Presentation on theme: "Paul Brylske, MSW, LCSW-C, Director"— Presentation transcript:
1 The Integration of Treatment Parent Training into the Treatment of Complex Trauma Paul Brylske, MSW, LCSW-C, DirectorLauren Capel, MSW, LCSW-C, Senior Clinical Social WorkerPaula 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 CareResearch & TrainingSpecial EducationCommunity Programs
3 Kennedy Krieger Institute Areas of Specialization Autism spectrum disordersBehavioral & emotional disordersBrain injuryCerebral palsyDevelopmental disordersFeeding disordersLearning disordersMuscular dystrophySpina bifidaSpinal cord injury and paralysisChildhood Traumatic Stress
4 The Family Center at the Kennedy Krieger Institute OutpatientNCSTN category II and III site for over 8 yearsMultiple EBP’s, psychiatry and specialty clinics550 active case;19,000 visits 2013Trauma Training AcademyTherapeutic Foster Care1986 -Licensed for 100 child/youthComplex trauma, developmental disabilities, medically fragile conditionsAdoptions & permanencyIndividual Family Care
5 Learning ObjectivesBeginning 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-basedTremendous variation in TFC in the “real world”Few programs resemble evidence-based modelFactors associated with positive outcomeTraining and supervision of the treatment parent – child relationshipSupervision of childrenBehavioral interventionsNIMH (Farmer) / Maryland. Science to Service (Bruns et al 2004)
8 What effects sustainability/fidelity? Agency Readiness to Implement and Implement and ImplementIs there buy-in at all levels, especially leadershipDoes it fit agency cultureAre there necessary resource to supportCan it be integrated into current practiceCan you measure adherence & outcomeIs there support to staffTrainingConsultationSupervision/Coaching
9 Ongoing Consultation and Supervision/Coaching Teach effective practiceEnsure fidelity to practiceEnsure good judgment & decision makingInsure flexibility to meet needs of treatment parents & children/youthIncrease staff & treatment parent satisfaction (“value added) through support and skill acquisitionEnsure positive outcomes
10 KKI-TFC Trauma Integrative Model (TIM) TFC Program ElementsEvidence-based TFC(Chamberlain)“Real World” TFC (Farmer)(Bruns)Trauma Integrative Model (TIM)Service Coordination/Case ManagementYesTreatment Parents as key providers/change agentsTeam approach to treatmentRespiteWork with youth’s familyReduce association with deviant peersIntensive supervision/supportNoProactive approach to behavior problemsAddressing previous trauma (ARC)N/AComprehensive Coordination of Somatic CareAddressing Developmental DisabilitiesPreparing for transition to adulthood (TIP)Not systematicPermanencyFamily and Youth VoiceFarmer 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/ WellbeingComponents of evidence based TFCRoles of clinical social worker and treatment parent with in the “Focus of Change”Treatment of…Complex trauma/neglectDevelopment disabilitiesMedically fragile conditionsCo-existing disorders (substance abuse & specialties)Needs of transition age youthPermanency and permanency planningMulti-generational complex traumaCommunity ServicesOut-patient Psychotherapy, Psychiatry, Medical, Educational, Vocational, Recreational, OT, PT, Nursing, OthersYouth, family, and stakeholders voice
13 Attachment, Regulation, Competency (ARC) Treatment Framework Component-based vs. manualized protocolGrounded in theory and research on complex traumaRecognizes core effects of complex trauma:AttachmentSelf-regulationCompetenciesUnderstands importance of intervening within the context of the child (family and system)Components inform treatment choicesRecognizes the need for individual tailored trauma interventionsRecognizes each practitioner’s skill levelBlaustein & Kinniburgh
15 ARC Model(Kinniburgh, Blaustein, Spinzola, Van der Kolk, May 2005)
16 ARC Implementation Collaboration Consultation Training staff The Trauma Center at Justice Resource InstituteConsultationClinicalProgrammaticTraining staffInitial / OngoingTraining Treatment ParentsCurriculum DevelopmentDevelopment of ToolsStaff & parent toolkitsProgrammatic toolsFidelity, Measurement & OutcomesManuals/Clinical ProtocolsMapping ARC & CANSOther 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 OnePhase ThreeRecruitmentFollowing placement of child in the homeOrientationformal presentations, support grouppre-service traininghome study processin home/child specific trainingPhase TwoPhase FourFollowing approval/matchingDevelopment of Professional Development Plantraining to particular child & their needsAnnual review of performance and training needs
19 Goals of Treatment Parent Training Acquisition of KnowledgeAcquisition of SkillSupportProblem 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 trainingDevelops the yearly training scheduleTrains and Supervises child life staffProvides food and resourcesMonitors RSVP and attendees lists (internal and external)Maintains curriculum of each trainingReviews and maintain training evaluations.
22 Structure of Training Topic Groups Trauma Informed Geared toward needs of youth in the programProvide knowledge and tools for skill acquisition.Adult Learning ModelSupport GroupsTreatment parents are provided support from facilitators and each other on various areas including permanency.Childcare GroupsActivity groups for youth attending training with parents.Supervised by experienced child life staff.
