for poor long term outcomes

8 Child Maltreatment Studies The National Incidence Studies (NIS) mandated by the U.S. Congress to establish the incidence of child maltreatment. 1981 (NIS-1), 1988 (NIS-2), 1996 (NIS-3), & 2009 (NIS-4) The total number of abused and neglected children was two-thirds higher in the NIS-3 published report than in the NIS-2 published report. Awaiting results of NIS-4.

9 Child Maltreatment Studies National Child Abuse and Neglect Data System (NCANDS, 2007), a federally sponsored analysis of annual data on child abuse and neglect submitted by the states. In 2006, there were 3.6 million reported cases of maltreatment 905,000 substantiated cases.


11 Child Maltreatment Prevalence 2007 NationallyArkansas 6 million Child maltreatment investigations 58,000 child maltreatment investigations 794,517 confirmed cases of abuse / neglect (1 out of every 94 children) 9,847 confirmed cases of abuse / neglect (1 out of every 71 children) 59% Neglect (436,944 children) 8% Sexual Abuse (56,460 children) 11% Physical Abuse (79,886 children) 13% Multiple types (97,123 children) 4% Psychological Abuse (31,366 children) 55% Neglect (5,439 children) 20% Sexual Abuse (1,961 children) 12% Physical Abuse (1,135 children) 7% Multiple types (711 children) 1% Psychological Abuse (31,366 children)

12 Comparisons 1 out of every 71 children in Arkansas were victims of abuse or neglect 1 out of every 6250 children were diagnosed with cancer (U.S. Department of Health and Human Services, 2009) 1 out of every 4032 individuals under 24 had a confirmed case of H1N1 (Centers for Disease Control and Prevention, 2009) 1 out of every 30,303 individuals under 24 had a confirmed case on H1N1 that required hospitalization (Centers for Disease Control and Prevention, 2009) 1 out of every 1,514,175 individuals under 24 died from a confirmed case on H1N1 (Centers for Disease Control and Prevention, 2009) 1 out of every 150 eight-year-old children were diagnosed with an Autism Spectrum Disorder (Centers for Disease Control and Prevention, 2002)

13 Posttraumatic Stress Disorder A.Exposure – Experienced or witnessed…actual or threatened injury or death – Responded with intense fear, helplessness, or horror B. Reexperiencing Intrusive recollections Recurrent dreams Acting or feeling as if the event were recurring Intense distress triggered by internal or external cues Physiological reactivity C. Persistent Avoidance (3+) – Avoiding thoughts, feelings etc – Places, activities, or people – Inability to recall events – Diminished interests in significant activities – Detachment or estrangement from others – Restricted affect – Foreshortened future

14 Posttraumatic Stress Disorder D.Persistent Increased Arousal (2+) Difficulty sleeping Irritability Difficulty concentrating Hypervigilance Exaggerated startle response E.Duration of 1 month or more F.Clinical impairment

15 What is the impact of Child Traumatic Stress? Capacity to regulate emotion and attention Social development Cognitive development: IQ and language Academic performance Substance use/abuse Numbness, desensitization to threat Re-victimization Recklessness and reenacting behavior Posttraumatic stress and other disorders (depression, anxiety, phobia, panic) Developmental Trauma Disorder Health effects

16 Traumatic Stress in Children Physical consequences can include impaired brain development and/or poor physical health (Kaufman & Charney, 2001; Perry, 2002; Shore, 1997; Springer, Sheridan, Kuo, & Carnes, 2007) Psychological consequences can include internalizing disorders, externalizing disorders, cognitive difficulties, and/or social difficulties (Kaufman & Charney, 2001; Morrison, Frank, Holland, & Kates, 1999; Silverman, Reinherz, & Giaconia, 1996; Springer, Sheridan, Kuo, & Carnes, 2007; Teicher, 2000; U.S. Department of Health and Human Services, 2003; Watts-English, Fortson, Gibler, Hooper, & DeBellis, 2006) Behavioral consequences can include juvenile delinquency, adult criminality, substance abuse, and/or abusive behavior (National Institute on Drug Abuse, 1998; Prevent Child Abuse America, 2001; Widom & Maxfield, 200; Widom, White, Czaja, & Marmorstein, 2007)

