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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 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 Natural disasters Kidnapping School violence Community violence Terrorism/war Homicide Physical abuse Sexual abuse Domestic violence Medical procedures Victim of crime Accidents Suicide Extreme neglect or deprivation Protective Factors for PostTrauma Adjustment 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 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 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 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 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 UCLA PTSD Index -Revised (Steinberg, Pynoos, Rodriguez, 2002) - screens for trauma exposure and trauma symptoms 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. Youth (school-age) version, parent version Common Trauma-Related Diagnoses 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 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 Functioning at 3 years or higher PTSD symptoms Trauma-related confusion or misconceptions Substantiated abuse/trauma Parents (nonoffending) supportive of treatment Inappropriate Clients 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 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 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 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 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 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 Deep breathing Mindfulness, visual imagery Belly breathing, pinwheel “Safe place” Progressive muscle relaxation Tin soldier/Raggedy Ann Raw/Cooked noodle Developmentally appropriate script SIT Techniques (cont.) Thought-stopping/replacement Stop sign, Change your channel Cognitive coping skills (positive focus) Mantra coaching “I’m safe now…I can do this…He’s locked up now…It wasn’t my fault…” Gradual Exposure (GE) 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 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 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) Feeling Identification and Expression Cognitive Triangle Feeling charades; Polaroid feeling chart; Feeling identification race Thoughts, Feelings, Behaviors Practice generating helpful thoughts Train game Affective and Cognitive Processing (cont.) Identify trauma-related inaccurate or unhelpful thoughts using open-ended inquiry, impact statement, narrative, observation, or self-report measures 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 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.) Model helpful thoughts Correct distortions Younger children: Insert mantras Coloring book example Narrative: “It’s not your fault” Older children: Help to reprocess Methods for Challenging Distortions 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 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 Assessment feedback Psychoeducation Parallel work in areas of SIT, GE, and CP Parenting Skills Building, Behavior Mgmt. Joint parent-child sessions 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 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 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 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 Consistent limit-setting Predict increase in negative behavior Reward positive behavior 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 Identify triggers or high-risk situations and plan ahead Red button exercise Increase awareness of physiological and cognitive components Teach/rehearse management strategies Counting, breathing Relaxation (turtle technique) Leave situation, SCAR Exercise Thought-stopping; replace with mantra Traumatic Bereavement 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 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 How violence affects youths Recognizing/managing feelings Positive coping strategies (SIT) Coping with trauma cues Challenging hurtful thoughts How the violence affected me - GE Self assessment of symptoms Psychoeducation Individual session, group sessions Challenging stuckpoints - CP Traumatic bereavement, positive reminiscing School TF-CBT Group Outline Continued 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 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 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 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! For additional questions, references, or referrals, contact Ally Burr-Harris, Ph.D. Phone: 314-516-5440 Email: [email protected]