CPP, PCIT, TF-CBT: DETERMINING

Transcription

1 CPP, PCIT, TF-CBT: DETERMINING THE BEST TREATMENT MODALITY AND KNOWING WHEN TO RE-EVALUATE AND SWITCH Leslie Peterson, LCSW, RPT Susan Gordon, LCSW Ashley Rambeau, MS, ASW

2 WELCOME! Leslie Peterson, LCSW, RPT Susan Gordon, LCSW Ashley Rambeau, MS, ASW Introductions and Icebreaker!!!

3 WORKSHOP OBJECTIVES: Discussion of CPP, PCIT, and TF-CBT: Similarities and Differences* How to complete a thorough trauma assessment Discussion of how the family assessment can help in choosing the right treatment modality Presentation of a decision tree and how to move from assessment to treatment Discussion of complex case example *This will not be a presentation of the 3 models

4 WHAT IS CHILD TRAUMATIC STRESS? Child traumatic stress occurs when children and adolescents are exposed to traumatic events or traumatic situations, and when this exposure overwhelms their ability to cope with what they have experienced. disturbed sleep, difficulty paying attention and concentrating, anger and irritability, withdrawal, repeated and intrusive thoughts, and extreme distress Traumatic experiences can result in a significant disruption of child or adolescent development and have profound long-term consequences.

5 EFFECTS OF TRAUMA EXPOSURE Attachment: Challenge to formation of basic trust Difficulties in co-regulation Intense separation anxiety Lack of consistent behavioral strategies to derive sense of safety from attachment figure Difficulty relating to and empathizing with others Biology: Activation of stress response system Altered neural pathways Problems with movement and sensation. Hypersensitivity to physical contact Insensitivity to pain. Unexplained physical symptoms. Increased medical problems. Mood Regulation: Difficulty regulating their emotions. Difficulty knowing and describing their feelings and internal states. Heightened emotional reactivity 5

6 EFFECTS OF TRAUMA EXPOSURE Dissociation: Feeling of detachment or depersonalization observing something happening to them that is unreal Behavioral Control: Poor impulse control Self-destructive or self-injurious behavior Aggression towards others Cognition: Problems focusing on and completing tasks Problems planning for and anticipating future events Learning difficulties Problems with language development Self-Concept: Disturbed body image Low self-esteem Shame Guilt

7 VULNERABILITY IN INFANCY Neurophysiologic dependency on their caregivers (dyadic co-regulation) Limited cognitive and behavioral coping capacities Require external regulation to manage physiological arousal that exceeds available coping capacities Loss of developmentally appropriate expectation that caregivers will protect from harm Interplay between challenges to basic trust and child s traumatic responses can have pervasively negative effects on the course of development Experience dependent brain development

8 INDICATORS OF TRAUMATIC STRESS IN INFANTS: Pre-verbal children express their trauma narrative through their bodies through disruption in their capacity to regulate body functions, relate to others, and explore their surroundings Neurophysiologic regulation: Disruptions in biological / regulatory rhythms: Eating, digestion and elimination Sleeping / state transitions Over or under responsively to external stimulation Somatic complaints Social relatedness: Socially indiscriminate, lack of selectivity or preference Lack of consistent or discernable engagement vs. disengagement cues Avoidance of social interaction Difficulties with pro-social skills; sibling relational aggression Developmental Regression - loss of previously acquired skills Exacerbation of normative developmental fears: self blame; fear of loss of love and separation; superego condemnation Disruptions to developmental processes Secure base behavior, inhibited exploration Basic trust vs. mistrust Autonomy vs. shame and guilt

9 EXPANDING CONCEPTIONS OF TRAUMA Hidden trauma : interpersonal context emotional unavailability of caregiver unpredictable response to cues interactive dysregulation without repair; etc. Experienced threat closely related to caregiver's affective states and availability New neurobiology research shows similar activation of stress response systems in hidden trauma of infancy and PTSD in older children (Siegel, Bryson 2012)

10 TREATING CHILD TRAUMATIC STRESS Treatment model must be versatile, treating a variety of different problems, addressing most or all areas of traumatic stress TF-CBT, CPP, and PCIT all effective to treat the symptoms of trauma and child traumatic stress Now, how do you know when to use which modality?