17 Traumatic Stress Symptoms in Children Compared to adults… Less numbing and difficulty recognizing avoidance More overt aggression, destructiveness, and reenactment (also in play and drawings) Older children – foreshortened future Over the age of 10 – react more like adults Dyregrov & Yule, 2005

18 Effect of increasing trauma exposures on cumulative rates of psychiatric diagnoses by age 16 years (Copeland et al., 2007)



21 Traumatic Stress Symptoms in Children Family Influences Children may tend underreport symptoms to parents Parents often underestimate children’s severity of symptoms Family climate effects child’s processing of traumatic events though has less impact than the event itself Dyregrov & Yule, 2005

22 Incidence of PTSD in Children 6% life-time prevalence in older adolescents Natural Disasters – 30-50% moderate symptoms – 5-10% full criteria Traffic Accidents – 29% at 4 wks – 36% at 6 wks – 6 – 25% at 12-15 wks – 14% at 9 months Exposure to war 25 – 70% Diseases or hospitalization X < 15% Sexual and Physical Abuse 11 – 20% Symptoms often remain for years without treatment (15-29% still meet criteria 5- 33 years later) Dyregrov & Yule, 2005

23 Predictors of PTSD Reactions in Children Level of Exposure Lack of social support Female gender Previous trauma exposure Prior psychiatric problems Strong acute response Family history of mental illness Cognitive variables – Negative appraisal – Unfairness – Rumination – Thought suppression – Confusion during the event

24 Assessment of Trauma Symptoms “The development of the abused or neglected child seldom follows a predictable course, because child maltreatment is characterized by many other negative socialization forces, such as family instability, parental inconsistency, and socioeconomic disadvantage.” Wolf & McEachran, In Mash & Terdal, 1997)

25 Assessment Process Assess existing risk and safety Identify general strengths and problems areas for family (marital problems, Family Stressors, etc.) Identify parental needs (support, child rearing, etc) Identify child needs (behavior, cognitive, social, mental health symptoms, etc) Reporting issues

26 Assessment Process Cognitive problems: Maladaptive patterns of thinking about self, others and situations, including distortions and unhelpful thoughts, like self-blame or rumination about the trauma Relationship problems: Difficulties getting along with peers, poor problem-solving or social skills, hypersensitivity in interpersonal interactions, maladaptive strategies for making friends, impaired ability to trust. Affective problems: Sadness, anxiety, fear, anger, poor ability to tolerate or regulate negative affective states, inability to self-soothe.

27 Assessment Process Family problems: Parenting skills deficits, poor parent-child communication, disturbances in parent-child attachment, disruption in family relationships or functioning due to abuse. Traumatic behavior problems: Avoidance of trauma reminders; trauma-related, sexualized, aggressive, or oppositional behaviors; unsafe behaviors Somatic problems: Sleep difficulties, physiological hyperarousal and hypervigilance toward possible trauma cues, physical tension, somatic symptoms. Cohen, Mannarino, & Deblinger, 2006

28 Assessment Instruments Family Adjustment – Family Adaptability, Cohesion and Expression Scale – Family Environment Scale Cognitive / Learning Ability – WISC, WPPSI, Stanford Binet, KBIT, WASI – WIAT, Woodcock-Johnson, WRAT, Social Functioning – Harter Self-Perception Profile for Children – Harter Social Support Scale for Children – Adolescent Interpersonal Competency Questionnaire – Children’s Attributional Style Questionnaire Emotional /Behavioral – Child Behavior Checklist – Behavior Assessment Scale for Children – Roberts Apperception Test – 2 – Child Depression Inventory – Manifest Anxiety Scale for Children – Strengths & Difficulties Questionnaire Traumatic Stress Symptoms – UCLA Posttraumatic Stress Index – Trauma Symptom Checklist for Children – Child PTSD Screen – Child Report of Posttraumatic Symptoms – Children’s Impact of Traumatic Events Scale – Child Dissociative Checklist – Traumatic Events Screening Inventory

