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Paul Brylske, MSW, LCSW-C, Director

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1 The Integration of Treatment Parent Training into the Treatment of Complex Trauma
Paul Brylske, MSW, LCSW-C, Director Lauren Capel, MSW, LCSW-C, Senior Clinical Social Worker Paula Waller, MSW, LCSW-C, Program Manager/Supervisor

2 Kennedy Krieger Institute Unlocking the Potential of Children with Special Needs since 1937.
Provides care for more than 16,000 children and adolescents annually with a focus on Disorders of the Brain & Spinal Cord: Patient Care Research & Training Special Education Community Programs

3 Kennedy Krieger Institute Areas of Specialization
Autism spectrum disorders Behavioral & emotional disorders Brain injury Cerebral palsy Developmental disorders Feeding disorders Learning disorders Muscular dystrophy Spina bifida Spinal cord injury and paralysis Childhood Traumatic Stress

4 The Family Center at the Kennedy Krieger Institute
Outpatient NCSTN category II and III site for over 8 years Multiple EBP’s, psychiatry and specialty clinics 550 active case;19,000 visits 2013 Trauma Training Academy Therapeutic Foster Care 1986 -Licensed for 100 child/youth Complex trauma, developmental disabilities, medically fragile conditions Adoptions & permanency Individual Family Care

5 Learning Objectives Beginning understanding the Trauma Integration Model (TIM). Beginning understanding of the Attachment, Regulation, and Competency (ARC) treatment framework. Understanding of how the treatment parent training can be used effectively in the integrated treatment of complex trauma. Apply tools which can be used in in training and practice with treatment parents in treating complex trauma. Understanding the use of data and outcomes in the treatment of complex trauma

6 Research Findings on Treatment Care (TFC)
M-TFC is evidence-based Tremendous variation in TFC in the “real world” Few programs resemble evidence-based model Factors associated with positive outcome Training and supervision of the treatment parent – child relationship Supervision of children Behavioral interventions NIMH (Farmer) / Maryland. Science to Service (Bruns et al 2004)

7 Limitations of Training

8 What effects sustainability/fidelity?
Agency Readiness to Implement and Implement and Implement Is there buy-in at all levels, especially leadership Does it fit agency culture Are there necessary resource to support Can it be integrated into current practice Can you measure adherence & outcome Is there support to staff Training Consultation Supervision/Coaching

9 Ongoing Consultation and Supervision/Coaching
Teach effective practice Ensure fidelity to practice Ensure good judgment & decision making Insure flexibility to meet needs of treatment parents & children/youth Increase staff & treatment parent satisfaction (“value added) through support and skill acquisition Ensure positive outcomes

10 KKI-TFC Trauma Integrative Model (TIM)
TFC Program Elements Evidence-based TFC (Chamberlain) “Real World” TFC (Farmer) (Bruns) Trauma Integrative Model (TIM) Service Coordination/Case Management Yes Treatment Parents as key providers/change agents Team approach to treatment Respite Work with youth’s family Reduce association with deviant peers Intensive supervision/support No Proactive approach to behavior problems Addressing previous trauma (ARC) N/A Comprehensive Coordination of Somatic Care Addressing Developmental Disabilities Preparing for transition to adulthood (TIP) Not systematic Permanency Family and Youth Voice Farmer and Bruns research using FFTA standard developed a framework of program elements for developing Hybrid TFC models which we have used at KKI in developing our hybrid model ‘the trauma integrative model’ or TIM. As you can see from their work components of in real world TFC models need to address and that are missing in the EBP model and we needed address in the development of our TIM Model. Farmer and Bruns identified preparing youth for Transition, and Addressing trauma. Based on our experience we added permanency, and inclusion of Family and Youth Voice .

11 KKI-TFC Trauma Integrative Model con’t
Principles/ Systems of Care & Safety/ Permanency/ Wellbeing Components of evidence based TFC Roles of clinical social worker and treatment parent with in the “Focus of Change” Treatment of… Complex trauma/neglect Development disabilities Medically fragile conditions Co-existing disorders (substance abuse & specialties) Needs of transition age youth Permanency and permanency planning Multi-generational complex trauma Community Services Out-patient Psychotherapy, Psychiatry, Medical, Educational, Vocational, Recreational, OT, PT, Nursing, Others Youth, family, and stakeholders voice

12 Focus of Change

13 Attachment, Regulation, Competency (ARC) Treatment Framework
Component-based vs. manualized protocol Grounded in theory and research on complex trauma Recognizes core effects of complex trauma: Attachment Self-regulation Competencies Understands importance of intervening within the context of the child (family and system) Components inform treatment choices Recognizes the need for individual tailored trauma interventions Recognizes each practitioner’s skill level Blaustein & Kinniburgh