11 TF-CBT: Components-based treatment model focused on direct discussion of traumatic material Feelings identification, cognitive processing, trauma narrative creation and sharing, in-vivo exposure, etc. Ages 4-18*, experienced one or more traumatic events, elevated symptoms of PTSD, supportive caregiver involved in treatment Child/Caregiver does not have any current substance use, suicidal ideation, psychotic symptoms, etc.

12 TFCBT CONTINUED: Strengths of the model: Direct discussion of the trauma Can be used with children residing in many types of settings (parental homes, foster care, kinship care, group homes, or residential programs) Can be used to treat single trauma, multiple traumas, as well as traumatic grief/bereavement Limitations of the model: Not a family therapy model Adaptations for younger ages (3-5yrs.) Trauma -focused Limited parenting/behavioral management techniques

13 SAMPLE GOALS FOR TF-CBT: Process and Resolve Traumatic Material Reduce symptoms of PTSD and Traumatic Stress Increase communication about traumatic material (sexual abuse, dv, physical abuse, etc.) between child and caretaker Increase child s emotion and behavior regulation, and ability to engage in calming/self-soothing

14 WHAT IS CHILD PARENT PSYCHOTHERAPY? A trauma-focused, relationship-based model Dual lens of attachment and trauma and transactional influence between the two Children ages 0-5 and a significant caregiver Caregiver, child and therapist are all present in the room and attended to throughout Session themes arise out of caregiver and child interaction Client as caregiver child relationship

15 PRIMARY CHARACTERISTICS OF THE MODALITY Always individually tailored to the family s specific history, socioeconomic status, cultural context, and needs. Model incorporates case management / resource building as needed Play!!! Play is the young child s primary way of connecting, communicating, learning, repairing, and healing Therapist serves as translator between parent and child. Verbal Interpretation the therapist observes out loud what appears to be happening in the parent/child interaction. Therapist provides developmental information and parenting guidance.

16 OVERARCHING GOAL OF CPP: PUTTING THE TRAUMA INTO PERSPECTIVE Assess and acknowledge the experience of trauma: Traumatic reenactments Avoidance of trauma reminders Dysregulation of biological rhythms Symbolize, verbalize, enact feelings and behaviors related to the trauma in emotional holding environment Decrease developmental anxieties: fear of separation, loss of love, self-blame Create a joint narrative of what happened to the child or family.

17 HOW GOALS ARE ACHIEVED: Therapeutic relationship / Parallel process Collaborative exploration / inquiry Empathic attunement and parallel process Provision of psychoeducation and developmental anticipatory guidance Therapist as play translator: expand on child s play to bring increased: narrative coherence to fragmented and disorganized aspects of child s experience Promote self regulation, co-regulation, and affect modulation Enhance self-reflection Decrease trauma-related symptoms by strengthening the attachment relationship Coping through play: Reenactments, movement towards mastery of trauma, exploration of cause and effect, experimentation with roles Create a safer and more protective caregiving environment. Increase age-appropriate capacity of caregiver and child to be accurately attuned to each other's needs and motivations. Low level behavioral cues

18 CPP: POINTS OF ENTRY Negative or unbalanced representation of child Limited attunement interactive mismatch without repair Challenges to self-regulation, co-regulation Inappropriate developmental expectations Unresolved trauma, ghosts of he nursery Challenges to goodness of fit Developmental delays, difficult temperaments

19 PCIT: Conjoint therapy focused on restructuring parent child interactional patterns. Two phase model: CDI and PDI utilizing coaching of the parent child dyad. Use of standardized pre/post treatment measures Inclusion of PRIDE skills and selective attention/ignoring concepts and weekly Homework Ages 2-8. Children exhibiting externalizing behaviors and who live with their caregiver or have liberal visitation and/or will be returned to the caregiver within 8-10 weeks of beginning therapy. Neither caregiver or child have a diagnosis that contraindicates PCIT.

