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Riskilaste konverents 2012: Tonje Holt: Treating traumatized children

Riskilaste konverents 2012: Tonje Holt: Treating traumatized children






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    Riskilaste konverents 2012: Tonje Holt: Treating traumatized children Riskilaste konverents 2012: Tonje Holt: Treating traumatized children Presentation Transcript

    • Treating traumatized children with TF-CBT - A study of process and outcome Estonia, Tallin, October 3-4, 2012 Evidence-Based Practice in Working with Children and Youth at Risk: The Norwegian Experience. Tonje Holt, Tine K. Jensen, Randi Saur & Silje M. Ormhaug
    • The Research Group - TF-CBT Tine K. Jensen, Project leader Karina Egeland, Research coordinator Silje S. Hukkelberg, PhD. Post doctoral candidate Silje M. Ormhaug, Research fellow/ PhD Candidate - assessments Tonje Holt, Research fellow/ PhD Candidate - assessments Shirley D. Stormyren, Specialist in psychology - training/treatment fidelity Live E. C. Hoaas, Specialist in psychology – training /treatment fidelity Lene B. Granly, Specialist in psychology – training /treatment fidelity Tore Indregard – Statistics ToRe Wentzel-Larsen - Statistics Ingeborg Dittmann, Psychologist – treatment fidelity Kristin Glad, Psychologist – treatment fidelity Tor Iversen, Professor in Health economy, Faculty of Medicine, Eline Aas, Accociate Professor in Health economy, Faculty of Medicine + 4 graduate students in Psychology 2
    • This Presentation:• The Norwegian context• What is TF-CBT?• The NorwegianTF-CBT study Design and Research q’s Sample Preliminary results (main results and process results) Satisfaction• Implementing an EBT in ordinary clinics• Asking about traumas
    • 4
    • The Norwegian Context I• Population: 4.7 million (CO = 5.0 mill)• 5 % subjected to violence every year• Figures are stable
    • Explanations Gender High Access to equality employment education A positive Equal economy income
    • The historical developmentFrom the private to the public sphere“the personal is political”• Women’s movement• Mens violence against women, late 1970 -• Political incentives; The past 10-15 years: – Activities initiated and stimulated from a political level – Resources are allocated – More knowledge – New target groups
    • National action plans from 2000The changing governments have presentedsuccessively three action plans, entitled… •Violence Against Women (2000 - 2003) •Violence in Close Relationships (2004 - 2007) •Turning Point; violence in Close Relationships (2008 - 2011) •Also released Action plans etc against; female genital mutilation (2008 – 2011), forced marriage have been presented (2008 – 2011), sexual and physical abuse of children (2005 - 2009) and Reports NOU on Combating rape (2008) & Rape- sexual assaults (2012-2014)
    • Objectives common to all action plans• Attitudinal changes in society• Strengthening professional communities and expertise• Assistance to victims of violence• Development of therapeutic services for perpetrators of violence
    • Two reports may be of interesthttp://www.nkvts.no/biblioteket/Sider/brn.aspx• Violence prevention in Norway. Activities and measures to prevent violence in close relationships (Saur, R., Hustad, A. E. & Heir, T. 2011)• Research and education on prevention of violence at the Norwegian Centre for Violence and Traumatic Stress Studies (Saur, R., Hjemdal, O. K. & Heir, T., 2011) 10
    • Overarching strategies in violence prevention Prevention through… • Teaching and knowledge dissemination • Interventions and treatment • Campaigns and information
    • However:- A minority of the activities in our materialare evaluated by external research bodies.- There is little systematic evidence of theeffects of violence prevention.