29 Tracking Outcomes Strengths & Difficulties Questionnaire – Overall Distress

30 Tracking Outcomes Strengths & Difficulties Questionnaire – Symptom Subscale Severity

31 Tracking Outcomes UCLA PTSD Index - Overall Traumatic Stress Symptoms

32 Tracking Outcomes UCLA PTSD Index Subscale Severity

33 Tracking Outcomes

34 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

35 Research On TF-CBT TF-CBT is the most rigorously tested treatment for traumatized children – 6 randomized trials 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

36 Reviews of Research “Well supported” by the CEBC (2009) “Best practice” by the Kauffman Best Practices Project (2004) “Well-supported and efficacious” by Saunders, Berliner, & Hanson (2004) “Well-established” by Silverman et al. (2008)

37 Statewide Dissemination 18 states including Arkansas

38 Evidence Based Treatments What it is not…

39 What is TF-CBT? A hybrid treatment model that integrates: Trauma sensitive interventions Cognitive-behavioral principles Attachment theory Developmental neurobiology Family therapy Empowerment therapy Humanistic therapy

40 Difficulties Addressed CRAFTS – Cognitive Problems – Relationship Problems – Affective Problems – Family Problems – Traumatic Behavior Problems – Somatic Problems

41 Core Values CRAFTS – Components-based – Respectful to Cultural Values – Adaptable and Flexible – Family Focused – Therapeutic Relationship is Central – Self-efficacy is Emphasized

42 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 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

43 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

44 JOINT FAMILY SESSIONS TF-CBT Components 1996 Deblinger & Heflin PARENT’S TREATMENT Education Skill Building Exposure/Processing Behavior Management CHILD’S TREATMENT Education Skill Building Exposure/Processing

45 Psychoeducation Begins during first session and continues throughout treatment Provide information about the specific trauma, common psychosocial reactions to trauma, etc. Review benefits of early, effective tx Explain treatment plan and theoretical rationale for skills, exposure and processing

46 Education and Hope

47 Parenting Skills TF-CBT views parents as central therapeutic agent for change Establish parent as the person the child turns to for help in times of trouble Explain the rationale for parent inclusion in treatment – Not because parent is part of the problem but because parent can be the child’s strongest source of healing Emphasize positive parenting skills, enhance enjoyable child-parent interactions, maximize perception/reality effective parenting

48 Parenting Skills (Praise) Focus on actively praising the child – Praise a specific behavior – Provide praise ASAP after behavior occurs – Be consistent – Do not qualify your praise – Provide praise with same level of intensity as criticism “Catch your child being good!”

49 Parenting Skills (Selective Attention) No reaction to certain negative behaviors – Defiant or angry verbalizations to parent – Nasty faces, rolling eyes, smirking – Mocking, mimicking Walk away, busy oneself with an activity Remain calm, dispassionate Expect a reactions of more provocative behavior Praise “the opposite”- wanted behavior

50 Parenting Skills (Time Out) Purpose: Interrupt child’s negative behaviors and allow him/her to regain control Explain to child Location: quiet, least stimulating Once in time out, parent should refrain from comments, and maintain calm demeanor. Be consistent!

