Transcript Treatment of Trauma in the Schools

Treatment of Trauma
in the Schools
Ally Burr-Harris, Ph.D.
Center for Trauma Recovery
Child Traumatic Stress Program
University of Missouri – St. Louis
Revised 11/8/04
Greater St. Louis
Child Traumatic Stress Program
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Free trauma-related assessment and
treatment of children
Cognitive-behavioral, family systems
treatment orientation
Consultation/training for professionals
School-based group therapy for
children/adolescents exposed to violence
National Child Traumatic Stress Network
(NCTSN)
www.nctsnet.org
Types of Traumas
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Natural disasters
Kidnapping
School violence
Community violence
Terrorism/war
Homicide
Physical abuse
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Sexual abuse
Domestic violence
Medical procedures
Victim of crime
Accidents
Suicide
Extreme neglect or
deprivation
Protective Factors for PostTrauma Adjustment
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Strong academic and social skills
Active coping, self-confidence
Social support
Family cohesion, adaptability, hardiness
High neighborhood/school quality
Strong religious beliefs, cultural identity
Effective coping and support by parents
Risk Factors for Post-Trauma
Adjustment Problems
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Severity of trauma
Extent of exposure
History of other multiple stressors
Proximity of trauma
Preexisting psychopathology
Interpersonal violence
Personal significance of trauma
Separation from caregiver
Extent of disruption in support systems
Lack of material/social resources
Parent psychopathology; parent distress
Genetic predisposition
Trauma Symptoms in
Preschool Children
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Regressive behaviors
Separation fears
Eating and sleeping disturbances
Physical aches and pains
Crying/irritability
Appearing “frozen” or moving aimlessly
Perseverative, ritualistic play
Reenactment of trauma themes
Fearful avoidance and phobic reactions
Magical thinking related to trauma
Trauma Symptoms in
School-Age Children
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Sadness, crying irritability, aggression
Nightmares
Trauma themes in play/art/conversation
School avoidance, failure
Physical complaints
Concentration problems
Regressive behavior
Eating/sleeping changes
Attention-seeking behavior
Withdrawal
Trauma Symptoms in
Adolescents
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Similar to adult response to trauma
Feelings of shame/guilt
Increased risk-taking behaviors
Withdrawal from peers/family
Pseudomature behaviors
Substance abuse
Delinquent behaviors
Change in school performance
Self-destructive behaviors
School Assessment of
Trauma Symptoms
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UCLA PTSD Index -Revised (Steinberg,
Pynoos, Rodriguez, 2002) - screens for
trauma exposure and trauma symptoms
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Youth (school-age) version, parent version
Trauma Symptom Checklist for Children
(TSCC, TSC/YC; Briere, 1995) - assesses for
PTSD and other trauma symptoms such as
depression, anger problems, etc.
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Youth (school-age) version, parent version
Common Trauma-Related
Diagnoses
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Adjustment Disorder
Acute Stress Disorder
Posttraumatic Stress Disorder (PTSD)
Depression (Dysthymic Disorder, MDD)
Behavior Disorder (ADHD, ODD, Conduct
Disorder)
Anxiety Disorder (GAD, Panic Disorder,
Specific Phobia)
Reactive Attachment Disorder (RAD)
Bereavement
CBT Treatment Objectives
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Break associations between negative feelings
and trauma cues
Increase tolerance of trauma thoughts and
memories
Decrease reliance on maladaptive coping
Facilitate processing of trauma
Correct trauma-related distortions
Model (therapist, parent) effective coping
Reinforce (therapist, parent) positive coping
and respond effectively to behavior problems
Appropriate Clients
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Functioning at 3 years or higher
PTSD symptoms
Trauma-related confusion or
misconceptions
Substantiated abuse/trauma
Parents (nonoffending) supportive of
treatment
Inappropriate Clients
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Psychotic symptoms
Substance dependence/abuse
Suicidal intent, high self-harm risk
Questionable validity of abuse/trauma
Extremely resistant after “best sell”
High intensity trauma ongoing
Outpatient
Individual TF-CBT
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Short-term (Average= 3 assessment
sessions plus 12 treatment sessions)
Divided individual sessions for child and
parent initially
Joint sessions begin once parent’s
symptoms have decreased and coping
skills are improved
School-Based TF-CBT
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Screen for trauma exposure/symptoms
Assess for treatment appropriateness
10 to 12 individual sessions with
parental involvement strongly
encouraged for elementary age
10 to 12 week group therapy with
option of 2 individual sessions and 2
parent feedback sessions if possible
Trauma-Focused CBT:
Components
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Psychoeducation
Ensuring Environmental Safety
Stress Inoculation Training (coping skills)
Gradual Exposure
Affective and Cognitive Processing
Safety Skills
Parental Involvement
Behavior Management Skills Training
Family Sessions
Psychoeducation
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Common reactions to trauma (parent, child)
PTSD in children
Accurate trauma-related information
Self-care after trauma; supporting child
Purpose, rationale, estimated length, typical
course of treatment
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Splinter or wound analogy
Ensuring safety
Healthy discipline; Healthy sexuality
Appropriate developmental expectations
Stress Inoculation Training (SIT)
Techniques for reducing physiological
stress reactions in response to trauma
reminders
Life Saver vs. Swim Lesson analogy
SIT Techniques
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Deep breathing
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Mindfulness, visual imagery
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Belly breathing, pinwheel
“Safe place”
Progressive muscle relaxation
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Tin soldier/Raggedy Ann
Raw/Cooked noodle
Developmentally appropriate script
SIT Techniques (cont.)