    • The Norwegian Context II• ≈ 5-25% of youth population exposed to interpersonal traumas in Norway (Mossige and Stefansen, 2007)• In 2007 4,5 % of the child population received psychological services (estimated need 5 %)• Little is known about the quality of interventions! 13
    • Trauma - Focused CBT (TF-CBT)• Developers: Judy Cohen, Anthony Mannarino & Esther Deblinger• Short term, 12-15 sessions• Based on theoretical principles from cognitive, behavioral, interpersonal and family therapy, in addition to trauma-theory 14 http://tfcbt.musc.edu/
    • TF-CBT Components• PRACTICE  Psychoeducation and Parenting Skills  Relaxation  Affective Modulation  Cognitive Processing  Trauma Narrative  In Vivo Desensitization  Conjoint parent-child sessions  Enhancing safety and social skills
    • TF-CBT Cont.• One of the most recommended treatments for children who have experienced severe trauma and present with significant post-trauma symptoms• 11 RCT studies so far• More improvement in child PTS symptoms, depression, anxiety, shame and behavior problems, compared to control groups• More improvement in parental distress, support and depression compared to control groups.Deblinger et al., 1996, 1999; Cohen & Mannarino, 1996, 1997, 1998; King et al., 2000; Cohen, Deblinger, Mannarino, & Steer, 2004; Cohen, Mannarino, Iyengar, 2011. 16
    • However٥ No RCT studies in clinics outside the U.S. by independent research groups٥ Few effectiveness studies٥ Can TF-CBT be implemented in regular clinics, with “regular” clients, with therapists that have ordinary case loads and that are not trauma specialists.٥ In Norway no special trauma clinics – Can TF-CBT be used where the children usually receive mental health services? 17
    • The Norwegian TF-CBT Study:Overall Aim:٥ Understand more of what treatment is beneficial for traumatized youth and why (both effect and process)Research questions٥ Is TF-CBT more efficient than TAU in reducing trauma related symptoms?٥ What role does the therapeutic alliance play in treatment outcome?٥ What role does parents’ reactions and support play in treatment outcome?٥ What role does child post-trauma cognitions play in treatment outcome?٥ Is TF-CBT more cost effective?٥ Do children and parents find the model useful?
    • The Norwegian TF-CBT study DesignRCT designIn 8 regular child guidance clinics156 child participants28 therapists trained in TF-CBT60 TAU therapists involved 19
    • The Norwegian TF-CBT study Cont.Inclusion criteria:٥ Youths aged 10-18.٥ Experienced a trauma٥ Have PTSD symptoms over cut-off of 15 on CPSS (clinical cut-off 11)٥ Speak NorwegianExclusion criteria:٥ Psychotic, suicidal 20
    • Treatment fidelity check Procedure Therapy as usual Assessed Assessment Assessment Assessment Follow-upReferral for trauma T1 After 6. session after 15. session 12 &18 month T2 T3 T4 & T5 TF-CBT Treatment fidelity check 21
    • Flow chart Assessed for eligibility (n=454) Met inclusion criteria (n=200) Declined to participate (n=44) Randomized (n=156) Allocated to Allocated to TF-CBT (n=79) TAU (n=77) Drop out Drop out before session 6 before session 6 (n=14) 18% 25% (n=19) 22
    • Participants• Gender: 80% girls, 20% boys• Age: mean age 15 years• 73 % Norwegian• Mean no. of different traumatic events: 3.6 (SD = 1.7, range 1-10)• Clinical population: multi-traumatized, high scores on PTS, depression and anxiety 23
    • Worst trauma (n = 156) 20,5 % Loss/accidents/ injury 20 % Violence outside 30 % Violence family 19 % SA outside 10,5 % SA family
    • Measures• PTSD (CAPS + CPSS)• Depression (MFQ)• Anxiety (SCARED)• Posttraumatic cognitions (CPTCI)• General mental health (SDQ)• Quality of life (16D)• Therapeutic Alliance (TASC-r)• Parental emotions and depr. (PERQ, CES)• Parental support (PSQ)• Social support (FFSQ) 25