51 Parenting Skills Time out: Interrupt child’s negative behaviors and allow him/her to regain control Contingency reinforcement programs: Decrease unwanted behaviors and increase desired behaviors Other behavior management issues as needed

52 Parenting Skills (Work Chore) Explain to child Caregiver has a list of chores that won’t take more than 5 minutes to complete When child needs a consequence, caregiver assigns one of the chores. When child completes chore, praise, still has to do original task if refusal was reason. Don’t over-attend to original problem, be calm and consistent

53 Parenting Skills (Contingency Reinforcement Program) Purpose: Decrease unwanted behaviors and increase desired behaviors Select only one behavior to target Explain process to child Involve child in decisions about rewards Add stars and give rewards weekly, and consistently

54 Parenting Skills (Behavior Management) Reasonable developmental expectations Limit-setting Numerous other techniques (logical and natural consequences, etc.) Behavioral interventions for: – Anxieties – Sleep problems – Aggressive behaviors – Sexually inappropriate behaviors

55 Relaxation/Affective Modulation Feeling Identification Accurately identify and express a range of different feelings – Board games – Feeling brainstorm – Color My Life or person Physiological responses to different feelings (spaghetti, robot/ragdoll, etc.) Can ask directly about feelings experienced during traumatic event. End on a positive note



58 Relaxation/Affective Modulation Reduce physiologic manifestations of stress and PTSD Explain body responses to stress Shallow breath, muscle tension, headaches Focused breathing/mindfulness/meditation – Bubble breaths, diaphramatic breathing Progressive Muscle Relaxation Physical Activity Positive Visual Imagery Anything that helps relax (e.g., art, reading, etc.)

59 Koeppen, A.S. (1974). Relaxation training for children. Elementary School Guidance and Counseling, 9, 14-21. (available online)

60 Relaxation/Affective Modulation Thought Interruption and Positive Imagery Use when overwhelmed with trauma reminders Temporary measure early in treatment Teaches child control over their thoughts “Changing the channel” Saying “go away” or “snap out of it” Imagining a stop sign Replace unwanted thought with a positive one

61 Relaxation/Affective Modulation Positive Self-talk Focus on child’s strengths Remind child to verbalize these Enhancing Sense of Safety Ask about child’s sense of safety right now Develop a safety plan

62 Relaxation/Affective Modulation Problem Solving / Impulse Control STOP Technique Turtle Technique



65 Cognitive Coping Help children and parents understand the cognitive triad: connections between thoughts, feelings and behaviors, as they relate to everyday events Help children distinguish between thoughts, feelings, and behaviors Help children and parents view events in more accurate and helpful ways Encourage parents to assist children in cognitive processing of upsetting situations, and to use this in their own everyday lives for affective modulation

66 Cognitive Coping

67 Thoughts, Feelings, and Behaviors Log EventsThoughtsFeelingsBehaviors

68 Cognitive Coping Types of Inaccurate Thoughts Personal, Pervasive, Permanent – All or Nothing Alan – Again and Again Agnes – Catastrophic Cassie – Negative Ned

69 Cognitive Coping Accurate Inaccurate Helpful Unhelpful It’s not my fault I was sexually abused My parents will always be able to keep me safe Violence can happen anywhere at anytime No one would like me if they knew what happened to me

70 Trauma Narrative and Processing Reasons we avoid this with children: – Child discomfort – Parent discomfort – Therapist discomfort – Legal issues

71 Trauma Narrative and Processing Reasons to directly discuss traumatic events: – Gain mastery over trauma reminders – Resolve avoidance symptoms – Correction of distorted cognitions – Model adaptive coping – Identify and prepare for trauma/loss reminders – Contextualize traumatic experiences into life – Gradual Exposure

72 Trauma Narrative and Processing Introduce the child to the rationale for the narrative Can introduce the idea by reading a book about a child who told their trauma story and felt better Use analogies: – Cleaning a wound – Rollercoaster Help the child to identify how they would like to tell their trauma story (e.g., book, poem, story, song, drawing, painting, video, audiotape, typing on computer, cartoon, talk show)

73 Trauma Narrative and Processing Chapter 1: Innocuous information about the child (name, age, school, hobbies, etc) Chapter 2: “Before” (for example, what the relationship was like with the person before the trauma started or what life was like before the traumatic event occurred)

74 Trauma Narrative and Processing Chapter 3: Encourage the child to “tell what happened” during the trauma itself – If multiple episodes, let the child choose one (example: first, last, one most remembered) – Typically, children proceed from first to last episode – Include disclosure, legal procedures, medical exams, removal from home, etc. – For the first telling, allow the child to tell the story with minimal interruption and little questioning.