14 Trauma Experiences Integration Caregiver Affect Management
ARC Building Blocks Blaustein & Kinniburgh Trauma Experiences Integration Executive Functions Self Dev’t & Identity Developmental Tasks Affect Identification Affect Modulation Affect Expression Caregiver Affect Management Attunement Consistent Response Routines & Rituals

15 ARC Model (Kinniburgh, Blaustein, Spinzola, Van der Kolk, May 2005)

16 ARC Implementation Collaboration Consultation Training staff
The Trauma Center at Justice Resource Institute Consultation Clinical Programmatic Training staff Initial / Ongoing Training Treatment Parents Curriculum Development Development of Tools Staff & parent toolkits Programmatic tools Fidelity, Measurement & Outcomes Manuals/Clinical Protocols Mapping ARC & CANS Other Measures (Youth Connection Scale, Trauma Symptom Index)

17 Core Principles of Training
Must be integrated throughout the program. Training goals must be clear and specific to needs of parents. Trauma Integrative Model (TIM) & ARC must be integrated in both staff and parent core training. The structure of training must be effective and efficient to meet the Treatment Parent training needs. Treatment of child will follow a parallel process which includes the development of staff and treatment parents. Must be an objective measure or evaluation of knowledge and skill acquisition, which includes performance of the parent and child. The promotion of self care as an important element of training and recognition of treatment parents through rewards, dinners, and incentives.

18 Treatment Parent Training
Phase One Phase Three Recruitment Following placement of child in the home Orientation formal presentations, support group pre-service training home study process in home/child specific training Phase Two Phase Four Following approval/matching Development of Professional Development Plan training to particular child & their needs Annual review of performance and training needs

19 Goals of Treatment Parent Training
Acquisition of Knowledge Acquisition of Skill Support Problem Solving

20 Professional Development Plan
Each treatment parent identify goals which can improve their effectiveness as a treatment parent. Goals are related to child(ren) in their home and training needs of treatment parent. Treatment parent progress is assessed routinely by clinician and evaluated yearly with clinician, program manager/supervisor & director through the annual re- licensure.

21 Role of Professional Development Committee
Oversees every aspect of parent training Develops the yearly training schedule Trains and Supervises child life staff Provides food and resources Monitors RSVP and attendees lists (internal and external) Maintains curriculum of each training Reviews and maintain training evaluations.

22 Structure of Training Topic Groups Trauma Informed
Geared toward needs of youth in the program Provide knowledge and tools for skill acquisition. Adult Learning Model Support Groups Treatment parents are provided support from facilitators and each other on various areas including permanency. Childcare Groups Activity groups for youth attending training with parents. Supervised by experienced child life staff.

23 Staff Integration

24 Staff Integration in Training
Staff Meetings Individual and Group Supervision Clinical Consultations ARC consultations Development of useful tools (CANS/ARC; All About _____ Forms)

25 Staff Integration in Practice
Knowledge and tools are reinforced in the home with treatment parent and child. Clinician trains parent how to utilize tools in the home. Clinician supervises parent’s use of tools. Clinician works with parent to get through difficult situations through use of tools.

26 Supervision and Integration
Knowledge and tools are reinforced with clinician. Supervisor provides clinician with support and direction on how to utilize tool. Supervisor tracks clinicians use of tools. Supervisor helps clinician navigate difficult situations by reinforcing clinical interventions. Parallel process with clinician

27 Case Presentation Demographics Client Parent Presenting Issue
13 year old male with history of physical abuse, neglect, homicidal and suicidal ideation. 44 year old treatment parent Educator Foster parent for 5 years Multiple placements including several hospitalizations, diagnostic center and RTC. Experienced treatment parent for youth with complex trauma and sexual predatory behaviors. First TFC placement Presenting Issue Youth exhibits poor self-regulation skills. Youth has limited capacity to attach to foster parent Treatment parent triggered by youth’s behavior. Integration of Trauma Tools in Practice

28 CANS/ARC Assessment: Self-Regulation Kisiel & Blaustein- NCSTN
Numbing Dissociation Attention Deficit Impulse Control Behavioral Regression Affect Dysregulation Depression Oppositional Explain under ARC Domains rather than CANS scores. Importance of treatment planning around entire team to address. Interpersonal Family Social Functioning Attachment Difficulties

29 Training Topic Example REGULATION


31 Perspective Is defined as…
a particular attitude toward or way of regarding something; a point of view

32 Who’s Perspective?

33 What It Takes To Set Your Story/Perspective Aside?
Reflect on your story/perspective Identify your feelings Reflect on your feelings Separate fact from fiction (story & feelings) Willingness to set story aside (not the same as giving it up)

34 What It Takes To Set Your Story/Perspective Aside? cont’d
Be Calm Be and Act Curious Be Attentive (especially to non-verbal cues) Be Open to Listen Know the “Right Time” and “Right Place”