20 CPP: POINTS OF ENTRY Negative or unbalanced representation of child Interactive mismatches without repair Low parental self-efficacy Challenges to dyadic co-regulation Multigenerational / unresolved trauma Poor goodness of fit Low skill set as adult play partner Developmental expectations that are too high or too low

21 PCIT CONTINUED: Strengths of the Model: Effectively addresses behavioral concerns Short term model Improves parent child relationship Family model Limitations of the Model: Does not directly address the trauma Must have consistent caregiver Adaptations for younger children Geared towards children with behavioral issues

22 SAMPLE GOALS OF PCIT Improve parent child relationship Decrease externalizing behaviors Increase compliant behaviors

23 ASSESSMENT-BASED TRAUMA TREATMENT: Development of an integrated plan of prioritized interventions, that is based on the diagnosis and bio-psychosocial assessment of the child to address wide range of areas. Using the information gathered in a thorough assessment to inform which treatment model to use.

24 Components of a Thorough Trauma Assessment: Gather collateral information/history (Social Worker, Bio Parent, Foster Parent, school, etc.) Administer wide range of standardized assessment measures for caregiver(s) and child (CBCL, TSCYC, ECBI, PSI, ASQ, Angels in the Nursery, Life Stressors Checklist, TSI, CESD, etc.) In-Depth Social-Emotional-Developmental Assessment of child and family Observations of child in a variety of settings and with relevant caregivers (assessment of the relationship ) Assess family resources and readiness (visitation schedule, transportation, caregiver able to participate in treatment, etc.) CPP: Ages 0-6 Appropriate caregiver Attachment/Relational difficulties Traumatic Experience (including separation from primary attachment figure) Treatment goals: Trauma Processing for parent and child, parent to understand child s experience of trauma TF-CBT: Ages 4-18 Appropriate Supportive Adult Identified Traumatic Experience PTSD symptoms Treatment Goals: Reduce PTSD, Process/Resolve Trauma PCIT: Ages 3-8 Appropriate Caregiver Behavioral Concerns Parent-Child relationship difficulties Treatment Goals: Enhance relationship with caregiver, reduce negative/acting out behaviors

25 Brandon, age 4 CASE EXAMPLE #1 B was removed from the home after witnessing a DV incident in which Dad attacked Mom and she sustained injuries. Dad was arrested, and has not had any contact with the family in over 6mo. B was placed in Polinsky Children s Center and was in 2 different foster homes before being placed back with Mom. B presents with high anxiety and trauma symptoms, hypervigilence, avoidance. Mom reports he has some regressive behaviors (baby talk and thumb sucking), and has a great deal of separation anxiety. He fears losing Mom and is afraid something bad will happen to her. Has recently displayed school refusal.

26 The Smith Family: Bio Mom: Stella Foster Mom: Brenda Sammi, age 5 ½ Bobby (Jr.), age 3 CASE EXAMPLE #2 Please read through case example, paying close attention to information gathered in the family assessment Begin thinking about how you would treat this family in your clinic

27 QUESTIONS TO THINK ABOUT WHILE WORKING ON CASE EXAMPLE: Is there more information that you need or more assessment that needs to be done? Which modality would you start with and why? Is there a clear cut best modality? Why or why not? Who will be involved in the therapy and why? What do you see as the Treatment goals for each child? If more than one modality could be used, discuss the process of choosing and how/when you might switch modalities. What other referrals might you make?

28 REFERENCES: Chadwick Center for Children and Families. (2009). Assessment Based Treatement for Traumatized Children: A Trauma Assessment Pathway (TAP). San Diego, CA: Author Cohen, J. A., Mannarino, A. P., & Deblinger, E. (2006). Treating trauma and traumatic grief in children and adolescents. New York, NY: Guilford Press. Lieberman, A., & Van Horn, P. (2005). Don't hit my mommy!: A manual for child-parent psychotherapy for young witnesses of family violence.. Washington, D.C. : Zero to Three Press. Lieberman, A., & Van Horn, P. (2008). Psychotherapy with Infants and Young Children: repairing the effects of stress and trauma on early attachment. New York: NY: Guilford Press. Rae, T., & Zimmer-Gembeck, M. (2011). Accumulating evidence for parent-child interaction therapy in the prevention of child maltreatment. Society for Research Child Development, 82(1), Urquiza, Ph.D, A. (2007). Child trauma and the effectiveness of pcit. In PCIT Training Center Sacramento, CA: UC Davis.

29 THE END! Thank You! Leslie Peterson, LCSW, RPT (858) , x.7319 Ashley Rambeau, ASW (858) , x Susan Gordon, LCSW (858) , x. 6534