Social Workers and LMHCs: How to Obtain Your Continuing Education Contact Hour for this Webinar

Transcription

1 Social Workers and LMHCs: How to Obtain Your Continuing Education Contact Hour for this Webinar Create a Username & Password at the NYU Silver CE Online Portal : Log on to the Continuing Education Online Portal for the NYU Silver School of Social Work page, click on All Events & Programs tab Scroll down & select today s webinar under Online Learning Click Register Fill in the billing information, click register, and pay the CE registration fee Remember: Our system works best with Google Chrome or Mozilla Firefox

2 Social Workers and LMHCs: How to Obtain Your Continuing Education Contact Hour for this Webinar, cont. After registering, you will receive a confirmation with a link to complete an evaluation Once the evaluation is submitted, within hours, log back on to NYU Silver CE Online Portal, go to Your Registrations and you will see Take Assessment in red next to the name of the program Complete assessment Once done, you will be directed how to download your CE certificate For Questions: Call us at or us at silver.continuingeducation@nyu.edu

3 Trauma Sensitive Schools Series Part 4: Providing services to students with clinically significant difficulties following trauma exposure SARAH KATE BEARMAN, PH.D. THE UNIVERSITY OF TEXAS AT AUSTIN DEPARTMENT OF EDUCATIONAL PSYCHOLOGY DEPARTMENT OF PSYCHIATRY, DELL MEDICAL SCHOOL

4 Clinical child psychologist Who am I? Assistant professor of School Psychology at UT Austin Director of the Laboratory for Leveraging Evidence and Advancing Practice for Youth Mental Health (LEAP Lab) Research focuses on the flexible, feasible use of evidence-based practices for children in complex, low-resource settings (schools, clinics, primary care, child welfare)

5 Plan for today Impact of traumatic events on children Review of the multi-tiered systems of support (MTSS) model of intervention in schools Tier III Clinical Presentation Common Elements Approaches to Treatment Key Practice: Prolonged Exposure via Trauma Narration Questions

6 Impact of Traumatic Events on Children

7 Trauma vs. Stress Stressful events: more common, less extreme than traumatic events Can be a single or multiple/ongoing event(s) Parental divorce, romantic breakups, childhood bullying Traumatic events: exposure to actual or threatened harm or fear of death or injury Uncommon or extreme Can be one time or complex, developmental traumas Physical, sexual abuse; neglect, exposure to violence, medical traumas, accidents, natural disasters, war, refugee trauma, traumatic loss

8

9 Prevalence of ACEs

10 Child Maltreatment Four primary acts of child maltreatment Physical abuse, neglect, sexual abuse, and emotional abuse A report of child abuse is made every 10 seconds in the United States. In North America, it is estimated that one in ten children experience some form of sexual victimization by an adult or peer 1:10 children also receive harsh physical punishment by a parent or other caregiver that puts them at risk of injury

11 Types of Child Maltreatment by Percentage

12

13 How Stress Affects Children Children and youths need a basic expectable environment to adapt successfully Stressful events affect each child in different and unique ways Hyperresponsive reactions Hyporesponsive reactions Allostatic load: progressive wear and tear on biological systems due to chronic stress

14 A Biological Model of Anxiety: How normal anxiety works Stimulus Accurate interpretation of threat Anxious Arousal Fight Flight Freeze

15

16 Stimulus How anxiety becomes disordered Misinterpretation of threat Anxiety Fight Flight Freeze

17 Generalization of Fears

18

19 Children, trauma, and schools

20 Multi-Tiered Systems of Support in Schools

21 MTSS In Schools Tier III: Few Students Tier II: Some students Tier I: All students

22 MTSS In Schools Universal Best Practices: Education for teachers/staff, school-wide supports, Social Emotional Learning Curriculum Tier III: Few Students Tier II: Some students Tier I: All students

23 MTSS In Schools For students atrisk or with some symptoms: Evaluation, Additional classroom supports/ Accommodation s, small-group programming Tier III: Few Students Tier II: Some students Tier I: All students

24 Students experience clinical impairment: evidence-based assessment and intervention provided by MH clinician MTSS In Schools Tier III: Few Students Tier II: Some students Tier I: All students

25 Tier III Services for Trauma Clinical Presentation of Youth with Clinical Impairment

26 Maltreatment and Trauma Predicts: PTSD (a small subset) Depression Co-morbid/overlap w/ptsd symptoms Conduct & externalizing problems (common outcome) High rates of prior victimization for youth in juvenile justice system Most common reason for referral Is predicted by trauma exposure and also predicts future trauma

