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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
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
Contact us: [email protected]