GOING DEEPER WITH THE CHALLENGES IN TREATMENT OF CHILDREN WITH COMPLEX TRAUMA HISTORIES.

Transcription

1 GOING DEEPER WITH THE CHALLENGES IN TREATMENT OF CHILDREN WITH COMPLEX TRAUMA HISTORIES. Valerie McClellan, LCSW, ACSW Diane Braman, LCSW Kelli Leo, LPC Matthew Anderson, LCSW Noreen Davidson, LPC Solomon Counseling Center Catholic Charities, Inc.

2 LEARNING OBJECTIVES What is complex trauma? What are the unique challenges of treating complex trauma Gain increased awareness of evidence based treatment practices available Specific considerations for special populations. Special considerations for caregivers and helping professionals.

3 UNIQUE CHALLENGES OF COMPLEX TRAUMA Definition of complex trauma is complex. Symptom presentation is complex. Professionals may not be Trauma Informed Not formally recognized in the DSM-V. Similar proposed cousins include: Disorders of Extreme Stress; NOS Developmental Trauma Disorder Yet, Clinicians are treating it & Researchers are researching it.

4 WHAT IS COMPLEX TRAUMA? Exposure to multiple traumatic events, often of an invasive, interpersonal nature, and the wide-ranging, longterm impact of this exposure (NCTSN, Impact of Complex Trauma) Traumas that are multiple, chronic, and interpersonal in nature and begin at an early age (Cohen, Mannarino, Deblinger, 2012, Trauma Focused CBT for Children and Adolescents, Treatment Applications) So, complex trauma must mean: Chronic exposure Interpersonal Early exposure Impaired functioning in many domains of functioning Complexity of symptoms

5 CAUSES OF COMPLEX TRAUMA OR ADVERSE CHILDHOOD EXPERIENCES (ACE S) Physical Abuse or Neglect Sexual Abuse Emotional Abuse or Neglect Witnessing Domestic Violence Witnessing a Sibling Being Abused Parental Substance Abuse Parental Mental Illness Being Homeless Discrimination of Any Form: Racism, Sexism, etc. Separation of Caregiver Foster Care Placement Parental Separation or Divorce Incarcerated Parents Minor Refugees / Immigrants Parental Death Community Violence Natural Disasters or War Not a complete list!

6 POTENTIAL CONSEQUENCES Can have devastating effects on a child s physiology, emotions, ability to think, learn, and concentrate, impulse control, self-image, and relationship with others. (NCTSN, Complex Trauma) OF COMPLEX TRAUMA Across the life span, linked to adolescent pregnancy, domestic violence, addiction, chronic physical conditions, depression and anxiety, self-harming behaviors, and other psychiatric disorders. (Adverse Childhood Experience Study)

7 Consequences carry high $$ costs for society. For example: POTENTIAL SOCIETAL CONSEQUENCES OF COMPLEX TRAUMA child who cannot learn, may grow up to be an adult who can t hold a job child with chronic physical problems may grow up to be a chronically ill adult child who learns to hate herself may become an adult with an addiction or eating disorder

8 POTENTIAL PERSONAL Changes child/adolescent s perspective of themselves and their world: Sense of Safety & Stability Self-perception: Mouse vs. Monster vs. Me Attachments in relationships become challenging-family, Caregivers, Peers, Authority figures Become people pleasing Withhold emotions Become parentified CONSEQUENCES OF COMPLEX TRAUMA

9 UNIQUE CHALLENGES IN TREATMENT OF COMPLEX TRAUMA Complex Trauma Causes Complex Problems Over Many Domains of Functioning Physical Health: Body & Brain: Immune system & Stress Response Emotional Responses Behavior Difficulties Cognition Problems: Thinking & Learning Self-Concept & Future Orientation Attachment & Relationship Difficulties Boundaries Difficulties Dissociation

10 SO WHAT? Why should we care about having an understanding of complex trauma? Is it a problem? What does it cost us? (as human beings, caregivers, adults with a trauma history, clinicians, parents, tax payers, etc)

11 ADVERSE CHILDHOOD EXPERIENCE U.S. STATISTICS 2012 U.S. Child Protective Services rec d 3.4 million referrals of children being abused/neglected. CPS estimated approx. 700,000 children were victims of maltreatment (1% of all children). Strong probability this # may be underestimated. Estimated 1,640 children DIED from maltreatment A non-cps study estimated that 1 in 4 U.S. children experience some form of maltreatment in their life. Estimates are 10 % of children are poly-victimized (3 or more events) Recent studies suggest 10% of children have an Adverse Childhood Experience score of 9 or more

12 MS CHILDREN S ADVERSE EXPERIENCES Most common ACE s and % prevalence among children 0-17 yrs: Economic Hardship 32% of our children Divorce 22% Alcohol (caregiver addiction) 13% Violence 12% o Compare MS ACE s to US statistics: MS: 3 rd highest in economic hardship (32%) 5 th highest in violence (12%) 2 nd in experiencing death of a loved one(6%) 2 nd in living with domestic violence (11%) How do you see these children?