27 Disorders related to Trauma and Maltreatment Trauma- and stressor-related disorders is new category in DSM-5 Includes: Acute Stress Disorder Adjustment Disorder Posttraumatic Stress Disorder (PTSD) Reactive Attachment Disorder Disinhibited Social Engagement Disorder

28 Post Traumatic Stress Disorder Development of symptoms following exposure to one or more traumatic events: Exposure includes directly experiencing, witnessing in person, learning of the trauma to a close family member/friend, or repeated/extreme exposure to aversive details Key symptoms: o Re-experiencing ( flashbacks ) or intrusive memories o Anhedonic or dysphoric mood states & negative/disrupted cognitions o Physiological arousal & reactive externalizing behaviors o Dissociative symptoms

29 PTSD - DSM5 A: Stressor (direct/witness/indirect family or friend; constant exposure) B: Intrusive symptoms (memories, dissociative, nightmares, prolonged distress/physiological after trigger) C: Avoidance (thoughts, feelings, external reminders) OR Negative cognitions and mood (thoughts, affect, poor memory for stressor, self-blame, etc.) D: arousal and reactivity (hyperarousal, startle, aggressive behavior, sleep disturbance) E: > 1 month F: Functional impairment G: Not d/t medication, substance use, other illness

30 PTSD - Preschool Subtype Intrusive: repetitive/re-enacting play Fewer symptoms: 1 sx from either C or D Not including: amnesia; foreshortened future; self-blame Developmentally tailored mood/behavior sx (e.g., sadness, loss of interest in play, temper tantrums) 3 to 8x more children qualified for diagnosis compared to the DSM-IV Scheeringa et al., 2011; Scheeringa et al., 2012

31 Trauma- and Stress-Related Disorders: Acute stress disorder is characterized by: The development during or within 1 month after exposure to an extreme traumatic stressor of at least nine symptoms associated with intrusion, negative mood, dissociation, avoidance, and arousal Children who react to more common (and less severe) forms of stress in an unusual or disproportionate manner may qualify for a diagnosis of adjustment disorder

32 Cognitive Model of PTSD Ehlers & Clark, 2000

33 Cognitive Model of PTSD Ehlers & Clark, 2000 The story of the event is disjointed Attention bias for threat messages increase Shift in awareness toward traumatic cognitions (at the expense of neutral cognition)

34 Cognitive Model of PTSD Ehlers & Clark, 2000 Memory of Abuse I am in danger NOW I m not safe. I can t handle this.

35 Cognitive Model of PTSD Ehlers & Clark, 2000 Physiologica l Arousal Fight, Flight, Freeze Avoidance Emotional Blunting Negative thoughts Hypervigilance

36 Risk Factors for PTSD Sociodemographic Female Gender Black or Latino ethnicity Trauma characteristics Type of trauma Highest risk for traumas involving interpersonal violence Pre-existing anxiety disorders and distress disorders (e.g., MDD) Behavioral disorders increase risk for exposure to traumas Previous trauma exposure/exposure to multiple traumas Not uncommon to have multiple exposures

37 Nature and Prevalence of Conduct Problems Oppositional Defiant Disorder: recurrent pattern of negativistic, defiant, disobedient and hostile behaviors leading to day-to-day impairment Conduct Disorder: Repetitive and persistent violation of the basic rights of others and societal norms 5-10% of youth have significant persistent oppositional, disruptive, or aggressive behavior problems 1 Conduct problems predict social dysfunction, academic failure, alcohol and substance abuse, adolescent homelessness and psychiatric comorbidity Well-documented negative trajectory for untreated cases 1. Moffitt & Scott, 2008

38 Conduct Problems and Mental Health Treatment Highest rates of referral for US mental health services involve aggression, acting-out, and disruptive behavior problems Most costly for society

39 Assessment is critical! Although many children are exposed to traumatic events, PTSD is rare Children who have effectively processed the traumatic event do not need treatment focused on trauma May need interventions to manage mood, anger, behavior Detailed assessment is necessary to determine if child is experiencing hallmark symptoms of PTSD (avoidance and re-experiencing) Child PTSD Symptom Scale (CPSS) (Foa et al., 2001) or UCLA PTSD- Reaction Index Other evidence-based assessment measures: ASEBA forms (CBCL & YSR), BASC to assess other broad-band concerns

40 Tier III Services for Trauma A Common Elements Approach

41 Common Elements across EBTs Recent reviews have dissected treatment protocols and point to a list of common elements that appear across diagnostic categories Chorpita and Daleiden (2007; 2011) looked at ESTs for Anxiety, Depression, ADHD and Conduct and identified more than 2 dozen elements that spanned diagnostic categories

