tf-cbt in early childhood
TRANSCRIPT
TF-CBT in
Early ChildhoodElizabeth Risch, Ph.D.
Amanda Mitten M.A.
Child Trauma Services Training Program
University of Oklahoma, Center on Child Abuse and Neglect
Overview of Today
Review Each Component of TF-CBT tailoring to early
childhood population.
Teaching & Practicing on Developmental Level
Repetition
Routines
Activity
Language
Caregiver Involvement
Logistical Support!
Prepared (or easy to do) activities
Structure for Session
Do you know anyone ages 3-6?
What are they like?
How do they talk?
How do they play?
How do they get your attention, needs
met?
How do they express emotions?
How do they use their body?
When a 3-6 year old is in your
therapy room…
Less is More (volume, intensity, words)
Off task ≠ Not cooperative
Young children are frequently off task
Be flexible!
Be fun!
Be quick!
PLAY!!!!
If you’re not having fun,
you’re not doing it right.
-Barbara Bonner
Trauma Impacts
Our
experiences
impact how we
see ourselves,
others & the
world.
Traumatic
Event(s)
Think
(Cognition)
Do
(Behavior)
Feel
(Affect)
Evidence for Using TF-CBT in
Early Childhood
Early on: TF-CBT demonstrated effective with young
children, but specific to sexual abuse sample
2011 Dismantling Study, ages 4-11 years, all trauma
types: PTSD improved & No difference in improvement
based on age. (Deblinger et al.)
2011 Early Childhood (3-6 years): Large improvement in
PTSD symptoms. (Scheringa et al.)
Evidence that young children could comprehend each of
the components
Gave guidance for increasing comprehension
Pschyoeducation
Relaxation
Affective
Modulation
Cognitive Coping
Trauma Narrative
and Processing
In vivo
Conjoint sessions
Enhancing safety
Trauma
Narrative
Phase
Integration/
Consolidation
Phase
Stabilization
PhasePare
nti
ng S
kills
Gra
dual Exposu
re
Tim
e:
12-1
6 s
ess
ions
1/3
1/3
1/3
TF-CBT Pacing
Enhancing Safety
Safety imbued throughout the model
Sense of safety may be lacking in kids’ environments
Model safety in your sessions
Just as you would with all other skills
Structure, consistency, and predictability build rapport by
increasing child and family’s comfort level in the therapeutic
environment
Structuring Sessions →
Increase Sense of Safety
A safe environment is predictable, controlled, calm
Comfort items, space
Visual Agenda
Brief Activities
Natural breaks provide gradual exposure
Repetition
Rewards
Need external motivators because young children lack
insight oriented, internal motivation
Enhancing Safety
Visual agenda provides:
Structure
Predictability
Consistency
Affords opportunities to praise and
shape behavior in session
Models for caregiver effective
structure
Enhancing Safety
In your session:
Use activity and role-play
Teach through doing
Abuse Prevention
No-Go-Tell
Body safety
Doctor’s names for private parts
Enhancing Safety
Teaching physical boundaries
Hula Space
Arm’s length
Special Handshake
Assertiveness
Lion, mouse, turtle
YouTube Video: My Body
Belongs to Me
Enhancing Safety for Caregivers
Caregiver’s responsibility
Risky situations
Open communication
Supervision and challenging situations
Not just “stranger danger”
Private Part Rules
Safety plan
Child care options
STOP IT NOW! as resource
Parenting
Working our
way out of
a job.
Parenting Goals
Empower parents as child’s strongest source of healing
The parent is the expert on their child.
The therapist and parent will work together as a team.
Bolster parenting skills to stabilize family
Trauma Informed
Attachment Focused
Positive Parenting Practices First
Caregiver is the conduit for child’s skill development
18
Parenting – Trauma Informed
Creating an emotionally and physically
safe environment
• Quality of Child’s Environment
• Home, Transitions, Daycare
• Routines, Predictability
• Volume & Tone
• Identifying & Reducing Triggers
Parenting – Supporting
Attachment
Identifying & Meeting Child’s Needs
Consistency: Provide comfort & don’t withdraw support
(even when child pushes away)
Involves some guess-work of child’s need & way of
receiving support, therapist & parent become a team
Emotional Validation
Labeling emotions in self & child
Let’s Connect – Hand to Heart
“Let’s Connect” Slides from Monica Fitzgerald, PhD,
University of Colorado at Boulder – Institute of Behavioral Science.
What am I feeling? What do I need?
What is my child feeling? What do they need?
How can I connect my resources with my
child’s needs?
© 2016 Let's Connect
Special Time to Connect
➢ Number 1 on the Parenting To-Do list!
➢ Gain buy-in
➢ Teach, Model, Practice skills
➢ Plan for at home
➢ Monitor use at home
➢ Both parent and child enjoy!
➢ Reduces behavior problems
➢ Not more time… Focused time.