75 Trauma Narrative and Processing My uncle came into my room to kiss me goodnight. He pulled down the covers and touched me down there. I felt scared. I pretended I was asleep. When he was done, he left. The next morning I got up and my uncle said, “Good morning, how are you?” and I said, “Fine”. I went to school.

76 Trauma Narrative and Processing Identify “hot spots” or “worst moments” Rate distress (SUDS scale) before, during, and after narrative Review the child’s description at subsequent sessions Help the child to describe more details Encourage child to describe thoughts and feelings related to trauma

77 Trauma Narrative and Processing Ask broad, open-ended questions – What were you thinking? – What were you saying to yourself? – How were you feeling? – What happened next? Make clarifying and reflective statements – Tell me more about it… – I wasn’t there, so tell me… – I want to know all about… – Repeat the part about… – So, your uncle began touching your vagina…

78 Trauma Narrative and Processing My uncle came into my room to kiss me goodnight. I felt good. He pulled down the covers and touched me down there, on my vagina. I felt scared and dirty, and thought why is he doing this, he’s my favorite uncle. I pretended I was asleep. When he was done touching my vagina, he left. The next morning I got up and my uncle said, “Good morning, how are you?” and I said, “Fine”. Inside I felt scared and I didn’t know what to say or do. I went to school.

79 Trauma Narrative and Processing Identify cognitions related to the trauma: – As reported in trauma narrative – Direct inquiry – Indirect reports

80 Trauma Narrative and Processing Common negative distortions – Self-blame – Overestimating danger – Changed world view

81 Trauma Narrative and Processing Sexuality – “Am I gay?” “I was abused because I dress sexy.” Body Concerns – “I might die of AIDS.” “I might be pregnant.” Interpersonal Concerns – Family “I tore apart my family.” – Friends “My friends think I’m a slut.” Safety Concerns – “I will never trust another man.” “I can’t go anywhere alone.” Self Image – “I am so stupid.” “I am unlovable.”

82 Trauma Narrative and Processing Examine contradictory evidence/facts Test the accuracy of thoughts Use the Socratic method Use role plays (e.g. best friend)

83 Let’s Practice Dear Dad, I am writing because I have some things to tell you. I’m glad you are in jail now. Now you can’t hurt me or other kids anymore. Everyone knows what you did to me. Some people think it was wrong, and some people think it was OK. I think you ruined my life. I keep asking why did I do that? I should have told you to stop. I’m really mad that I told 2 years too late. From, The daughter you hate

84 Trauma Narrative and Processing Include the following in the final chapter: – What have you learned? – What would you tell other children who experienced this? – How are you different now from when it happened/when you started treatment?

85 Trauma Narrative and Processing My uncle came into my room to kiss me goodnight. I felt good. He pulled down the covers and touched me down there, on my vagina. I felt scared and dirty, and thought why is he doing this, he’s my favorite uncle. I pretended I was asleep. When he was done touching my vagina, he left. The next morning I got up and my uncle said, “Good morning, how are you?” and I said, “Fine”. Inside I felt scared and I didn’t know what to say or do. I went to school.

86 Trauma Narrative and Processing I came here because I was sexually abused by my uncle. I used to feel scared and dirty. Now I know my body is OK. I don’t know why he did that, but he has a problem and it wasn’t my fault. I didn’t know what to say or do about the sexual abuse. I felt like I didn’t do anything, but I did. I told my Mom and a wrote a book about it. That makes me feel proud. If this ever happens to you, you could say, “No!”, get away and tell. If it’s hard to say no or get away – just tell – that is the most important thing anyway! Tell someone you trust.

