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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.

  • Objectives

    • 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

  • Toxic Stress

    • Proposed classification of stress: – Positive – Tolerable – Toxic

    • Toxic stress, like all stress, triggers a neuroendocrine response. – Specific neuroendocrine responses to toxic stress may become

    pathogenic.

    • 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

  • Addressing Behaviors

  • 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

  • PCIT Outcomes

    • 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

    situations.

  • Decreasing Distress

  • 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

    • 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

  • TF-CBT

    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

  • TF-CBT

    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

    Communication and Case

    Management = CFTSI

  • 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