Psychoeducation
Goal to provide accurate information, help family
understand experiences:
What is (trauma)?
How do kids feel, act after (trauma)?
Who is responsible? Why don’t kids tell?
Do kids get better?
Adjust expectations, but don’t avoid discussion
***DO GRADUAL EXPOSURE***
Your comfort with the topic and terminology
will communicate safety and acceptance to the
child.
Make it fun! Games! Points!
23
Psychoeducation with Caregivers
Provide an accurate developmental context for
symptoms
Communicate hope in healing
12 - 16 sessions to treat PTSD
Additional sessions for behaviors, as needed
Education on child’s symptoms followed by how
that impacts caregiver and how he/she
responds.
May lead to cognitive processing with caregiver
Psychoeducation
Words we use are important…Be clear!
Find out from caregiver what words child uses
May need to teach words to describe trauma
Avoid vague terms (bad thing, hurt, it)
Child Sexual Abuse → Grown-up broke the private
part rule (requires teaching of the private part
rules)
Child Physical Abuse →Grown-up hit or hurt kids
Neglect → Kid didn’t have food and hugs and
clothes and things kids need
Domestic Violence → Grown-ups in the family hit
or yell or hurt.
Placement Change → Live in a new home
Relaxation
Psychoeducation begins gradual exposure & Relaxation is your
companion tool for distress reduction.
Teaching of relaxation skills will begin from day one of
interactions with the family
Intake/Assessment – increase comfort level through relaxation
Enhancing Safety –Relaxation is a part of your therapy routine &
home routine
Psychoeducation – Used in support of beginning gradual exposure
work
Parenting – relaxation as homework and as a support for
caregivers in their child’s behavior
Relaxation
Teach through Practice
“Calm your body”
Teach multiple skills for increasing child’s tool box
AND have one consistently used relaxer
Caregivers should model relaxation
Make it a fun, family activity to practice
Practice only at calm times
Use skills at home and in session
Progressive Muscle Relaxation
Use large muscle
groups or full body
Tense & Release
Combine with visual &
cue word
Be playful….But avoid
child bouncing around
room
More Relaxation Ideas
Calm breathing
bubble breaths
birthday candles, flower, soup, plate of warm cookies
Sensory relaxation
feather, squishy ball
Parent combing hair
Create a Calming Box
Song
Relaxation songs & Calming songs
Naturally relaxing activities
Favorite show, milk, blanket, toy
Relaxation with Caregivers
Discuss trauma triggers, both external and internal.
Problem solve application of learned skills
Anticipate and discuss common problems heard
“my child won’t do these” “this has never worked before”
Encourage
Praise for practicing relaxation
Relaxation should be a positive experience
Practice together
Do not pair relaxation with discipline
AFFECT REGULATION
What can we expect of
preschoolers?
During the preschool years the growth of children’s social, cognitive and
linguistic abilities lead to significant advances in their understanding of
emotions and their ability to communicate that understanding
They can suggest specific situations that could make one feel happy, sad,
surprised, scared or angry.
They can identify feelings in self, but 3-4 year olds less likely to differentiate
between happy and excited, or angry and furious
Four-year-olds generally understand that another person may have feelings
that are different from their own
Feelings Identification
Make it active and engaging!
All activities can be done with caregiver and child together
Feeling charades
Feeling balloons
Feeling stations game
Incorporate social stories
Include a drawing component
Feelings Books for
Preschoolers
The Way We Feel – Shelley Rotner
Lots of Feelings- Shelley Rotner
Glad Monster Sad Monster- Ed Emberley
Shy Spaghetti and Excited Egg – Marc Nemiroff, PhD, & Jane Annunziata, PsyD
Feelings Identification
Multiple feelings (6 & 7 year olds)
Double Dip Feelings
Home Practice
Have parents model use of feeling words
HW Activity: Popsicle Feelings
Emotion Support
➢Validate
➢Empathize
➢Normalize
➢Be present
Image Credit: The Royal Society for the
Encouragement of Arts, Manufactures & Commerce
https://www.youtube.com/watch?v=1Evw
gu369Jw
Emotion Support
Trying to “fix” too soon
Minimizing “It’s not a big deal. You’ll be okay. Don’t be so upset.”
Silver linings “At least…”
Judgmental questions or tone “You were mad!!??”
Doubt/Disbelief “You really felt sad about that!?”
Invalidating Body language Rolling eyes, shaking head, arms crossed
Hanging out to dry No response to a child sharing important feelings
Criticism/blame “Maybe if you hadn’t _____, you wouldn’t feel so sad”
Traps
Emotion Coaching
o Extending Children’s Understanding of Emotion
o Coping Strategies
o Problem-Solving
© 2016 Let's Connect
COGNITIVE COPING
Can young children do
cognitive therapy?