87 Trauma Narrative and Processing How caregivers talk to and behave towards children can greatly influence developing beliefs about self, others and the world. How might parents’ feelings and thoughts about the trauma impact on their children’s behaviors and developing beliefs? Provide parents with a forum to share their feelings and thoughts related to the trauma (even the socially undesirable ones)

88 Trauma Narrative and Processing Examine thoughts which are permanent, pervasive, or too personalized – Permanent: “ My child will never be happy again.” – Pervasive: “No one can be trusted with my child.” “The world is not a safe place.” – Personalized: “This happened because I am a terrible parent.” “I should have known that man was a sex offender.” "If my best friend had a child who experienced a similar traumatic experience, would I say to him or her what I am saying to myself?“ "Would I want my child to overhear me making this statement out loud?"

89 In Vivo Desensitization Resolve generalized avoidant behaviors – Gradually help the child get used to the feared situation Identify the feared situation Design the in vivo desensitization plan Praise and reinforce in vivo work Therapist MUST have confidence that this will work or it won’t

90 Conjoint Sessions Format of sessions Meet individually with parent and child prior to joint part of session Meet together after child and parent prepared for session

91 Conjoint Sessions Content of sessions Therapist models appropriate support of child Praise for progress made Caregiver models skillful coping Facilitates open communication – Trauma knowledge and education – Sharing the trauma narrative – Sex education – Personal Safety – Relaxation – Affective modulation – Psychoeducation – Cognitive Coping – In-vivo desensitization – Prepare for future reminders

92 Conjoint Sessions Sharing the narrative Parent may not know details of what happened – Avoidance – Legal issues Explore what parent knows about the traumatic event Monitor their reactions Prepare them before Share with parent what child has said in therapy – Confidentiality – Developmental issues

93 Conjoint Sessions When NOT to have joint sessions: Parent unable to provide appropriate support Child adamantly opposed (evaluate how realistic objections are) Parent(s) continue to be disbelieving or unsupportive Parent(s) feel emotionally incapable of hearing narrative Child is refusing to participate in joint parent child sessions

94 Enhancing Safety and Future Development Sex Education Dependent on the age of the child Start young and continue through adolescence Model open communication beginning use of accurate terms for private parts Broad or specific – Puberty – Sex vs. sexual abuse – Relationship issues Talk with caregiver first Identify resources

95 Enhancing Safety and Future Development

96 Brown, L. K. & Brown, M. (1997). What’s the big secret? Talking about sex with girls and boys. Boston: Little, Brown and Company. Colblentz, J. (1992). God’s will for my body; Guidance for adolescents. Harrisonburg: Christian Light Publications, Inc. Gravelle, K., Castro, N., & Castro C. (1998). What’s going on down there? Answers to questions boys find hard to ask. New York: Walker and Company. Gravelle, K., & Gravelle, J. (2006). The period book: Everything you don’t want to ask (but need to know). New York: Walker and Company. Haffner, D.W. (1999). From diapers to dating; A parent’s guide to raising sexually healthy children. New York: Newmarket Press. Harris, R. H. (1994). Changing bodies, growing up, sex and sexual health; It’s perfectly normal. Cambridge: Candlewick Press. Harris, R. H. (1999). It's So Amazing!: A Book about Eggs, Sperm, Birth, Babies, and Families. Cambridge: Candlewick Press. Harris, R. H. (2006). It’s not the stork; A book about girls, boys, babies, bodies, families, and friends. Cambridge: Candlewick Press. Jones, S. & Jones B. (1995). What’s the big deal? Why God cares about sex (Ages 8 – 11). Colorado Springs: Navpress Books & Bible Studies. Jones, S. & Jones, B. (1995). Facing the facts; The truth about sex and you (Ages 11-14). Colorado Springs: Navpress Books & Bible Studies. Jukes, M. (1998). Growing up it’s a girl thing; straight talk about first bras, first periods, and your changing body. New York: Alfred A. Knopf. Kirberger, K. (2003). No body’s perfect; Stories by teens about body image, self-acceptance, and the search for identity. New York: Scholastic.