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Thought-stopping/replacement
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Stop sign, Change your channel
Cognitive coping skills (positive focus)
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Mantra coaching
“I’m safe now…I can do this…He’s locked
up now…It wasn’t my fault…”
Gradual Exposure (GE)
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Purpose is to gradually expose child to
thoughts, memories, and other reminders of
the trauma until child can tolerate those
memories without significant emotional
distress and no longer needs to avoid them.
Techniques used to disconnect cues of
traumatic event from overwhelming negative
emotions.
Gradual Exposure
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Hierarchical exposure starting from moderate
distress (e.g., facts about trauma) and
working toward extreme distress (e.g., worst
moment)
Modalities: play, art, visualization, narratives,
drama, in vivo exposure (for feared but safe
situations)
Reduce arousal through reprocessing and
elaboration across sessions
Can use SIT skills during exposure phase
Exposure Examples
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Writing anonymous book about trauma;
advising others who face similar situations
Playing out trauma with toys and gradually
incorporating positive resolution
Drawing pictures of trauma images and later
shredding them
Getting rid of upsetting thoughts or images
(thought funeral)
Writing rap song about impact of trauma
Sharing trauma narrative
Affective and Cognitive
Processing (CP)
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Feeling Identification and Expression
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Cognitive Triangle
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Feeling charades; Polaroid feeling chart;
Feeling identification race
Thoughts, Feelings, Behaviors
Practice generating helpful thoughts
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Train game
Affective and Cognitive
Processing (cont.)
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Identify trauma-related inaccurate or
unhelpful thoughts using open-ended inquiry,
impact statement, narrative, observation, or
self-report measures
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Why do you think this happened to you?
What caused it?
How trusting were you of other people?
How about now?
Why do bad things happen to good people?
What would keep it from happening again?
Common Trauma-Related
Cognitive Distortions
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Self-blame
Guilt, survivor guilt
Shame/embarrassment b/c of trauma or symptoms
Hero fantasies related to trauma
Overgeneralization of danger/risk
Minimization of trauma
Omen formation
Foreshortened future
Magical thinking
Revenge fantasies
Affective and Cognitive
Processing (cont.)
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Model helpful thoughts
Correct distortions
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Younger children: Insert mantras
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Coloring book example
Narrative: “It’s not your fault”
Older children: Help to reprocess
Methods for
Challenging Distortions
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Identify feelings, behaviors, outcomes related
to negative thought and generate more
helpful thought instead
One-down Columbo style approach
Mirror distortions in the extreme and push
child to amend distortion
Progressive logical questioning
Cartoon bubbles
Role plays, talk shows, peer counseling
Books/narratives
Safety Skills
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Recognize dangerous situations
Good touch/bad touch (SA cases)
Problem-solving skills
Support-seeking skills
Calming skills if risk of self-injury
Present carefully so as not to blame
Develop safety plan
Parental Involvement
in Individual Treatment
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Assessment feedback
Psychoeducation
Parallel work in areas of SIT, GE, and CP
Parenting Skills Building, Behavior Mgmt.
