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The Integration of Treatment Parent Training into the Treatment of Complex Trauma Paul Brylske, MSW, LCSW-C, Director Lauren Capel, MSW, LCSW-C, Senior.

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Presentation on theme: "The Integration of Treatment Parent Training into the Treatment of Complex Trauma Paul Brylske, MSW, LCSW-C, Director Lauren Capel, MSW, LCSW-C, Senior."— Presentation transcript:

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 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 Kennedy Krieger Institute Unlocking the Potential of Children with Special Needs since

3 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 Kennedy Krieger Institute Areas of Specialization 3

4 The Family Center at the Kennedy Krieger Institute The Family Center ◦ 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  Licensed for 100 child/youth  Complex trauma, developmental disabilities, medically fragile conditions  Adoptions & permanency  Individual Family Care 4

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 5

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) 6

7 Limitations of Training 7

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 8

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 9

10 KKI-TFC Trauma Integrative Model (TIM) 10

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 11

12 Focus of Change 12

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 13

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

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

16 ARC Implementation Collaboration ◦ 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) 16

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. 17

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

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

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. 20

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. 21

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. 22

23 Staff Integration 23

24 Staff Integration in Training Staff MeetingsIndividual and Group SupervisionClinical ConsultationsARC consultations Development of useful tools (CANS/ARC; All About _____ Forms) 24

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. 25

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. 26

27 Case Presentation Demographics ◦ Parent  44 year old treatment parent  Educator  Foster parent for 5 years  Experienced treatment parent for youth with complex trauma and sexual predatory behaviors. Client  13 year old male with history of physical abuse, neglect, homicidal and suicidal ideation.  Multiple placements including several hospitalizations, diagnostic center and RTC.  First TFC placement 27 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 Interpersonal Family Social Functioning Attachment Difficulties 28

29 Training Topic Example REGULATION

30 30

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

32 Who’s Perspective? 32

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) 33

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” 34

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 35

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 36

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

38 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”? Trigger Protection Plan Tool 38

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

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

41 How It All Comes Together 41

42 O utcomes 42

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 43

44 44 Domain Items Case-Specific Score Comparison

45 CANS Scores Over Time 45

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

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

48 Percentage Domain Total Percentages All Domains Domain: Child Behavioral Emotional 48

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

50 50 CANS/ARC Score Comparison

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

52 CANS/ARC Component Measurement T1, T2 & Overtime 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 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 Integration of Assessment/Treatment Intervention/Outcomes/Training 53

54 n=138Prior Placement % Discharge Placement % RESTRICTIVENESSENVIRONMENT 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 TFC2.40%2.60% Total 2.40%2.60% Less Restrictive Regular Foster Care Relative Independent Living Adoption 32.00% 6.40% 0% 9.09% 23.37% 14.29% 15.59% Total 38.40%60.14% Other Armed Services Runaway 0% 1.30% Total 0%2.60% Restrictiveness of Placement Jamora, Brylske et al

55 Permanency Fiscal Year TotalPercentage Adoption % Reunification % Transition % Year Total %Outcomes 55

56 Placement StabilityMean (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<0.001 Royes, Brylske & Belcher 2011 Placement Stability 56

57 EducationCompleted High School Cook (1991)54% Bloome(1997)77% Courtney (2005)67% Pecora (2003)86% Baltimore City71.4% Baltimore County92.3% Maryland86.5% National86%-90% TIM/TFC98% Level of Education Achievement

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 58

59 Contact Information 59 Paul Brylske Lauren Capel Paula Waller


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