42 What does the evidence base say about treating child PTSD? Best Support CBT with parent involvement (4) Good support: CBT (5) Minimal Support Play Therapy (1) Psychodrama (1) CHORPITA ET AL.(2011)

43 What does the evidence base say about treating child disruptive behavior? Best Support Parent Management Training/Behavioral Parent Training (41) Multisystemic Therapy (9) Social Skills Training (7) CBT (4) Assertiveness Training (3) CHORPITA ET AL.(2011)

44 Unpacking the single-disorder EBTs Defiant Children BPT for Conduct TF-CBT

45 How do you derive common elements? Family of Treatment Protocol Protocol Protocol

46 How do you derive common elements? Behavioral Parent Training for Conduct Problems Parent Management Training PCIT Defiant Children

47 How do you derive common elements? Type of Treatment Protocol Protocol Protocol Practice Element Practice Element Practice Element Practice Element Practice Element Practice Element

48 How do you derive common elements? Behavioral Parent Training Parent Management PCIT Defiant Children Attending Attending Attending Active Ignoring Active Ignoring Active Ignoring Time Out Reprimands Time Out Time Out School Behavior Plan These are practice elements.

49 How do you derive common elements? Evidence Based Treatments Defiant Children Coping Cat Copjng With Depression Course Attending Exposure Mood Monitoring Active Ignoring Cognitive Restructuring Cognitive Restructuring Problem Solving Problem Solving Problem Solving Rewards Rewards Rewards These are practice elements.

50 What are the practice elements used in treatment of PTSD? Most Used Elements Exposure (91%) Cognitive Restructuring (91%) Child Psychoeducation (82%) Relaxation (64%) Caregiver Psychoeducation (45%) Lower Frequency Elements Personal Safety Skills (27%) Assertiveness Training (27%) Communication Skills (27%) Modeling (27%) CHORPITA & DALEIDEN (2009)

51 What are the practice elements used in treatment of disruptive behavior? Most Used Elements Parent/Teacher Praise (53%) Time out (51%) Tangible Rewards (46%) Use of Effective Commands (43%) Lower Frequency Elements Insight building (9%) Assertiveness Training (9%) Communication Skills (26%) Relaxation (13%) CHORPITA & DALEIDEN (2009)

52

53

54

55 Key Practice Prolonged exposure via trauma narration

56 Evidence Based Intervention Techniques (Cohen, Mannarino, & Deblinger, 2006) P R A C T I C E Psychoeducation & Parenting Strategies Relaxation Skills Affective Modulation Skills Cognitive Coping Skills Trauma Narration In-Vivo Exposure to Trauma Triggers Conjoint Sessions with Caregivers Enhancing Feelings of Safety

57 History, despite its wrenching pain, cannot be unlived, but if faced with courage, need not be lived again -Maya Angelou

58 Prolonged Exposure for PTSD PE is a key treatment strategy for effective treatment of PTSD in children Often use the story of the trauma, or trauma narrative as a way to approach exposure Detailed description of traumatic events that the child experienced or witnessed Creating a story about the traumatic event within a safe environment can help integrate the experience and help the child learn that the memory is not dangerous Activate fear structure in a gradual way to decrease distress

59 How a Trauma Narrative helps Creating a TN helps the child: organize the emotional and physiological effects of an experience distinguish between thinking about the trauma and actually re-encountering it learn that they can revisit the memory without feeling overwhelmed/feel in control of the memory Results in habituation, so that the trauma can be remembered without intense, disruptive anxiety

60 Trauma Reminder Prolonged Exposure: Interrupting the Cycle THOUGHTS: THOUGHTS: These It s happening memories can t again hurt me I m not safe I am safe now I can t handle I can handle these feelings these feelings FEELINGS: FEELINGS: Panic, Sadness, Calmer Distress BEHAVIOR: BEHAVIOR: Deliberately focus on Avoid thoughts, Memories in a safe Distraction, numbing environment Corrective Experience: Absence of Corrective Distress goes up but Experience; comes lowered arousal back down

61 Avoidance Maintains Trauma-Related Symptoms Not talking about the trauma does not help the child! The child is already thinking about it! PTSD characterized by biphasic reliving and denial, with alternating intrusive and numbing responses Prolonged exposure decreases dysregulation and numbing through active confrontation with feared stimuli, resulting in habituation of distressing emotions and physiological arousal.

