Treating Children: What Treating Children: What WorksWorks

Lucy Berliner Lucy Berliner

FCAP SeminarFCAP Seminar

February 2, 2004February 2, 2004

Tx Needs of Foster Tx Needs of Foster ChildrenChildren

Emotional and behavioral problemsCompromised relationships Functional impairment:• Home• School• Community

Causes of Causes of Problems/RisksProblems/Risks

Genetic loading; neurobiological insultsAttachment insecurity• Early inconsistent, unresponsive, frightening

parental style

Trauma/abuseHarsh and inconsistent parenting; coercive family environmentDisconnectedness from family, school, positive peers

The State of The State of InterventionIntervention

Why most affected children do not receive necessary treatment• Not identified• Not referred• Do not f/u for services or complete tx

When children do receive tx• Often crisis driven• Insufficient dose• Mostly traditional child psychotherapy (supportive

listening + random acts of intervention) • Evidence based tx not used

Problems to SolveProblems to Solve

Engage children/familiesApply proven strategies

Barriers to EngagementBarriers to Engagement

Attitudes toward therapy [stigma, problem can solved without outside assistance]Logistical problems [$, child care, inconvenience]Readiness to change [problem recognition, motivation]Avoidance coping

Barriers to Evidenced Barriers to Evidenced Based TxBased Tx

Lack of knowledge/trainingInstitutional environment [inadequate supervision, productivity/paperwork requirements]Thx attitudes/beliefs• Current practice effective• Evidence-based tx is cookbook/inflexible• Protocols unhelpful with complex case

situations

Solution # 1Solution # 1

What does the child/family need?• Safety?• Stabilization?• Concrete services [referrals, access, case

coordination]

What helps for those needs?• Crisis response• Advocacy• Case management

Take Home Take Home MessageMessage

Triage

Give people what they need

Distinguish therapy from other services

When Treatment is the NeedWhen Treatment is the Need

Characteristics of Treatments Characteristics of Treatments With Empirical SupportWith Empirical Support

Tend to be behavioral or cognitive-behavioral

Use specific procedures, not much “free-styling”

Goal directed

Skill-building oriented

Use of practice and feedback methods Role play

Homework

Goals of TreatmentGoals of Treatment

Reduce sx/behavior problemsEnhance positive relationships with adults and peersRestore/maintain normal developmental functioning

Tx for Trauma ImpactTx for Trauma Impact

Exposure to trauma does not = clinically significant trauma-related problems/needsSource of problems may/may not be traumaProblems/needs should be focus of interventionMost disruptive/riskiest problems are prioritized

Tx PrioritiesTx Priorities

Severe oppositionalityAggressionDifficulties regulating negative emotionsSevere depression/suicidalitySubstance abuseHigh risk behavior: self destructive, association with deviant peers, antisocial activities

Components of Components of Effective TreatmentsEffective Treatments

Emotion regulation skills

Problem solving skills

Identification and correction of maladaptive beliefs

Social skills

Positive parenting

Unique Trauma-Specific Unique Trauma-Specific ComponentComponent

Gradual exposure/Creating the trauma narrative

Role of the TherapistRole of the Therapist

Key qualities of effective clinicians • Warm• Empathic• Genuinely concerned and interested

Function of therapeutic relationship• Vehicle for delivering therapy; guide• Limited, contained, passing through

ENGAGEMENTENGAGEMENT

Engaging Families in Engaging Families in TreatmentTreatment

Establish common groundEmphasize importance/primacy of parental/caregiver roleReduce parental/caregiver distressAssess readiness to change and motivateInclude parents/caregivers in child treatment sessionsBe flexible and responsive to logistical concerns

Engagement When Engagement When Patient ReluctantPatient Reluctant

“Dance don’t Fight”Invite patient to give perspectiveListen reflectivelyFocus on strengthsExamine ambivalenceElicit motivational statements Convey “I can help you”

Therapists Motivational Therapists Motivational TasksTasks

Precontemplative Raise doubt about problem. Increase client’s

perception of the risks and problems associated with the behavior

Contemplative Strengthen client’s self efficacy for change Evoke reasons for change and risks of not

changing

Preparation Help client determine the best course of action to

take in making the change happen

Therapists Motivational Therapists Motivational TasksTasks

Action Help client take steps towards change

Maintenance Help client identify and use strategies to

maintain change

Relapse Help client renew process of

contemplation, determination and action

ASSESSMENTASSESSMENT

Assessment before treatment so Assessment before treatment so that intervention that intervention

is matched to needis matched to need

Targets for AssessmentTargets for Assessment

Emotion dysregulation Behavior problemsRelationships with significant others FunctioningStrengths in patient, family and environment

Behavior Problems Behavior Problems

Social Problems• Immature, teased, lonely, doesn’t get along,

not liked

Attention problems• Inattentive, daydreams, unable to concentrate,

impulsive, can’t sit still, fails to finish tasks

Externalizing• Aggression, defiance, disobedience, bad

temper, disruptive, destructive, lying, stealing, negative peers

Problematic CognitionsProblematic Cognitions

Self-blame (e.g. what did/did not do)Shame (e.g., overall negative self)Helpless and hopelessSelf-defeating (e.g., automatic negative)Perceived hostile intent of othersInflexible (e.g., over generalized, black/white, catastrophizing)

Assessment of Assessment of CognitionsCognitions

Use open-ended inquiry• Why do you think people are upset with

you?• What causes you to have these problems?• Why do you think you got abused?• How trusting are you of other people? • Why do bad things happen to good

people?• What would make a difference?

Assessment of Assessment of Family/Caregiver Family/Caregiver

Capacity and ResponseCapacity and ResponseGeneral• Sensitivity/responsiveness• Disciplinary style• Level of supervision of activities

Trauma-specific• Distress re trauma• Belief• Level/type of support

Treatment PlanningTreatment PlanningProvide feedback from assessment Identify child and/or family/caregiver goals Specify targets (e.g., can’t fall asleep, blames self, is afraid all the time, disobedient, no friends, in trouble at school)Explain tx process and gain commitment

The ComponentsThe Components

EMOTION REGULATIONEMOTION REGULATION

Emotion RegulationEmotion Regulation

Potential strategies (depending on emotion)• Feelings identification/expression• Progressive muscle relaxation• Controlled breathing• Thought stopping/replacement• Cognitive coping• Count to ten/leave situation

Feelings Feelings IdentificationIdentification

Feelings Feelings identificatiidentificationon

Use non-verbal Use non-verbal vehicles for trauma vehicles for trauma emotion expressionemotion expression

Relaxation SkillsRelaxation Skills

Progressive muscle relaxation• Tensing and relaxing muscle groups• Focus on feeling difference• Demonstrate possibility of change

Controlled breathing• Breath in/exhale slowly• Grounding in the moment

IdentifyiIdentifying ng tension tension and and relaxatiorelaxationn

Cognitive CopingCognitive Coping

Focusing on the positive instead of the negative aspects • Positive self-talk• Recognizing how one is coping

well• Learned optimism

Positive Self TalkPositive Self Talk

I am safeI am safe

My Mom will protect meMy Mom will protect me

He can’t hurt me nowHe can’t hurt me now

I know how to handle I know how to handle feelingsfeelings

I am strongI am strong

Anger ControlAnger Control

Identify causes/stimuliDescribe physiological and cognitive componentsTeach management strategies• Count to ten• Leave situation• Exercise• Relaxation

Anger ControlAnger Control

What makes you mad?• Kids bugging me, thinking about my step dad

Tell me how you feel when you get mad.• Tense, hot, heart pounding, like I’m going to explode

Ok, here’s a plan for keeping your coolThe first part is to calm down. Try this: take a deep breath, let it out slowly and then count to 10• 1, 2, 3

Good job. Now the second part is taking a break. How could you do that?• Go to my room, walk around the block

IDENTIFICATION AND IDENTIFICATION AND CORRECTION OF MALADAPTIVE CORRECTION OF MALADAPTIVE

COGNITIONSCOGNITIONS

Identifying and Altering Identifying and Altering Maladaptive CognitionsMaladaptive Cognitions

Explain connection between thoughts, feelings, and behaviorsIdentify inaccurate or unhelpful cognitionsGenerate alternative realistic, accurate and more helpful beliefs/attributionsChallenge maladaptive cognitionsGive homework for practice

Typical Maltreatment-Typical Maltreatment-Related Maladaptive Related Maladaptive

CognitionsCognitionsSelf blame, shameOver estimation of dangerNegative, ruined selfOther’s hostile intentUntrustworthy othersDangerous world

Cognitive StrategiesCognitive StrategiesProgressive logical questioningEliciting alternative attributions (e.g, regret versus responsibility)“Best friend” role playLearned optimismFinding value in bad experience (e.g., capacity to handle difficulties, realize what’s important)

Allocating Blame/FaultAllocating Blame/Fault

Offender

His Wife

Me

She didn’t give sex

She knew what was happening

I shouldn’t have gone back

He did it

He knew it was wrong

Problem SolvingProblem Solving

Name problemGenerate total possible solutions (without evaluation)Evaluate and discard non-feasible alternativesChoose possible solutionTry it outCheck back and re-evaluate

Problem solvingProblem solvingSo the problem is that you don’t have any friends. Let’s make a list of all the possible ways to solve the problem. But you can’t say whether it is a good way or a bad way until we get them all out.Can you think of a way• No

Problem solvingProblem solving

How about this? • Your dad will call up the kids and tell

them to be your friend, or• You can bring candy to school and

give it to kids

Now can you think up a way?• I could tell the kid I’ll help on the class

project

OK we need 3 more

EXPOSURE &EXPOSURE &CREATING THE TRAUMA CREATING THE TRAUMA

NARRATIVENARRATIVE

Reasons for ExposureReasons for Exposure

Desensitization/habituation to disturbing memories/remindersIdentification/preparation for trauma/loss remindersResolution of maladaptive avoidance symptoms

Capacity to talk about experience as part of life hx: obtain support, put into perspective, connect with others

Accomplishing Accomplishing ExposureExposure

Assess child’s capacity to talk about without extreme distress; identify “hot spots” or worst moments as primary targetsExplain mechanism (e.g., hard in the beginning, get’s easier)Do not force, be gradual as necessary Use verbal and non-verbal strategies

Identifying and recognizing trauma Identifying and recognizing trauma cuescues

Introducing Exposure Introducing Exposure

Sounds like when you remember what happened you get back the bad feelings, sometimes it can feel like it’s happening again.What makes you remember? Figuring those things out can help you be prepared.It might seem kinda weird but the best way to make the scary feelings get less is to remember and talk about it in a safe place

Introducing ExposureIntroducing Exposure

In the beginning it’s a little bit hard, but you know what? After a while it doesn’t feel so bad. Then you won’t have to keep trying to forget because it won’t bother you so much.We can do it slow, step by step. You pick a time.

Picture tells the story; child and brother Picture tells the story; child and brother witness mother being stabbed to deathwitness mother being stabbed to death

Traumatic Grief Traumatic Grief

Traumatic stress + griefNormal grieving: sadness, longing, emptiness, sense of loss, memories of positive experiencesTraumatic grief: sadness + memories/intrusions of manner of death

Sharing the Trauma Narrative Sharing the Trauma Narrative with the Parentwith the Parent

Parent/caregiver needs to know in order to appreciate child’s experienceIssues to consider:

•Confidentiality•Developmental considerations

Use child’s artwork, stories, drawings (with child’s permission)

Caretaker InterventionsCaretaker Interventions

Parent/Caretaker GoalsParent/Caretaker Goals

Reduce distressPromote supportProvide informationEnhance relationshipTeach positive behavior management skills

Behavior ManagementBehavior Management

Reward positive behavior• Praise• Reflect• Describe

Ignore inappropriate behaviorGive effective instructionsConsequences for misbehavior• Time-out• Removal of privileges

StrategiesStrategiesAnxieties• Reassurance, accurate cognitions, reinforce coping

strategies, safety rituals

Sleep problems• Sleep hygiene, environmental adjustments, dream

reconstruction

Sexually inappropriate behaviors• Rules/expectations, decrease

stimulation/environmental containment, supervision

Aggressive behaviors• Rules/expectations, alternative behaviors, modeling,

consequences, supervision

Attachment InsecurityAttachment Insecurity

Ambivalent• Whiney, clingy, demanding, angry outbursts

Avoidant• Aloof, distant, unusually independent,

unaffectionate, indiscriminate friendliness to strangers

Disorganized• Manipulative, sneaky, deceptive, superficial

emotionality or fake sweetness

General StrategyGeneral Strategy

Understand behavior as adaptive response to early environmentDon’t take it personallyBe prepared to adjust expectationsFind support for frustration/disappointment

Specific StrategiesSpecific Strategies

Ambivalent style• Constant reinforcement and praise;

attending/responding

Avoidant style• Respectful, go-slow approach; non-

demanding of affectionate responses

Disorganized style• Clear expectations; consistency; non-

coerciveness; firmness; opportunities for choice

Most Important GoalMost Important Goal

Child Who Child Who Feels Feels LovedLoved

Environmental StrategiesEnvironmental Strategies

Make home a safe haven physically and emotionallyGive high levels of supervision/oversight

Have close connection to schoolProvide non-therapy opportunities for relationship enhancement and skill acquisition (e.g., mentor, sports/clubs, after school activity centers)

C.O.W.’SC.O.W.’S

Strategies for Managing Strategies for Managing the typical “Crisis of the the typical “Crisis of the

Week”Week”

COW StrategiesCOW Strategies

Acknowledge identified COW. Address COW briefly and then return to treatment goal, or……Address COW through components-based intervention (problem solving, cognitive coping, emotional regulation…)

Therapist ApproachTherapist Approach

Be clear about the purpose of therapy/have an agendaMatch interventions to problemsTeach/practice/reinforce skills at each sessionAvoid distraction onto COWs (or apply skills to COWs)