97 Langford, L. (1998). The big talk; Talking to your child about sex and dating. New York: John Wiley & Sons. Lasser, M. (1999). Talking to your kids about sex; how to have a lifetime of age-appropriate conversations with your children about healthy sexuality. Colorado Springs: WaterBrook Press. Leman, K. & Bell, K.F. (2004). A chicken’s guide to talking turkey with your kids about sex. Grand Rapids: Zondervan. Madaras, L. (2003). Ready, set, grow! A “what’s happening to my body?” Book for younger girls. New York: Newmarket Press. Madaras, L. & Madaras, A. (2000). The what’s happening to my body? Book for boys. A growing up guide for parents and sons. New York: Newmarket Press. Marsh, C.S. (1991). Sex stuff for Connecticut parents and teachers of kids 7-17. Atlanta: Carole Marsh/Gallopade. Marsh, C.S. (1998). Sex stuff for kids: A book of practical information & ideas for kids 7-17. Atlanta: Carole Marsh/Gallopade. Mayle, P. (2000). “Where did I come from?” A guide for children and parents. New York: Kensington Publishing Corp. Mayle, P. (1975). “What’s happening to me?” An illustrated guide to puberty. New York: Kensington Publishing Corp. Richardson, J. & Schuster, M.A. (2003). Everything you never wanted your kids to know about sex (but were afraid they’d ask). New York: Crown Publishers. Roffman, D.M. (2001). Sex & Sensibility; The thinking parents guide to talking sense about sex. Cambridge: Perseus Publishing Royston, A. (1996). Where do babies come from? New York: DK Publishing. Schwartz, P. & Cappello, D. (2000). Ten talks parents must have with their children about sex and character. New York: Hyperion.

98 Enhancing Safety and Future Development Increasing Awareness Develop a safety plan which is responsive to the child’s and family’s circumstances and the child’s realistic abilities (No-Go-Tell, private part or sexual behavior rules, etc.) Improve problem solving skills in stressful situations Increase awareness (Boundaries, Hula Space, Personal Bubble, etc.) Counteract shame by enhancing confident body language Increase assertive communication skills (mouse/lion)


100 Private Part Rules No touching other’s private parts No other people touching your private parts No showing your private parts to other people

101 Sexual Behavior Rules It is not ok to show your private parts to other people. It is not ok to look at other people’s private parts. It is not ok to touch other people’s private parts. It is ok to touch your private parts as long as its in private and does not take too much time. It is not ok to use sexual language or make other people uncomfortable with your sexual behavior.

102 Enhancing Safety and Future Development Coach child to make verbal and nonverbal communication congruent (Mouse/Lion) – Look the person in the eye – Neutral facial expression – Confident body posture – Firm voice – Tell the person what you want

103 Terminating Therapy Review skills and progress achieved Fade out and/or plan booster sessions Discuss and plan for natural setbacks Encourage clients’ confidence in managing setbacks Emphasize parents’ role as a continued therapeutic resource for the child Celebrate clients’ therapy graduation

104 Applying TF-CBT in Real Life First things first Provide crisis response (usually for parents) Know what your setting can do Triage for priority focus – Basic needs (e.g., place to live) – Response to system activities (e.g., placement, legal processes) Psychiatric emergencies/active substance abuse Severe behavior problems Sexual behavior problems

105 Applying TF-CBT in Real Life Match length and intensity to child presentation Focus on what is most distressing for child Incorporate into interventions for other concerns/problems Be flexible

106 Strategy for Less Affected Children Psychoeducation Identification of potential areas of problems Review of coping strategies Revictimization prevention

107 Children with History of Multiple Traumas Integrate trauma treatment into broader intervention Be prepared to offer longer term relationship based therapy Provide assistance with managing every day life