24 Staff Integration in Training Staff MeetingsIndividual and Group SupervisionClinical ConsultationsARC consultationsDevelopment 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 parentEducatorFoster parent for 5 yearsMultiple placements including several hospitalizations, diagnostic center and RTC.Experienced treatment parent for youth with complex trauma and sexual predatory behaviors.First TFC placementPresenting IssueYouth exhibits poor self-regulation skills.Youth has limited capacity to attach to foster parentTreatment parent triggered by youth’s behavior.Integration of Trauma Tools in Practice
28 CANS/ARC Assessment: Self-Regulation Kisiel & Blaustein- NCSTN NumbingDissociationAttention Deficit Impulse ControlBehavioral RegressionAffect Dysregulation DepressionOppositionalExplain under ARC Domains rather than CANS scores. Importance of treatment planning around entire team to address.InterpersonalFamilySocial FunctioningAttachment Difficulties
33 What It Takes To Set Your Story/Perspective Aside? Reflect on your story/perspectiveIdentify your feelingsReflect on your feelingsSeparate 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 CalmBe and Act CuriousBe Attentive (especially to non-verbal cues)Be Open to ListenKnow the “Right Time” and “Right Place”
35 Benefits of Therapeutic Listening Helps to clarify informationKeeps you talking about problems and feelings(affect identification & expression)Helps you to solve problemsTalking out problem prevents acting out problems (affect modulation)Builds trust and relationshipMinimizes 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...to understand the emotions...to understand and change thinking and behavior
37 Aggressive Driver- Angry Driver vs. Preggie Lady Cognitive Behavioral TriangleAggressive Driver- Angry Driver vs. Preggie Lady
38 Trigger Protection Plan Tool What is most important may be source of your triggerHow 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 SoothingTime outsWhat are your strategies?
40 Putting the Pieces Together: Work in Progress How do we work together to support a youth with complex trauma?ClientParentClinicianSupervisor
43 Training Pre-Post Evaluations Establish objectivesClarify areas of knowledge & skillProgram/trainers/treatment parentsAssess baseline knowledgeAssess effectiveness knowledge & skill acquisitionIdentification of future training needsProgram/trainer/treatment parents
52 CANS/ARC Component Measurement T1, T2 & Overtime Measure outcomes of child/youth functioning at youth & program level over timeMeasures outcomes of trauma treatment (ARC) at youth & program level over timeCan be used at case level to measure effectiveness of interventions/toolsAt program level can be used to assess training needs of treatment parentsBecause measures of ARC components are reliable and valid measures can be used in research
53 Integration of Assessment/Treatment Intervention/Outcomes/Training CANS AssessmentARC ComponentsRegulationIntervention of ARC ToolsTherapeutic listingTrigger protection planSelf-Care strategiesCognitive triangleCANS OutcomesARC OutcomesAdditional InterventionsIdentification of training needsIndividual Tx ParentProgram
54 Restrictiveness of Placement Jamora, Brylske et al 2010n=138PriorPlacement %Discharge Placement %RESTRICTIVENESSENVIRONMENTMore RestrictiveInpatient Psych HospitalResidential Tx CenterGroup Home/Shelter11.20%16.00%32.00%12.98%3.90%18.18%Total59.20%25.06%Equally RestrictiveTFC2.40%2.60%Less RestrictiveRegular Foster CareRelativeIndependent LivingAdoption6.40%0%9.09%23.37%14.29%15.59%38.40%60.14%OtherArmed ServicesRunaway1.30%
55 Outcomes Permanency Fiscal Year Total Percentage 2010 2011 2012 2013 Adoption1591064028%Reunification1371133425%Transition842620%Year Total36203110073%
56 Placement Stability Placement Stability Mean (S.D.) Placement Changes Prior to TFC3.7 (3.6)*Placement Changes While in TFC1.7 (0.8)Comparison of placement changes before & during TFC, t-statistics 4.8, p<0.001Royes, Brylske & Belcher 2011
57 Level of Education Achievement 2013 Completed High SchoolCook (1991)54%Bloome(1997)77%Courtney (2005)67%Pecora (2003)86%Baltimore City71.4%Baltimore County92.3%Maryland86.5%National86%-90%TIM/TFC98%
58 Future Goals Completion of ARC treatment parent curriculum Increase “user friendliness” of CANS/ARC mapping toolContinual training for foster parents on CANS & ARC use and toolsIntegrate CANS/ARC Mapping within our Kidnet data systemIntegrate case/treatment noteMeasure change over timeMeasure at program levelEffectiveness of ARC/Trauma treatmentTreatment Parent Interventions/ToolsClinical Social Worker Intervention/ToolsIdentifying factors effecting effectiveness (outcomes)Program/Practice ImprovementPresentations/Publication/ResearchCompare with other measures & outcomesTrauma (NCSTN)Youth Connections ScaleROLES/Placement Stability/LOS/Education