Kiser connors-vaughn lee


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Kiser connors-vaughn lee

  1. 1. Maryland Moves To Trauma- Informed Care: Be Part of It Laurel J. Kiser, Ph.D., M.B.A., Kay M. Connors, LCSW, and Angela Vaughn-Lee
  2. 2. Why Prioritize EBPs? While the goal of increasing dissemination of effective services to improve routine care is valid: – implementation is not routine (Hoagwood, et al., 2001) – implementation requires significant time and resources: for creating change in system, provider, and clinician practices, adapting EBPs for local conditions, practice-related exigencies, and specific populations, providing extensive supervision during implementation and afterwards monitoring fidelity and outcomes Since implementation is a resource intensive activity, only a few can be implemented at a time.
  3. 3. Prioritizing Evidence-Based Practices Number of youth Program cost High risk population Funding mechanisms Expensive population Grants Family perception Demonstration projects Provider perception Need Resources Community support Agency perception Shared departments Existing providers On-going costs of EBP replication & sustainability Administrative & system supports needed Ease of Evidence Implementation Buy-in Competing interests Training requirements Effect sizes Cost of implementation Number of studies Local vs. national resources MH Focus EfficacyEBP Name Effectiveness Sole focus Cost effectiveness High Medium Low Primary, but shared focus GeneralizabilityNeed Relevance (age, Combined focusResources Secondary focus urban/rural, cultural) DD/DA/LD interests Fidelity instrumentsEvidenceImplementation Score is the sum of the five ratings. High = 5; MediumMH Focus = 3; Low = 1. Midpoints can be used and scored as a Total Score: 2 or 4.
  4. 4. RecommendationsImplement trauma-specific EBPs within a trauma-informed statewide system of care in children’s mentalhealth.Support ongoing efforts for implementing an effective EBPTFC modelSupport ongoing efforts to increase use of Family TreatmentEBPsImprove practice-based evidence for Respite and PsychiatricRehabilitation ProgramsWork in partnership with Early Childhood Mental Health,School Based Mental Health, and Wraparound Initiatives todisseminate the core competencies of these service deliveryframeworks and promote implementation of EBPs
  5. 5. Principles of Trauma-Informed Practice Goal is to reduce the adverse impact of trauma exposure on children and adolescents Trauma-informed principles of care embedded within child serving systems Strength-based, focus on resilience Promote respect for child in all situations Purposeful, therapeutic approach: – Safety is first priority – Arousal and self-regulation – Conditions that cause arousal are minimized
  6. 6. Core Components of EffectiveTrauma-Informed Practice Identification – increase public awareness of trauma’s impact – risk screening and triage – psychoeducation on trauma – engagement in process Assessment and Service Planning – systematic trauma assessment – conceptualization of intervention targets and intervention planning Intervention – delivery of empirically supported trauma-informed treatment – evaluation of intervention response and effectiveness Adapted From: National Child Traumatic Stress Network
  7. 7. Current Practices forIdentifying Trauma1)2)3)4)5)
  8. 8. Public Awareness Definitions of trauma Pervasiveness of exposure Common reactions to exposure Recognition of trauma as basis for maladaptation
  9. 9. Trauma-InformedScreening Universal screening Upon admission to system of care Identify children and adolescents at high risk
  10. 10. Screening Exposure Instruments – Traumatic Events Screening Inventory for Children – Brief Form (TESI-C-Brief) – Psychosocial Assessment of Childhood Experience (PACE) – Violence Exposure Scale for Children- Revised (VEX-R) Impact Instruments – PTSD Checklist (PCL)
  11. 11. Psychoeducation For all adults that interact with children and adolescents: – Understand behavior in context – Developmentally appropriate expectations – Normalization of traumatic response – Impact of trauma – Differentiation between reliving and remembering – Differentiating adult trauma history from child’s experience
  12. 12. Engagement Goals Open information sharing (duty to warn or report) Clarify the helping process Understanding the family’s expectations and priorities Empowering families Advocacy and ongoing safety/risk reviews Support parental coping
  13. 13. Action Steps forImproving Identification Families Practitioners Policy Makers Service Providers
  14. 14. Current Practices forAssessing Trauma1)2)3)4)5)