108 Family Complications Do not agree that child was victimized/ harmed Overwhelmed with own reactions to child victimization Compromised relationship with child Inadequate parenting skills/child behavior out of control Depressed, substance abusers, anti-social Unstable, in financial straights, homeless, facing legal problems

109 Summary of TF-CBT Empirically supported trauma-focused treatment for children exposed to a variety of traumas and their parents/caretakers May be provided in as little as 12 sessions or adapted for longer term therapy Components-based hybrid treatment which incorporates principles of a variety of theoretical frameworks Flexible and adaptable (provides a treatment guideline but it us to the therapist to create an effective treatment)

110 Trauma-Focused Cognitive-Behavioral Therapy Web Site

111 Arkansas BEST for Children The mission of AR BEST is to improve outcomes for traumatized children and their families in Arkansas through excellence in clinical care, training, advocacy and research/evaluation.

112 Arkansas BEST for Children Clinical Care & Training – Provide state-of-the-art training, supervision and learning environments that will maximize the adoption of evidence-based interventions for traumatized children and adolescents. Website List serve Free on-line assessments and feedback reports (CBCL, UCLA) 2 Day Conference April 15 & 16 with one of the developers of TF-CBT Post-conference Consultation 6 – months Yearly conference On-line trainings Tele-video Conferences Certification of completion of TF-CBT training

113 Website

114 Trauma-Focused Cognitive-Behavioral Therapy Dissemination Process PRE-IMPLEMENTATION PHASE  Clinician registers for free on-line tutorial of TF-CBT through  Clinician registers for TF-CBT certification process through AR BEST website (TBN)  Clinician completes on-line tutorial of TF- CBT; receives 10 continuing education credits  Clinician sends certificate of TF-CBT completion to UAMS; registers for face-to-face training at UAMS April 1-2  Identification of State Champions PRE-IMPLEMENTATION PHASE IMPLEMENTATION PHASE  Clinician registers for free on-line tutorial of TF-CBT through  Clinician registers for TF-CBT certification process through AR BEST website (TBN)  Clinician completes on-line tutorial of TF- CBT; receives 10 continuing education credits  Clinician sends certificate of TF-CBT completion to UAMS; registers for face-to-face training at UAMS April 1-2  Identification of State Champions  Face-to-face training held at UAMS April 1-2  Phone consultation with Learning Collaborative twice monthly for six months  List Serve  Website Access  Technical Assistance  Enrollment of clients in TF-CBT (minimum of two per clinician for certification)  Completion of standardized assessments  Completion of treatment record SUSTAINABILITY  Clinician certification  Website posting of clinician’s completion of training  Clinician eligible for consultant training EVALUATION IMPLEMENTATION PHASE  Clinician registers for free on-line tutorial of TF-CBT through  Clinician registers for TF-CBT certification process through AR BEST website (TBN)  Clinician completes on-line tutorial of TF- CBT; receives 10 continuing education credits  Clinician sends certificate of TF-CBT completion to UAMS; registers for face-to-face training at UAMS April 1-2  Identification of State Champions

115 Research / Evaluation Part 1 – Program Outcomes – CSCs implementing screeners – MHPs trained – MHPs in ongoing supervision/televideo conferencing – Referrals to CMHCs – Web site hits

116 AR BEST For Children Part 2 – Child Outcomes – Electronic registry of all children at CSC – Baseline trauma screening in CSC – Year 1 – Baseline trauma screening in CMHC – Year 2 – 3, 6, and 12-month mental health screening – Years 1 and 2

117 Contact Info Benjamin A. Sigel, MS, LPE Adam H. Benton, PhD, LPP Psychiatric Research Institute University of Arkansas for Medical Sciences 4301 W. Markham Little Rock, AR 72205 Phone (501) 526-8200 Fax (501) 526-5296

118 Effective Psychotherapy

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