social workers and lmhcs: how to obtain your continuing ... · recent reviews have dissected...

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 : • https://sswforms.es.its.nyu.edu/ ‣ 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

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

‣ After registering, you will receive a confirmation email with a link to complete an evaluation

‣ Once the evaluation is submitted, within 24 - 48 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 212-998-5973 or email us at

silver.continuingeducation@nyu.edu

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

Who am I? ‣ Clinical child psychologist ‣ Assistant professor of School Psychology at UT Austin ‣ Director of the Laboratory for Leveraging Evidence and Advancing

Practice for Youth Mental Health (LEAP Lab) https://sites.edb.utexas.edu/leap/

‣ Research focuses on the flexible, feasible use of evidence-based practices for children in complex, low-resource settings (schools, clinics, primary care, child welfare)

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

Impact of Traumatic Events on Children

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

Prevalence of ACEs

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

Types of Child Maltreatment by Percentage

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

A Biological Model of Anxiety: How “normal” anxiety works

Stimulus

Accurate interpretation of threat

Anxious Arousal

Fight

Flight

Freeze

How anxiety becomes disordered

Stimulus Misinterpretation

of threat

Anxiety

Fight

Flight

Freeze

Generalization of Fears

Children, trauma, and schools

Multi-Tiered Systems of Support in Schools

MTSS In Schools

Tier III: Few Students

Tier II: Some students

Tier I: All students

MTSS In Schools

Tier III: Few Students

Tier II: Some students

Tier I: All students

Universal Best Practices:

Education for teachers/staff,

school-wide supports, Social

Emotional Learning

Curriculum

MTSS In Schools

Tier III: Few Students

Tier II: Some students

Tier I: All students

For students at-risk or with some

symptoms: Evaluation, Additional classroom supports/

Accommodations, small-group programming

MTSS In Schools

Tier III: Few Students

Tier II: Some students

Tier I: All students

Students experience

clinical impairment:

evidence-based assessment and

intervention provided by MH

clinician

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

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

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

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

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

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

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

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)

Cognitive Model of PTSD

Ehlers & Clark, 2000

Memory of Abuse

I’m not safe. I can’t handle this.

I am in danger NOW

Cognitive Model of PTSD

Ehlers & Clark, 2000

Physiological Arousal

Fight, Flight, Freeze

Avoidance Emotional Blunting Negative thoughts

Hypervigilance

Cognitive Model of PTSD

Ehlers & Clark, 2000

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

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 problems1

‣ 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

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

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

Tier III Services for Trauma A Common Elements Approach

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

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)

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)

Unpacking the single-disorder EBTs

Defiant Children BPT for Conduct

TF-CBT

How do you derive common elements?

Protocol Protocol Protocol

“Family” of Treatment

How do you derive common elements?

Parent Management

Training PCIT Defiant

Children

Behavioral Parent Training

for Conduct Problems

How do you derive common elements?

Protocol Protocol Protocol

Type of Treatment

Practice Element

Practice Element

Practice Element

Practice Element

Practice Element

Practice Element

How do you derive common elements?

These are “practice

elements.”

Behavioral Parent Training

Parent Management PCIT Defiant

Children

Attending Attending Attending

Active Ignoring

Time Out

Active Ignoring Active Ignoring

Time Out Time Out

Reprimands School Behavior

Plan

How do you derive common elements?

These are “practice

elements.”

Defiant Children Coping Cat Copjng With Depression Course

Evidence Based Treatments

Attending Mood Monitoring Exposure

Active Ignoring

Problem Solving

Cognitive Restructuring

Cognitive Restructuring

Problem Solving Problem Solving

Rewards Rewards Rewards

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)

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)

Key Practice Prolonged exposure via trauma narration

Evidence Based Intervention Techniques (Cohen, Mannarino, & Deblinger, 2006)

P Psychoeducation & Parenting Strategies R Relaxation Skills A Affective Modulation Skills C Cognitive Coping Skills T Trauma Narration I In-Vivo Exposure to Trauma Triggers C Conjoint Sessions with Caregivers E Enhancing Feelings of Safety

“History, despite its wrenching pain, cannot be unlived, but if faced with courage, need not be lived again “

-Maya Angelou

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

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

Prolonged Exposure: Interrupting the Cycle

BEHAVIOR: Avoid thoughts,

Distraction, numbing Absence of Corrective

Experience; lowered arousal

THOUGHTS: “It’s happening

again” “I’m not safe” “I can’t handle these feelings”

FEELINGS:

Panic, Sadness, Distress

Trauma Reminder

BEHAVIOR: Deliberately focus on

Memories in a safe environment Corrective Experience:

Distress goes up but comes

back down

THOUGHTS: “These

memories can’t hurt me”

“I am safe now” “I can handle

these feelings”

FEELINGS:

Calmer

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.

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

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

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

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

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

Trauma Narrative Over Many Sessions

1st 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)

2nd 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)

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

Ava (10yo Caucasian girl) Syndrome

Scale Child Behavior

Checklist (Foster Mom)

Youth Self Report (Ava)

Anxious/Depressed

51 51

Withdrawn/Depressed

60 52

Somatic Complaints

50 54

Social Problems

57 52

Attention Problems

50 69

Rule-Breaking Behavior

50 54

Aggressive Behavior

51 55

‣ Results of initial assessment • T-scores >65 indicate clinical

problems • PTSD Index elevated ◦ Ava = 34 ◦ Foster Mom = 30

‣ Included for Trauma

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.

Trauma Narrative Example - DV

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 : • https://sswforms.es.its.nyu.edu/ ‣ 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

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

‣ After registering, you will receive a confirmation email with a link to complete an evaluation

‣ Once the evaluation is submitted, within 24 - 48 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 212-998-5973 or email us at

silver.continuingeducation@nyu.edu

Contact us: Ctac.info@nyu.edu