35 Benefits of Therapeutic Listening
Helps to clarify information Keeps you talking about problems and feelings (affect identification & expression) Helps you to solve problems Talking out problem prevents acting out problems (affect modulation) Builds trust and relationship Minimizes judgment and triggers

36 What Does Our Story Have to Do With Competency & Regulation?
If were caught in our story we can’t hear the child's story? If we can’t hear the child's story we can’t ...get under the behavior ...get to the emotions understand the emotions understand and change thinking and behavior

37 Aggressive Driver- Angry Driver vs. Preggie Lady
Cognitive Behavioral Triangle Aggressive Driver- Angry Driver vs. Preggie Lady

38 Trigger Protection Plan Tool
What is most important may be source of your trigger How do we know we are being trigger? How do we respond? Do you have a plan to “step-back”?

39 Self-Care Strategies Deep breathing Muscle Relaxation Distraction
Self Soothing Time outs What are your strategies?

40 Putting the Pieces Together: Work in Progress
How do we work together to support a youth with complex trauma? Client Parent Clinician Supervisor

41 How It All Comes Together

42 Outcomes

43 Training Pre-Post Evaluations
Establish objectives Clarify areas of knowledge & skill Program/trainers/treatment parents Assess baseline knowledge Assess effectiveness knowledge & skill acquisition Identification of future training needs Program/trainer/treatment parents

44 Case-Specific Score Comparison
Domain Items

45 CANS Scores Over Time

46 Item-Specific Counts and Percentages
Domain Items: Count & Percentage Domain: Child Behavioral Emotional

47 Domain-Specific Percentages
Domain Total Percentage Domain: Child Behavioral Emotional

48 Total Percentages Domain: Child Behavioral Emotional All Domains

49 CANS Domain Score Comparison: Statistical Significance t1: Admission, t2: Discharge, n=104 2013

50 CANS/ARC Score Comparison

51 Percentage of Actionable CANS Items/ ARC Domains & Self Regulation Block

52 CANS/ARC Component Measurement T1, T2 & Overtime
Measure outcomes of child/youth functioning at youth & program level over time Measures outcomes of trauma treatment (ARC) at youth & program level over time Can be used at case level to measure effectiveness of interventions/tools At program level can be used to assess training needs of treatment parents Because measures of ARC components are reliable and valid measures can be used in research

53 Integration of Assessment/Treatment Intervention/Outcomes/Training
CANS Assessment ARC Components Regulation Intervention of ARC Tools Therapeutic listing Trigger protection plan Self-Care strategies Cognitive triangle CANS Outcomes ARC Outcomes Additional Interventions Identification of training needs Individual Tx Parent Program

54 Restrictiveness of Placement
Jamora, Brylske et al 2010 n=138 Prior Placement % Discharge Placement % RESTRICTIVENESS ENVIRONMENT More Restrictive Inpatient Psych Hospital Residential Tx Center Group Home/Shelter 11.20% 16.00% 32.00% 12.98% 3.90% 18.18% Total 59.20% 25.06% Equally Restrictive TFC 2.40% 2.60% Less Restrictive Regular Foster Care Relative Independent Living Adoption 6.40% 0% 9.09% 23.37% 14.29% 15.59% 38.40% 60.14% Other Armed Services Runaway 1.30%

55 Outcomes Permanency Fiscal Year Total Percentage 2010 2011 2012 2013
Adoption 15 9 10 6 40 28% Reunification 13 7 11 3 34 25% Transition 8 4 26 20% Year Total 36 20 31 100 73%

56 Placement Stability Placement Stability Mean (S.D.)
Placement Changes Prior to TFC 3.7 (3.6) *Placement Changes While in TFC 1.7 (0.8) Comparison of placement changes before & during TFC, t-statistics 4.8, p<0.001 Royes, Brylske & Belcher 2011

57 Level of Education Achievement 2013
Completed High School Cook (1991) 54% Bloome(1997) 77% Courtney (2005) 67% Pecora (2003) 86% Baltimore City 71.4% Baltimore County 92.3% Maryland 86.5% National 86%-90% TIM/TFC 98%

58 Future Goals Completion of ARC treatment parent curriculum
Increase “user friendliness” of CANS/ARC mapping tool Continual training for foster parents on CANS & ARC use and tools Integrate CANS/ARC Mapping within our Kidnet data system Integrate case/treatment note Measure change over time Measure at program level Effectiveness of ARC/Trauma treatment Treatment Parent Interventions/Tools Clinical Social Worker Intervention/Tools Identifying factors effecting effectiveness (outcomes) Program/Practice Improvement Presentations/Publication/Research Compare with other measures & outcomes Trauma (NCSTN) Youth Connections Scale ROLES/Placement Stability/LOS/Education

59 Contact Information Paul Brylske Lauren Capel Paula Waller

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