13 CAUSE I AIN T GOT A PENCIL I woke myself up Because we ain t got an alarm clock Dug in the dirty clothes basket, Cause ain t nobody washed my uniform Brushed my hair and teeth in the dark, Cause the lights ain t on Even got my baby sister ready, Cause my mama wasn t home. Got us both to school on time, To eat us a good breakfast. Then when I got to class the teacher fussed Cause I ain t got a pencil. By Joshua T. Dickerson

14 WHEN DOES A CHILD GET REFERRED FOR A MENTAL HEALTH ASSESSMENT? How many ACE s does a child need to have experienced before we refer for an assessment? Do we make an distinction between ACE s are some worse than others? What if the child looks okay, like everything is fine? Does a child only warrant counseling if they display behavioral problems?

15 RESOURCES FOR IDENTIFYING AN EVIDENCED BASED PROGRAMS SAMHSA National Registry of Evidence- Based Programs and Practices Nat l Child Traumatic Stress Network California Evidence-Based Clearinghouse for Child Welfare Additional states have similar databases

16 RESOURCES FOR IDENTIFYING AN EVIDENCED BASED PROGRAMS o SAMHSA, National Registry of Evidence-Based Programs and Practices (NREPP) o Filters: 1) Program Type Mental Health Treatment 2) Ages 6 17 (Children & Adolescents) 3) Settings Outpatient Facility 4) Outcome Rating Effective (the best rating) Only Identified EBP: Trauma Focused CBT

17 RESOURCES FOR IDENTIFYING AN EVIDENCED BASED PROGRAMS Nat l Child Traumatic Stress Network: Treatments That Work (tab): Individuals who wish to know the evidence supporting an intervention may search online databases such as the National Registry of Evidence-Based Programs and Practices (NREPP) and the California Evidence-Based Clearinghouse for Child Welfare (CEBC). These websites offer a rigorous review of interventions and the evidence supporting them for a variety of child and adolescent mental health problems. Those searching for an intervention to best match the needs of the populations they serve are encouraged to consider other interventions than those summarized here. 43 interventions listed, no way to filter results (TFCBT was listed, PET & EMDR were not.)

18 RESOURCES FOR IDENTIFYING AN EVIDENCED BASED PROGRAMS California Evidence-Based Clearinghouse for Child Welfare, Program Registry, Topic Areas (tabs): Trauma Treatment Client-Level Interventions (Child & Adolescents) EBP s with Scientific Rating #1 (Well-Supported by Research Evidence) 1) TF-CBT 2) Prolonged Exposure Therapy (PET) 3) Eye Movement Desensitization & Reprocessing (EMDR)

19 CA CLEARINGHOUSE FOR CHILD WELFARE SCIENTIFIC RATING #1, EBP S FOR TX OF CHILD/ADOL. TRAUMA -EMDR- -PET- -TFCBT- Addresses: PTSD, anxiety, PTSD PTSD, shame, distorted behavioral problems beliefs, behavioral problems Caregivers: no no directly provides services- involvement involmt parenting, trauma related emotional distress Intensity: weekly weekly weekly # sessions:? (3-12) All 3 txs have available: materials in languages other than English; manuals and training, can be delivered in numerous settings.

20 TF-CBT: TREATMENT APPLICATIONS FOR COMPLEX TRAUMA Overview: o Personal resources that should be allocated for development, were used for survival o They lost or never developed, the ability to regulate themselves. Dysregulation, hallmark characteristic o Initial TFCBT goal is to return child to pretrauma functioning. Survivors of complex trauma may not have a pretrauma baseline to return to. o Environment may remain chaotic with numerous crisis. o Trauma work may dissolve into series of stops & starts

21 TF-CBT: TREATMENT APPLICATIONS FOR COMPLEX TRAUMA Why Are Applications Necessary: o Therapeutic Relationship: Trauma work necessitates a solid working alliance. Attachment difficulties often create a tenuous therapeutic relationship. o Need to process current pressing issues as well as past events. o Adolescents with hx of complex trauma ill-equipped to jump into trauma tx. May not be prepared to benefit from PRACTICE components without modifications.