62 Main Steps Develop Narrative Begin writing (or adding to) narrative May start out with non-traumatic chapter What child likes, who they live with, etc. Then start writing about event slowly Describe what happened before, during, and after event Praise child/youth throughout process Remember NOT to challenge any facts or distortion child/ youth describes Writing the narrative will probably take more than one session

63 Main Steps Create Feeling of Safety Assure child/youth they are safe and you are their to support them Take ratings of distress Rate fear talking about or thinking about event now Do not rate how scary event was when it was happening Relaxation Teach/practice relaxation Take ratings before and after relaxation

64 Main Steps Encourage Thoroughness Encourage child/youth to write about all memories Encourage child/youth to describe thoughts and feelings too Provide Reassurance and Elicit Coping Strategies If child is overwhelmed, remind child/youth that they are safe now feelings are about memories that happened before remembering is not the same thing as re-experiencing If child/youth too anxious, practice relaxation strategies

65 Main Steps Develop Final Chapter After child/youth has written about traumatic event Then child/youth writes a final chapter about: How they have changed How their life is different now Advice they would give another child/youth Practice Reading At the end of every trauma narrative session, the child/youth (or therapist) should read everything the child/youth has written (including TN from previous sessions) Take ratings before and after each reading Keep reading until ratings decrease

66 Main Steps Address Cognitions Once the narrative is written and has been read many times Look through narrative for cognitive distortions It s all my fault. If only I had It s going to happen again. Use Cognitive Restructuring to address these thoughts. Include new, more helpful thoughts in narrative Relaxation End all sessions with Relaxation Remember best way to decrease anxiety is to reread the narrative over and over until habituation occurs

67 Trauma Narrative Over Many Sessions 1 st TN Session 1. Rationale 2. Feelings of Safety 3. Fear Rating 4. Relaxation 5. Write Narrative 6. Practice* 7. Rate fear before and after* 8. (Relaxation) 2 nd TN Sessions 1. Fear Rating 2. Relaxation 3. Write narrative 4. Practice* 5. Rate fear before and after* 6. (Relaxation) Last TN Session 1. Fear Rating 2. Relaxation 3. Address Cognitions 4. Write Final Chapter 5. Practice* 6. Rate fear before and after* 7. (Relaxation)

68 Common Concerns about Trauma Narratives It will re-traumatize the child/youth Emphasis is on gradual retelling with habituation Isn t fear of traumatic events expected? Goal is the help child/youth learn that the memory cannot hurt them; not habituate them to trauma itself. Will normalize child s/youth s feelings of anxiety/anger/sadness related to past experiences I m not sure I can handle hearing about this stuff Remember to seek support from your colleagues! Remember that this is a way that you are helping the child What if this stirs up other things/makes things worse? You are not creating memories; the memories are already there and getting in the way

69 Syndrome Scale Child Behavior Checklist (Foster Mom) Youth Self Report (Ava) Ava (10yo Caucasian girl) Anxious/Depres sed Withdrawn/Depr essed Somatic Complaints Social Problems Attention Problems Rule-Breaking Behavior Aggressive Behavior Results of initial assessment T-scores >65 indicate clinical problems PTSD Index elevated Ava = 34 Foster Mom = 30 Included for Trauma

70 Top Problems Ava s Top Problems 1. I feel sad sometimes when my brother feels sad. 2. I feel sad when I think about not being with my mom. Foster Mom s Top Problems 1. She worries a lot about the possibility of seeing her biological father again. 2. She feels sad about being away from her mom and dad. 3. She is withdrawn and doesn t have many friends.

71 Trauma Narrative Example - DV

72

73 Social Workers and LMHCs: How to Obtain Your Continuing Education Contact Hour for this Webinar Create a Username & Password at the NYU Silver CE Online Portal : Log on to the Continuing Education Online Portal for the NYU Silver School of Social Work page, click on All Events & Programs tab Scroll down & select today s webinar under Online Learning Click Register Fill in the billing information, click register, and pay the CE registration fee Remember: Our system works best with Google Chrome or Mozilla Firefox

74 Social Workers and LMHCs: How to Obtain Your Continuing Education Contact Hour for this Webinar, cont. After registering, you will receive a confirmation with a link to complete an evaluation Once the evaluation is submitted, within hours, log back on to NYU Silver CE Online Portal, go to Your Registrations and you will see Take Assessment in red next to the name of the program Complete assessment Once done, you will be directed how to download your CE certificate For Questions: Call us at or us at silver.continuingeducation@nyu.edu

75 Contact us: