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?