22 TF-CBT: TREATMENT APPLICATIONS FOR COMPLEX TRAUMA Assessment Challenges: o Adol. may not bring a long-term, informed caregiver to tx o May take months for adolescent to trust therapist o Behavior may get worse o Be mindful of level of arousal o o o o Obtain info from other sources: teacher, caseworker, etc. Conceptualize assessment as peeling an onion No complex trauma assmt tool exists for children/adolescents Use assmt tools that examine multiple areas of functions and obtain info from mult. informants: TSSC, MMPI-A, BASC, CBRS, CBCL, TRF, TSCC, Wechsler Intelligence, Stanford- Binet Intelligence Scale

23 TF-CBT: TREATMENT APPLICATIONS FOR COMPLEX TRAUMA Facilitating Engagement, Safety, and Stability Thru TF-CBT: Engagement important of therapeutic relationship cannot be overemphasized; be patient; may need to be less directive & structured; adolescent is gradually exposed to therapist. Safety may need to be prioritized early & ongoing; include safe people, places, assertiveness training, problem solving; caring adults may need to be trained due to youth deficits that impact safety; necessary to discontinue trauma work if adolescent is at risk

24 TF-CBT: TREATMENT APPLICATIONS FOR COMPLEX TRAUMA Facilitating Engagement, Safety, and Stability Thru TF-CBT: o Psychoeducation initially devoted to educating youth and caregivers on impact of stress and trauma on youth s current functioning; defn of stress, responses to stress and trauma, trauma triggers, coping mechanisms (healthy/unhealthy) o o Youth & caregivers are helped to understand the adol. emotional/behavioral dysregulation as overreactions to stress rather than willful misbehavior. Support youth & caregiver identify their own adaptive & maladaptive responses to stress.

25 TF-CBT: TREATMENT APPLICATIONS FOR COMPLEX TRAUMA Facilitating Engagement, Safety, and Stability Thru TF-CBT: o Parenting if traditional caregiver present, therapist models appropriate engagement strategies. o If there is NOT a traditional caregiver, parenting component is conceptualized as the systems component and includes any caregiver or authority figure who play a significant role in the adol. life. Therapist should be transparent about contacting these systemic entities. o Goal is to crease a trauma-informed system of caregivers/professionals working with the adolescent.

26 TF-CBT: TREATMENT APPLICATIONS FOR COMPLEX TRAUMA Facilitating Engagement, Safety, and Stability Thru TF-CBT: o Relaxation Incorporate coping strategies the adolescent has used in the past. o Due to neurobiological alarm system being overactive, physically based activities, such as yoga, stretching, PMR, may be more beneficial than cogn. activities. o Affective Regulation may be challenging due to past use of emotional numbing or dissociative responses, lots of psychoeducation about emotions.

27 TF-CBT: TREATMENT APPLICATIONS FOR COMPLEX TRAUMA Facilitating Engagement, Safety, and Stability Thru TF-CBT: o Cognitive Coping increase awareness of cognitions during stressful experiences increases realization that thoughts they experience may increase likelihood of becoming distress and engaging in problematic behavior develop cognitive coping strategies identify triggers gradual exposure is incorporated.

28 TF-CBT: TREATMENT APPLICATIONS FOR COMPLEX TRAUMA Facilitating Engagement, Safety, and Stability Thru TF-CBT: o Achieving Good-Enough Stability perfect stability is not required therapeutic relationship should be stable adolescent need to demonstrate sufficient mastery of self-regulation skills when PTSD symptoms become manageable

29 TF-CBT: TREATMENT APPLICATIONS FOR COMPLEX TRAUMA Facilitating Engagement, Safety, and Stability Thru TF-CBT: Trauma Narrative & Processing may not have explicit verbal memory if occurred prior to 3yo may not be feasible to complete detailed account of each traumatic event due to length of narrative allow adolescent to guide what events should be included the meaning attributed to the events is of greater importance than repeated processing of the details of the trauma understanding underlying trauma themes and how these relate to the youth s current functioning is often the most critical and meaningful aspect

30 TF-CBT: TREATMENT APPLICATIONS FOR COMPLEX TRAUMA Facilitating Engagement, Safety, and Stability Thru TF-CBT: In Vivo Mastery needs to be initiated early in tx to facilitate the development of stability and engagement; often of critical importance because they need to develop the capacity to self-regulate sufficiently to tolerate uncomfortable but essentially safe situations

31 TF-CBT: TREATMENT APPLICATIONS FOR COMPLEX TRAUMA Facilitating Engagement, Safety, and Stability Thru TF-CBT: o Conjoint Session (if there is a caregiver) o used to facilitate engagement & stability o because of disrupted attachment, relationship may be strained or dysfunctional o used to practice decreasing signals of danger while increasing signals of care

32 TF-CBT: TREATMENT APPLICATIONS FOR COMPLEX TRAUMA Facilitating Engagement, Safety, and Stability Thru TF-CBT: o Enhancing Safety & Future Development essential to provide adolescent with appropriate safety & prevention skills that can be applied to future life situations provide info regarding healthy relationships and sexuality help adol. understand some of the factors associated with complex trauma increasing risk of revictimiation begin to identify potential future goals, identify inaccurate/unhelpful beliefs about the future and assist in addressing these

