1. Assessment-Based Treatment for Traumatized Children: A Trauma Assessment Pathway Model (TAP) Presented by: Alicia Gilbert, PhD Robyn Igelman, PhD

2. Chadwick Center for Children and Families Chadwick Center for Children and Families Chadwick Center Programs Trauma Counseling Forensic and Medical Services Family Support Professional Education Research Linkage Child & Adolescent Services Research Center (funded by the NIMH)

3. Trauma Counseling Program  Assessment-based individual, group and family therapy for children who have experienced traumatic events.  Therapy and advocacy to domestic violence victims and their children at the Family Justice Center.  School-based counseling services.  Parent-child interaction therapy.  Medication & psychological assessments.  Crisis intervention, advocacy, information and referrals.

4. TAP Model Overview  A treatment manual for traumatized children ages 2 to 18 years  Incorporates assessment data, clinical interview, and observation to create a Unique Client Picture  Includes specific components of trauma- specific treatment described by the Trauma Wheel  Draft completed and undergoing revisions

5. What Is Assessment Based Treatment (ABT)? Development of clinical assessment-based treatment refers to the “ development of an integrated plan of prioritized interventions, that is based on the diagnosis and psychosocial assessment of the client, to address mental, emotional, behavioral, developmental and addictive disorders, impairments and disabilities, reactions to illnesses, injuries, and social problems. ” (Social work, consolidated laws, effective Sept. 1, 2004)

6. Clinical Pathways A sequence or path that clinicians follow in making assessment, triage, and clinical decisions. A sequence or path that clinicians follow in making assessment, triage, and clinical decisions. Found increasingly useful within the medical field. Found increasingly useful within the medical field. Evaluation of UCLA ’ s Asthma Pathway showed substantial cost effectiveness and adherence to medical standards (Chest, 1998) Evaluation of UCLA ’ s Asthma Pathway showed substantial cost effectiveness and adherence to medical standards (Chest, 1998) Rady Children ’ s Hospital developed over 40 pathways, starting with Asthma in 1994, domestic violence in 2001, and TAP in 2005. Rady Children ’ s Hospital developed over 40 pathways, starting with Asthma in 1994, domestic violence in 2001, and TAP in 2005. TAP includes a pathway that directs triage, assessment, referrals, and clinical interventions. TAP includes a pathway that directs triage, assessment, referrals, and clinical interventions.

7.  The therapeutic goal is to resolve the impact of a single or series of traumatic experiences to the child and their family.  Therapeutic decisions emerge from clinical and standardized assessment. Chadwick’s Philosophy of Trauma Treatment

8. 3 Components of TAP 1. Assessment Creating a Unique Client Picture 2. Triage 3. Treatment

9. Assessment: Is the client appropriate for your Center and for the TAP Model?

11. To get the full rich unique client picture, gather information via:  Clinical Interviews  Behavioral Observation  Standardized Measures

13. Standardize your Assessment Choices What measures exist to help you know your client? DomainInformants ChildCaretakerClinician Trauma HistoryUCLA PTSD IndexCaretaker Trauma- TSI Clinical Interview Symptom PresentationTrauma Symptoms TSCC, UCLA PTSD Index Other Symptoms: YSR, CDI, BAIC Trauma Symptoms CSBI, CDC, UCLA PTSD Index Other Symptoms: CBCL Clinical Interview/Observation * Teacher can complete TRF Relevant Contextual History Family Dynamics FAM-III, FRI, FACES Peers YSR Family Dynamics FAM-III, FRI Parenting: PSI Peers CBCL Clinical Interview/Observation Developmental HistoryClinical Interview IQ: WISC,KBIT, Stanford Binet Clinical Interview ITSEA, BITSEA, ASQ Clinical Interview/ Observation Denver, Bayleys

14. Measurement Considerations  Psychometric Properties Reliability and Validity Reliability and Validity Clinical Cutoffs Clinical Cutoffs  Sensitivity to Change  Feasibility Issues Time to administer Time to administer Staff training Staff training Costs of using measures Costs of using measures  Language  Multiple vs. Single Informants  Real World Validity  Clinical Utility

