Evidence Based Psychotherapy Interventions: ... Evidence Based Psychotherapy Interventions: Parent...
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Evidence Based Psychotherapy Interventions: Parent-Infant and Trauma Informed MODERATOR: TAMMER ATTALLAH, LCSW, MBA PRESENTERS: QUINCEY G. ATKIN, PHD & BROOKS KEESHIN, MD
The content of my presentation does not
relate to any product of a commercial entity; therefore, I have no relationships to report.
• Review Evidence Based strategies for treating children exposed to trauma
• Discuss brief therapeutic models designed for children and families to enhance parenting and decrease child distress
• Identify methods to include evidence based trauma treatment components into MHI
• Proposed classification of stress: – Positive – Tolerable – Toxic
• Toxic stress, like all stress, triggers a neuroendocrine response. – Specific neuroendocrine responses to toxic stress may become
• Effects may be developmentally sensitive.
Shonkoff et al, JAMA 2009
Johnson, Riley, Granger & Riis, Pediatrics (2013)
Framing an acceptable intervention
• Parents are under increased scrutiny. • May be resistant to changes. • Recognize and normalize ambivalence towards meeting own
needs versus needs of children. • Buy-in
– Intervention framed within context of empowerment. – Increase of skills as needs of the child increases.
Borrow from 2 evidence based models
• Parent Child Interaction Therapy – Behaviors
• Trauma Focused Cognitive Behavioral Therapy – Distress
Issues for Violent and Abusive Homes
• Report high levels of child behavior problems. • Have less awareness of child positive behaviors—few positive
interactions. • Have inappropriate expectations for child. • Admit high endorsement of corporal punishment. • Have difficulty discriminating levels of misbehavior. • Exhibit coercive relationship between parent and child.
What is Parent Child Interaction Therapy?
• Highly specific, step-by-step, live-coached behavioral parenting model.
• Provides immediate prompts to parents while they are interacting with their child, using “bug in the ear” system.
• Combines elements of attachment and learning theory, systems theory, and behavior modification.
• Short-term: 14-20 sessions. • Empirically validated in >100 studies. • Gives parents responsibility, not blame.
Child Directed Interaction
• Child Directed Interaction (CDI) – Relationship enhancement focus. – Parent is coached in session on using specific strategies to
improve relationship. – Parent is given homework to practice skills during “special
time” with child. – Parent must meet criteria in order to move on to next
stage of treatment. – Parent learns to use selective attention.
CDI “PRIDE” Skills - Do’s
• Labeled Praise: “Nice job picking up the blocks” • Reflect: child- “It’s a blue doggy” parent- “The dog is blue” • Imitate: Parent closely follows child’s actions • Describe Behavior: “You’re building a tall tower” • Enthusiasm: Voice tone, eye contact, etc.
Parent Directed Interaction
• Parent Directed Interaction (PDI) – Parent learns to give effective commands to increase child
compliance. – Parent learns positive discipline approach. – Parent is coached live in session on giving commands and
using positive discipline with generalization planned and implemented.
– Parent must meet criteria in order to complete treatment.
Parent Directed Interaction (PDI)
Dealing with Challenging Behaviors – Key features of the discipline phase of PCIT:
• Consistency • Predictability • Follow-through
• Improved parenting skills. • Decreased child behavior problems. • Improvement in the quality of the parent-child relationship. • Gains are maintained over time. • Parenting skills learned will generalize to other children and
Trauma Focused - CBT
• TF-CBT is a manualized 12-16 week individual treatment for children 3-17.
• Stepwise approach for the treatment of individuals who have been traumatized, either acutely or chronically, and suffer psychiatric and/or behavioral complications from their trauma.
• Potential patients include those with PTSD, anxiety, depression, behavior and self-image changes as a result of a traumatic event or series of traumas.
Cohen et al., 2006
• TF-CBT uses a combination psycho-education, relaxation, didactic and narrative techniques.
• Empower the child to better cope with remembering the trauma. – Help the child process the trauma(s) – Become desensitized to memories
• Therapist works with both the patient and parents.
Cohen et al., 2006
Efficacy of TF-CBT
Keeshin and Strawn. Child and Adol Psych Clinics of NA 2014
Psychoeducation and parenting skills Relaxation Affective expression & modulation Cognitive coping Trauma narrative processing In vivo mastery of trauma Conjoint parent-child sessions Enhancing safety and future development
Cohen et al., 2006
What can we use in clinic? CHILD FAMILY TRAUMATIC STRESS INTERVENTION & PCIT ADAPTATION
Psychoeducation and parenting skills
Affective expression & modulation
Trauma narrative processing
In vivo mastery of trauma
Conjoint parent-child sessions
Enhancing safety and future development
Cohen et al., 2006
Communication and Case
Management = CFTSI
• Child and Family Traumatic Stress Intervention.
• 4-6 session brief intervention/prevention model for 7-17 year olds.
• Evidence based treatment for trauma exposed youth and their families.
CFTSI Clinical Goals
• Anxiety • Depression/Withdrawal • Intrusive Thoughts/Traumatic
Reminders • Sleep Disturbances • Tantrums/Oppositional
Behavior • Sexualized Behaviors
• Improved communication • Improved awareness of
distress and skills • Generalization
– Within child – Other children
• Increased access to other systems – Empowerment – Awareness
Symptom Reduction Additional goals
PCIT MHI Adaptation
• Teach concepts of behavioral modification
• Provide parents with PRIDE skills with practice suggestions
• Encourage the development of a consistent plan for behavioral consequences
• Monitor for change in behaviors in time
• Referral for ongoing behavior modification when indicated
Wrap Up Points
• Modalities exist for treating trauma exposed children with emotional and behavioral challenges
• EBT provide techniques applicable to the primary care setting
Questions to consider • When is trauma informed practice appropriate for an MHI
setting? If not appropriate, whom should I refer out?
• Parent can often be anxious and sensitive about providing this treatment. How should I introduce this practice?
• What are common barriers to these practices?
Evidence Based Psychotherapy Interventions: Parent-Infant and Trauma Informed Objectives Toxic Stress Framing an acceptable intervention Borrow from 2 evidence based models Addressing Behaviors Issues for Violent and Abusive Homes What is Parent Child Interaction Therapy? Child Directed Interaction CDI “PRIDE” Skills - Do’s Parent Directed Interaction Parent Directed Interaction (PDI) PCIT Outcomes Decreasing Distress Trauma Focused - CBT TF-CBT Efficacy of TF-CBT TF-CBT What can we use in clinic?� TF-CBT CFTSI CFTSI Clinical Goals PCIT MHI Adaptation Wrap Up Points Questions to consider