    • Measures Interviews• PTSD (CAPS + CPSS) • Children &• Depression (MFQ) parents about• Anxiety (SCARED) assessments• Posttraumatic cognitions (CPTCI) • Children &• General mental parents about health (SDQ) therapy• Quality of life (16D) • TF-CBT• Therapeutic therapists Alliance (TASC-r) about using the• Parental emotions model and depr. (PERQ, CES)• Parental support (PSQ)• Social support (FFSQ) 26
    • Measures Interviews Other ifo• PTSD (CAPS + CPSS) • Children & • Demographics• Depression (MFQ) parents about • Other services• Anxiety (SCARED) assessments provided• Posttraumatic • Life changes cognitions (CPTCI) • Children &• General mental parents about • New traumatic health (SDQ) therapy incidents• Quality of life (16D) • TF-CBT • Therapist data• Therapeutic therapists Alliance (TASC-r) about using the• Parental emotions model and depr. (PERQ, CES)• Parental support (PSQ)• Social support (FFSQ) 27
    • Some preliminary Results: Child Symptoms 28
    • PTS symptoms 30 TAU 26.88 TF-CBT 26.82 Effect size: .51 25 p= .001 20.68 CPSS Sum Score 20 18.90 16.87** 15 11.34 11 T1 T2 T3 TimeResults based on mixed effect analysis. Significant difference at T3. 29n = 156
    • PTS - symptoms’ influence on daily functioning 11 10.33 Effect size: - .55 p= .001 10 FCPSS Sum Score 8.90 9 9.22** 8.03 8.47 8 7.99 TAU TF-CBT 7 T1 T2 T3 Time Higher values indicate less influence on daily functioning Results based on mixed effect analysis. Significant difference at T3. n = 156 30
    • % that met PTSD (diagnosis) measured by CAPS * p = .035 n = 110
    • Depression 35 35.32 TAU 35.43 TF-CBT Effect size: .54 30 27.82 p = .006 25 MFQ Sum Score 24.73 22.66** 20 15 14.40 11 T1 T2 T3 TimeResults based on mixed effect analysis. Significant difference at T3.n = 156 32
    • 35 Anxiety TAU 33.32 TF-CBT Effect size: .30 34.12 p = .150 30.38 30 SCARED Sum Score 28.56 25 24.82 19.67 20 T1 T2 T3 TimeResults based on mixed effect analysis. No significant difference at T3.n = 156 33
    • Preliminary results: What do we know about the therapy processes? -any active ingrediens in therapy?• 1) Parents• 2) Post trauma cognitions• 3) Therapeutic alliance
    • Preliminary Results -active ingredients 1) Parental stress Do the parents show less emotional reactions at the end of therapy?- And do the emotions have a mediating effect on outcome? Measurements: PERQ, CES-D ”I have felt upset about my child’s trauma» “I felt that everything I did was an effort” 35
    • Parental depression 20 BOTH GROUPS Parental distress 18CESD Sum Score 16 22.5 14 BOTH GROUPS PERQDistress Sum Score 20.0 12 10 17.5 T1 T2 T3 Time 15.0 T1 T2 T3 Time
    • PERQShame Sum Score 4.0 4.5 5.0 5.5 T1 Shame T2 Time BOTH GROUPS T3 PERQGuilt Sum Score 8 9 10 11 12 T1 Guilt T2Time BOTH GROUPS T3
    • Baron & Kenny, 1986 Mediation Parental emotional reactions a b Intervention C Outcome TF-CBT/ TAU C’
    • Baron & Kenny, 1986 Mediation Parental emotional reactions B C Intervention A Outcome TF-CBT/ TAU D
    • Preliminary Results -active ingredients? 2) Post-trauma cognitions Measurement: CPTCI“My reactions since the frightening event mean I have changed for the worse” “I am a coward” “I don’t trust people” 40
    • Baron & Kenny, 1986 Mediation Post trauma cognitions a bβ = .28, t(112) = 3.10, p < .001 β = .85, t(112) = 17.07, p < .001 C’ β = .01, t(112) = .11, p =.915 Intervention TF-CBT/ TAU Outcome C β = .25, t(121) = 2.77 p < .001