  15. 15. Assessment:General Issues No “gold standard” Multisources needed Multiscore instruments necessary to measure subdomains Across multiple areas of functioning Developmental specificity
  16. 16. Challenges in AssessingChildren Symptomotology may be transient or alternating Symptoms may change as developmental functions emerge Caregiver disagreement on descriptions of behaviors/symptoms Current diagnostic criteria may not be appropriate for children Children may benefit from intervention even if they do not meet specific diagnostic criteria Ippen, 2002
  17. 17. Assessment:Techniques and Instruments Clinical Interview with Child and Parent Semi-structured interviews – K-SADS-PL – Clinician Administered PTSD Scale, Child and Adolescent version (CAPS-CA) – Children’s PTSD Inventory Observation Parent Report Self-Report – UCLA PTSD Index for DSM-IV – Trauma Symptom Checklist for Children – Checklist of Child Distress Symptoms – Children’s Impact of Traumatic Events Scale
  18. 18. Assessment:Techniques and InstrumentsAssessing complex traumatic stress disorders Trauma Symptom Checklist for Children Sense of Safety Scale Dissociation Checklists
  19. 19. Assessment:Techniques and InstrumentsAssessing co-morbidity Child Behavior Checklist Children’s Depression Inventory Multidimensional Anxiety Scale for Children
  20. 20. Action Steps forImproving Assessment Families Practitioners Policy Makers Service Providers
  21. 21. Current Practices forTreating Trauma1)2)3)4)5)
  22. 22. Treatment:General Considerations For some children, cognitive-behavioral therapy (CBT) is the one intervention with empirical support. There is inadequate evidence of effectiveness for other psychosocial treatments and for psychopharmacology. There is a lack of empirical evidence and clinical support for current models of treatment for children who have experienced chronic trauma. There is clinical consensus although limited data supporting use of a combined treatment components.(Perrin, et al 2000; Cohen, et al 2000a; AACAP 1998; Scheeringa 1999; Carr 2000)
  23. 23. Treatment for Traumatic Stress Disorders in Youth Assure the child’s safety• Overarching Goals Return to normal developmental trajectory Relief of symptoms Coping skill development Provide clear information to the child• Child Therapy Prevent re-exposure or re-victimization Restore trust in self and others Renew sense of mastery and positive meaning Parent education• Parent Therapy Developmental guidance Differentiation
  24. 24. Treatment for Traumatic Stress Disorders in Youth Building representations or working models• Parent - Child of trusting relationships Coaching Therapy Constructing joint understanding of trauma Stabilizing family functioning Connecting family members• Family Therapy Developing a shared sense of meaning Using coping/problem solving techniques for minimizing additional stresses• Community Fostering connections Interventions Provide a safe haven
  25. 25. EBP EngagementProtocolsVanderbilt Study: Increase knowledge andself-efficacyParticipation Enhancement Intervention(Nock and Kazdin, 2005): Increaseattendance and adherence
  26. 26. Trauma Focus:Overcoming Avoidance PPT model Anticipate parental and child patient avoidance Problem solve Outreach and follow up“The most symptomatic children almost always have the most symptomatic parent/families ( Scheeringa and Zeanah, 2001).”
  27. 27. Follow up: OvercomingAvoidance “Did you feel reluctant to come today like I talked about last week?” Rate reluctance 1-10 “Why did you feel reluctant?” “What did you do to overcome it?” PPT Scheeringa (2003)
  28. 28. Treatment of Single EventTrauma and Childhood SexualAbuse Trauma Focused – Cognitive Behavior Therapy (TF-CBT) – Most frequently used treatment for childhood trauma – Most commonly used in outpatient therapy – Manualized treatment – Internet training available
  29. 29. TF-CBT: The EvidenceMultiple RCTsSamples– 3-17 years of age, mostly 8-12 years old– racially mixed, but predominantly White– sexual abuse; 1 sample of multiply traumatized children with sexual abuse-related PTSD symptomsComparisons– nondirective supportive therapy (NST)– child centered supportive therapy (CCT)– treatment as usual (TAU)Results– TF-CBT was significantly better than NST, CCT, and TAU– improvements in children’s PTSD, internalizing, externalizing, and sexual problems– differences sustained up to 24 months
  30. 30. Components of Trauma-Focused CBTOrientation Stress Cognitive Child’s Cognitive to Inoculation Triangle Trauma Processing TF-CBT Techniques Narrative Parent Support/Parent-Child Sessions
  31. 31. Action Steps forImproving Treatment Families Practitioners Policy Makers Service Providers