Joint parent-child sessions
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Continuation of GE and CP jointly
Parent models positive coping with trauma
Parent assumes role of therapist as child’s
supporter related to trauma
Behavior Management
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Caregiver interventions
Anger control skills with child
Skills training (problem-solving, social
skills, communication)
Specific behavior plans (sleep problems,
sexual behavior problems)
Intervene in relevant systems
Caregiver Interventions for
Behavior Management
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Create predictability for child
Make expectations clear
Reasonable developmental expectations
Don’t personalize child’s behavior
Avoid power struggles
“Emotionally unplug” when disciplining;
“Emotionally plug in” when rewarding
Caregiver Interventions for
Behavior Management
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Identify triggers that upset child and
plan ahead
Expect angry outbursts
Address aggressive/self-destructive
behaviors quickly and firmly
Model self-control
Be patient and calm
Caregiver Interventions for
Behavior Management
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Consistent limit-setting
Predict increase in negative behavior
Reward positive behavior
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PRIDE skills (from PCIT)
Naturally occurring reinforcers
Jump start material reinforcers when necessary
Ignore negative behavior
Give effective instructions
Time-out, removal of privileges
Anger Control Skills
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Identify triggers or high-risk situations and
plan ahead
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Red button exercise
Increase awareness of physiological and
cognitive components
Teach/rehearse management strategies
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Counting, breathing
Relaxation (turtle technique)
Leave situation, SCAR
Exercise
Thought-stopping; replace with mantra
Traumatic Bereavement
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PTSD in the case of traumatic loss often
impedes the grieving process. The person
focuses on the traumatic death rather than
the loss.
After exposure, additional treatment
components include recognition/acceptance
of the loss, positive reminiscing, coping with
future loss reminders, and addressing
conflicting thoughts about the deceased.
Group CBT of PTSD
in Children and Adolescents
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Same components as Individual CBT
Members need to have similar level/type of
trauma exposure
Provides opportunity for social skills-building,
peer feedback, and stigma reduction
Advantageous if large-scale trauma or school
setting with high violence rate
School-wide trauma exposure/symptom
screening yields best referrals
Modules include traumatic bereavement
School TF-CBT group outline
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How violence affects youths
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Recognizing/managing feelings
Positive coping strategies (SIT)
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Coping with trauma cues
Challenging hurtful thoughts
How the violence affected me - GE
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Self assessment of symptoms
Psychoeducation
Individual session, group sessions
Challenging stuckpoints - CP
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Traumatic bereavement, positive reminiscing
School TF-CBT Group
Outline Continued
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Changing problem behaviors
 Support-seeking
 Anger management, emotional control
 Communication skills, problem-solving
 Building healthy relationships
Feeling good about myself
 Positive self-esteem
 Goal-setting
Group closure
Empirical Support for PTSD
Treatment in children
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TF-CBT (individual, group) - 13 randomized
trials, mostly with SA samples - treatment
effects for PTSD, depression, behavior
problems, social competence, parental
distress, and parental support
School-based TF-CBT (treatment effects for
GPA, PTSD, school attendance and behavior)
CBT > Nondirective Supportive Therapy
Parent involvement in CBT improved child’s
symptoms, even when child not involved in tx
SIT, EMDR
TF-CBT References
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Deblinger, E., Heflin, A. H. (1996). Treating
Sexually Abused Children and Their
Nonoffending Parents: A Cognitive Behavioral
Approach. Sage Publications, Inc. Thousand
Oaks, CA.
Cohen, J. A., Mannarino, A. P., Deblinger, E.
(2001). Child and Parent Trauma-Focused
Cognitive Behavioral Therapy: Treatment
Manual. Allegheny General Hospital, Center
for Traumatic Stress in Children and
Adolescents.
School-Based
TF-CBT References
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Burr-Harris, A. (Sept, 2004). School-Based TraumaFocused Cognitive-Behavioral Group Therapy Manual
(7th -12th grades). Greater St. Louis Child Traumatic
Stress Program, University of Missouri-St. Louis
Layne, C. M., Saltzman, W. R., Pynoos, R. S. (2002).
Trauma/Grief-Focused Group Psychotherapy Program.
UCLA Trauma Psychiatry Service.
Jaycox, L. (2004). Cognitive Behavioral Intervention
for Trauma in Schools. Longmont, Co: Sopris West
Educ. Services. (ages 11-15).
We’re Done!
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For additional questions, references, or
referrals, contact Ally Burr-Harris, Ph.D.
Phone: 314-516-5440
Email: [email protected]