Preschoolers are potentially more open to a change in
their way of thinking than at any other age
Preschoolers do not have mature cognitive skills
Therapy will focus on less sophisticated cognitive coping
skills
Do not expect: perspective taking, self-reflection, causal
reasoning
Do expect: Learning! Integrating new information to
Change Existing Understanding
Cognitive Coping – It’s Needed!
Developmentally, young children tend to:
Overgeneralize “Everything is this way”
Egocentric explanations “I caused it”
Limited in considering alternative explanations
“Only way I know…only way there is”
Can lead to VERY problematic beliefs after trauma
Cognitive Coping
Ages 5-6 can understand the triangle!
More practice with young children at this point
Teach thoughts and feelings
Use play and social stories
Use graphics
Adjust language
Differentiate between thoughts, feelings, and
behavior
T/F/B bean bag toss
T/F/B triangle game
Cognitive Theory for
Preschoolers
Cognitive Coping Skills for
Preschoolers
Positive self-talk (5-6yo)
Turtle Steps
Place skills in a story
Use of puppets
Happy Channel or Happy Song
Thought replacement
“Poof” or “go away” or “I’m safe”
Cognitive Coping Skills for
Preschoolers
Trauma Narrative
Remember your enhancing safety
skills for sessions? Use those here!
Structure
Consistency
Predictability
Opportunity to use all skills learned
from beginning to now
Put that creative hat on!
Keep drawing on natural interests
Lower your expectations
Trauma Narrative Structure
Introduce rationale
May reread book from
psychoeducation to
introduce idea
Create a simple story
Can pair pictures with a
couple of sentences of
description
Be sure to record their
words so you can still do
rewind and replay to
achieve gradual exposure
Use movement
Use visuals
TN Considerations
Have difficulty with source attribution –
where they obtained knowledge/information
Telling a story may be challenging
Concepts, understanding, and language for
time may not be developed
TN Considerations
Questions need to be open AND directive
Where were you? Who was there? What were you doing?
Tell me what you were playing. What did you see? Hear?
Avoid leading questions Did daddy touch you? → What did daddy do when he
came in the room?
Ask open-ended questions within the
context of what you ALREADY know
“One of the scary times you’ve had is
when mom and dad fought, tell me about…
“Walk through the
Story of … “
Visual Prompts
Placed
Throughout Room
Early childhood Trauma
Narrative Examples
Keep in mind it is the trauma narration
process…not product that is important
Often the product may be an
incomprehensible drawing, or not
viewable after the fact (e.g. play with
dolls)
Cognitive Processing
Beliefs are malleable in early childhood → May have
become healthier, more accurate already
Many techniques used are NOT developmentally
appropriate (metaphors, socratic q-ing, perspective
taking)
Looks a LOT like psychoeducation for younger children
Use teaching, stories, examples to replace unhelpful
thoughts with more helpful ones
Bring in their caregiver!
Daddy and mommy had a fight because of me → Parents
fighting is not the kid’s fault
Daddy doesn’t love me → Daddy is trying to get better and
lots of people love me. I am a great kid!
In Vivo
Desensitization to nonharmful trauma
related fears
Bedtime, Bathroom fears common in early childhood
1. Get a play by play breakdown of current child fear
behaviors and caregiver responding
2. Develop fear hierarchy with caregiver & explain to
child the plan
3. Problem solve with caregiver
4. Monitor & adapt plan
In vivo – Making it successful
Biggest challenge is failure to allow fear
to desensitize
Backing out in the midst of a step
Will lead to increased fear and avoidance
Problem Solving with caregiver is crucial
How do you expect child to respond?
What will that feel like for you? Thoughts? What would
help you persist?
If caregiver unable to tolerate child distress, select an
easier step in the fear hierarchy.
CONJOINT SESSION
Conjoint Session
Goal for caregiver to continue healing process
through hearing child’s worst moments and
responding in validating and supportive ways
3 important ingredients for every conjoint
session:
Validate Feelings
Praise
Accurate Information
Conjoint Session
How might you coach a caregiver to
validate & praise:
“It was the worst feeling in the world when you and dad
fought”
How might you coach a caregiver to
validate & praise:
(fidgety child avoiding conjoint session starting)
How might you coach a caregiver to
provide accurate information regarding:
“Dad hit me because I was being bad.”
Preparing for Conjoint
Preparation with child
Decide how child will share their story
Therapist cues story aloud
Child describes drawings
Therapist whispers and child repeats
Parent reads aloud and pauses through story
Give control – Feelings check-ins, relaxers to use, pick a snack, seating arrangement, end activity
Parent preparation
How do you imagine it will feel hearing your child tell their trauma story?
Plan how they will give validation, praise, & correct information
Role play, Script, and Plan to extent needed
Structuring the Conjoint
Session
Pair conjoint with celebration or
graduation
Incorporate activities and break up stories
to keep child engaged
Therapist may need to be more active in
assisting child in sharing the narrative
Use of special rewards
Questions? Comments?
Early Childhood Open Consultation Call
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