15. Assessment Pathway Process 1. Core measures administered 2. Problem areas identified 3. Other measures are administered to probe more deeply

16. Guiding Therapists via Assessment Pathways integrated into assessment measures

17. Therapists’ Use of Assessment Measures: Guiding the assessment and providing feedback.

18. How to make sense of assessment results:  Know what each measure assesses and applicable populations  Have a general understanding of each subscale  Examine the validity scales (if any)  Use assessment results as an adjunct to your clinical interview  Clarify inconsistencies between assessment results and clinical impressions

19. How to make sense of assessment results (cont.):  Involve the parents and children in your interpretive process  Integrate results with clinical impressions & think about how the results can be used to plan treatment  Don’t discount your clinical judgment!!

20. Problem Solving: What Happens When the Measures & Clinician Don’t Agree?

21. Critical Items

22. How do you discuss feedback with your clients?

23. Parent and client feedback: Dos & Don’ts DO:  Allow one therapy session to discuss results and give feedback  Elicit client feedback and impressions regarding assessment results  Discuss results with parent and child to confirm clinical impressions  Address areas of concern not initially revealed through clinical interview  Most important: Engage them in the process!

24. Parent and client feedback: Dos & Don’ts (cont.) DON’T:  Avoid discussing results with your clients  Act like the assessments are a waste of time (because your clients will too!)  Be afraid to share written feedback and printouts with parents and children  Underestimate the ability of your clients to understand and appreciate your feedback

25. How to form your clinical hypothesis  Consider all assessment feedback  Which family members need to be included in treatment? What are the dynamics in the family?  Family and client buy in  Consider the cause of distress

26. Heuristics of Using the Clinical Pathway  One skill builds upon another.  All spokes of the Trauma Wheel will be addressed at some point during treatment.  The length of time and intervention type depend upon the unique client picture.  The wheel is fluid – you move back and forth between spokes of the wheel.

27. Trauma Integration Systemic Dynamics Skill Building & Psychoeducation Addressing Maladaptive Cognitions Affect Regulation Relationship Building Culture Child Development The Trauma Wheel

28. Case Example: Referral Information Referral Information Interview with Child & Family Interview with Child & Family Standardized Assessment Results Standardized Assessment Results Consider family buy-in & needs before making treatment decisions Consider family buy-in & needs before making treatment decisions Re-Assess Re-Assess

29. On-going Re-assessment  Weekly interviews/updated goals  Progress notes  Supervision  Follow-up standardized measures Must use the same measures for each time period (to measure change over time) Must use the same measures for each time period (to measure change over time) Can add measures over time (once added must continue to administer added measure to assess change over time). Can add measures over time (once added must continue to administer added measure to assess change over time).

30. Symptom Change Over Time

31. Trauma Assessment Pathway Model (TAP): At a Glance Initial Screening Process Triage Assessment: Clinical Interview and Standardized Measures Integrate Assessment Information Form Unique Client Picture Narrow the Clinical Focus Select Symptom Domains Hypotheses/Prioritize Treatment Pathway Guides treatment decisions and the use of the Trauma Wheel Reassess: Weekly interviews, update goals Supervision Follow-up standardized measures Continue Treatment Following the Treatment Pathway Refer out Refer to a specialized program if needed Termination Trauma Wheel Establish Treatment Goals

32. You’re the Experts  What are some basic assumptions you may have about traumatized clients?  How have you validated those assumptions?  What is your experience with using assessment measures?

33. Resources  www.ChadwickCenter.org (Chadwick) www.ChadwickCenter.org  www.nctsn.net (National Child Traumatic Stress Network) www.nctsn.net  www.musc.edu/cvc/ (TF-CBT on-line and OVC guidelines) www.musc.edu/cvc/  www.cachildwelfareclearinghouse.org www.cachildwelfareclearinghouse.org

34. Contact Information Alicia Gilbert, PhD 858-966-8682 agilbert@rchsd.org Robyn Igelman, PhD 858-576-1700, ext. 3211 rigelman@rchsd.org