    • Preliminary Results -active ingredients 3) Therapeutic alliance “The Alliance-Outcome Relationship in Treatment of Traumatized Youths” TF-CBT vs TAU (Ormhaug, 2012) Measured by TASC“The therapist and I have found a good way to work on the difficult thoughts and feelings I got after what happened”“The therapist tries to help me with the difficult thoughts and 42 feelings I got after what happened”
    • How is the alliance related to outcome?Therapeutic Aliiance Outcome
    • How is the alliance related to outcome? Outcome Est: -0.48** Est: 0.05TF-CBTTAU Therapeutic alliance
    • Preliminary results: What do we know about the processes? -the active ingrediens in therapy?• 1) The child’s improvement is not related to parents’ reduction in emotional reactions/ stress.• 2) Change in dysfunctional thoughts within the child seems to be an important explanatory variable.• 3) Good results are dependent on WHAT the therapist does, and HOW this is done (tecnique and theraputic alliance)
    • Client satisfactionWhat do the children think about the treatment? 47
    • Children (TF-CBT n = 56, TAU n = 59) I liked coming to the clinicNot at all ----------------------------All the time
    • Children (TF-CBT n = 56 , TAU n = 59)If I needed help again, I would come back to this clinic Yes --------------------------------------------------No
    • Children (TF-CBT n = 56, TAU n = 59)Coming to this clinic helped me with my problems Not at all--------------------------------------All the time
    • Implementation an EBT in ordinary clinics - challenges and experiences • Resources • Anchoring/ grounding in leadership/ management • More than one therapists • Fidelity • Training 54
    • Therapists Training 2-6 days of training session by session consultation – from audiotapes web based training No. of cases per therapist: mean = 3 (1-6) Learning the model as the study is being conducted 55
    • Initial challenges for implementing an EBTResistance to manualsTherapists with different educationalbackgroundsMy cases are special – need longer time.Hard to stay on track - COWsAvoidance of trauma narrativeStayed on the first (PRAC) components 56
    • “The importance of asking for traumas” Traumas are often omitted from the referrals Trauma screening & assessments rarely done Treated for other disorders (depression, ADHD, social phobia) Almost none receive trauma focused interventions Therapists feel they are not giving adequate treatment(Hjemdal, 2006; Ormhaug, Jensen, Hukkelberg, Holt & Egeland, in press)
    • What do the children think of beingasked about their trauma and trauma problems (in a research setting) 58
    • Children (n = 97) Did you think it was upsetting or distressing to answer questions about your trauma experience(s)?60 49,5504030 19,620 10,310 7,2 8,2 3,1 2,1 0 Not 2 3 4 5 6 Very distressing distressing 59
    • Children (n = 97)Did you have a lot of feelings when you answered the questions? 40 35,1 35 30 25 21,6 20 18,6 18,6 15 10 6,2 5 0 No feelings Minimal Some, but Some Very strong feelings not strong strong feelings feelings 60
    • Children (n = 97)Would you be willing to answer the same questions again? 60 50,5 50 40 30 27,8 20 12,4 9,3 10 0 Quite willing Might be Dont think be Definitely not willing willing willing 61
    • Summary• TF-CBT had a significant better improvement in child’s trauma related symptoms• Parents emotional reactions do also decline during the childs therapy process, but in this study this was not related to the child’s improvement• Change in dysfunctional thoughts seem to be an important active ingredient in therapy• A good alliance is important, but there has to be something more; not sufficient in TAU• TF-CBT can, should and will be implemented in Norwegian clinics: better outcomes, clients and therapists happy about it.• Screening for trauma is important
    • Thank you for your attention!tonje.holt@nkvts.unirand.no