33 TF-CBT: TREATMENT APPLICATIONS FOR COMPLEX TRAUMA Facilitating Engagement, Safety, and Stability Thru TF-CBT: o Ending Treatment plan for termination early in tx & revisit as necessary, conclusion should be predictable support adolescent in processing feelings re: termination and how end of therapeutic relationship is different from previous experiences present termination as an achievement therapeutic relationship continues after end of session, albeit in different form model appropriate emotions associated with completion of tx

34 TF-CBT: TREATMENT APPLICATIONS FOR COMPLEX TRAUMA Facilitating Engagement, Safety, and Stability Thru TF-CBT: o Conclusion o Clinicians advocate phase-based approach for complex trauma o TF-CBT most researched EBP for treating children and adolescents exposed to trauma o TF-CBT model is consistent with a phase-based approach to tx of complex trauma o Even after tx, trauma doesn t end for kids with complex trauma

35 TF-CBT IN SPECIFIC POPULATIONS TFCBT has been modified to address the needs of Latino, Native American, deaf and hearing impaired, military and many international populations. It has been provided in group formats and in multiple settings (e.g. homes, foster homes, schools, residential tx facilities). It has been tested in U.S. Caucasian, African American and Latino populations as well as in European, Australian and African youth. It has been translated into Chinese (Mandarin), German, Dutch, Polish, Japanese and Korean. French and Russian translations are underway.

36 ADDITIONAL CHALLENGES: POSSIBILITY OF GENERATIONAL TRAUMA o Where trauma has been untreated, what is fairly common is that the untreated trauma in the parent is transmitted through the child through the attachment bond and through the messaging about self and the world, safety, and danger. (Stephanie Swann, PhD, LCSW) o Previous research assumed that the trauma transmission was mainly caused by the parents child-rearing behavior, however, it may have been also epigenetically transferred. (Wikipedia) o Two clinical studies of children exposed to a violent event strongly suggest that children whose parent(s) were previously traumatized may be more likely to be subsequently exposed to a traumatic event and are at risk of experiencing increased symptoms following a traumatic event. (Nader K.O. Violence: Effects of parent s previous trauma on currently traumatized children.)

37 CASE STUDY: 16 YO, COMPLEX TRAUMA 16 yo female with extensive trauma hx: neglect, DV, parents in/out of jail Raised by bio. uncle and his wife by age 4 yo. Uncle sexually abused her, 6-15yo Client & younger sister now being raised by non-bio. Aunt Client s trauma has triggered her aunt s trauma hx (sex. abuse, rape, physical abuse, parental kidnapping) Client has difficulty regulating her emotions, will become physically aggressive Aunt is high functioning but struggles with parenting & managing her own trauma symptoms. Treatment:

38 CASE STUDY 4 YO, NEGLECT 4 yo male, removed from home due to severe neglect due to parent s substance abuse Client is in 3rd foster home. Now living with adoptive foster parents with 3 yo sibling. Requested therapy due to multiple behavior problems: hoarding food & water, eating until he threw up, poor sleep, biting the wooden bed, bed wetting, temper tantrums, breaking things, anger outbursts, difficulty paying attention & following rules, etc. Presents like a typical 4 yo Lots of strengths: stable, safe foster parents, resilient, etc. Treatment:

39 CASE STUDY 4 YO, NEGLECT (CONT D)

40 PRACTICE SELF CARE DO NO HARM, we have to know ourselves & what kind of work we do, don t do, can t do and should or shouldn t do. We all have limitations. Importance of self care Sleep / Food Move your body / Yoga Nature / Pets / Fun Therapy / Supportive relationships Spiritual beliefs

41 REFERENCES Greeson, J. P., Briggs, E. C., Kisiel, C. L., Layne, C. M., Ake III, G. S., Ko, S. J., &... Fairbank, J. A. (2011). Complex Trauma and Mental Health in Children and Adolescents Placed in Foster Care: Findings from the National Child Traumatic Stress Network. Child Welfare, 90(6), Cohen, J, Mannarino, Anthony, Deblinger, Ester, (2006). Treating Trauma and Traumatic Grief in Children and Adolescents. Cohen, J, Mannarino, Anthony, Deblinger, Ester, (2012). Trauma-Focused CBT for Children and Adolescents. Treatment Applications. Cohen, J, Mannarino, Anthony, Deblinger, Ester, with Melissa Runyon and Anne Heflin, (2015). Child Sexual Abuse. A Primer for Treating Children, Adolescents, and Their Nonoffending Parents. Emerson, David, Hopper, PhD, Elizabeth, (2011). Overcoming Trauma through Yoga. Websites: National Child Trauma Stress Network The California Evidence-Based Clearinghouse For Child Welfare Samhsa s National Registry of Evidence-based Programs and Practices Centers for Disease Control and Prevention Kid s Count, Data Center