CPP, PCIT, TF-CBT: DETERMINING

CPP, PCIT, TF-CBT:

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Leslie Peterson, LCSW, RPT Susan Gordon, LCSW

W

ELCOME

!

 Leslie Peterson, LCSW, RPT

 Susan Gordon, LCSW

 Ashley Rambeau, MS, ASW

W

ORKSHOP

OBJECTIVES

:

 Discussion of CPP, PCIT, and TF-CBT:

Similarities and Differences*

 How to complete a thorough trauma assessment

 Discussion of how the family assessment can help

in choosing the right treatment modality

 Presentation of a “decision tree” and how to move

from assessment to treatment

 Discussion of complex case example

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

Child traumatic stress occurs when children

and adolescents are exposed to traumatic

events or traumatic situations, and when this

exposure

overwhelms their ability to cope

with

what they have experienced.

 disturbed sleep, difficulty paying attention and

concentrating, anger and irritability, withdrawal, repeated and intrusive thoughts, and extreme

distress



Traumatic experiences can result in a

significant disruption of child or adolescent

development and have profound long-term

consequences.

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 Attachment:

• Challenge to formation of basic trust • Difficulties in co-regulation

• Intense separation anxiety

• Lack of consistent behavioral strategies to derive sense of safety from

attachment figure

• Difficulty relating to and empathizing with others

 Biology:

• Activation of stress response system • Altered neural pathways

• Problems with movement and sensation.

• Hypersensitivity to physical contact • Insensitivity to pain.

• Unexplained physical symptoms. • Increased medical problems.

 Mood Regulation:

• Difficulty regulating their emotions.

• Difficulty knowing and describing their feelings and internal states. • Heightened emotional reactivity

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 Dissociation:

 Feeling of detachment or depersonalization

• “observing” something happening to them that is unreal

 Behavioral Control:

 Poor impulse control

 Self-destructive or self-injurious behavior  Aggression towards others

 Cognition:

 Problems focusing on and completing tasks

 Problems planning for and anticipating future events  Learning difficulties

 Problems with language development

 Self-Concept:

 Disturbed body image  Low self-esteem

 Shame  Guilt

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 Neurophysiologic dependency on their caregivers

(dyadic co-regulation)

 Limited cognitive and behavioral coping capacities  Require external regulation to manage physiological

arousal that exceeds available coping capacities

 Loss of developmentally appropriate expectation

that caregivers will protect from harm

 Interplay between challenges to basic trust and

child’s traumatic responses can have pervasively negative effects on the course of development

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 Pre-verbal children express their trauma narrative through their bodies –

through disruption in their capacity to regulate body functions, relate to others, and explore their surroundings

 Neurophysiologic regulation:

 Disruptions in biological / regulatory rhythms:  Eating, digestion and elimination

 Sleeping / state transitions

 Over or under responsively to external stimulation  Somatic complaints

 Social relatedness:

 Socially indiscriminate, lack of selectivity or preference

 Lack of consistent or discernable engagement vs. disengagement cues  Avoidance of social interaction

 Difficulties with pro-social skills; sibling relational aggression

 Developmental

 Regression - loss of previously acquired skills

 Exacerbation of normative developmental fears: self blame; fear of loss of love and

separation; superego condemnation

 Disruptions to developmental processes

 Secure base behavior, inhibited exploration  Basic trust vs. mistrust

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 “Hidden trauma”: interpersonal context

 emotional unavailability of caregiver  unpredictable response to cues

 interactive dysregulation without repair; etc.

 Experienced threat closely related to caregiver's

affective states and availability

 New neurobiology research shows similar

activation of stress response systems in hidden trauma of infancy and PTSD in older children (Siegel, Bryson 2012)

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 Treatment model must be versatile, treating a

variety of different problems, addressing most or all areas of traumatic stress

 TF-CBT, CPP, and PCIT all effective to treat the

symptoms of trauma and child traumatic stress

 Now, how do you know when to use which

TF-CBT:

 Components-based treatment model focused on

direct discussion of traumatic material

 Feelings identification, cognitive processing, trauma narrative creation and sharing, in-vivo exposure, etc.

 Ages 4-18*, experienced one or more traumatic

events, elevated symptoms of PTSD, supportive caregiver involved in treatment

 Child/Caregiver does not have any current

substance use, suicidal ideation, psychotic symptoms, etc.

TFCBT C

:

 Strengths of the model:

 Direct discussion of the trauma

 Can be used with children residing in many types of settings (parental homes, foster care, kinship care, group homes, or residential programs)

 Can be used to treat single trauma, multiple

traumas, as well as traumatic grief/bereavement

 Limitations of the model:

 Not a “family” therapy model

 Adaptations for younger ages (3-5yrs.)  “Trauma”-focused

 Limited parenting/behavioral management techniques

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TF-CBT:

 Process and Resolve Traumatic Material

 Reduce symptoms of PTSD and Traumatic Stress

 Increase communication about traumatic

material (sexual abuse, dv, physical abuse, etc.) between child and caretaker

 Increase child’s emotion and behavior regulation,

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SYCHOTHERAPY

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 A trauma-focused, relationship-based model

 Dual lens of attachment and trauma and transactional influence between the two

 Children ages 0-5 and a significant caregiver

 Caregiver, child and therapist are all present in

the room and attended to throughout

 Session themes arise out of caregiver and child

interaction

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 Always individually tailored to the family’s specific

history, socioeconomic status, cultural context, and needs.

 Model incorporates case management / resource

building as needed

 Play!!!

 Play is the young child’s primary way of connecting,

communicating, learning, repairing, and healing

 Therapist serves as translator between parent and child.

 Verbal Interpretation

 the therapist observes out loud what appears to be

happening in the parent/child interaction.

 Therapist provides developmental information and

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CPP: P

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P

 Assess and acknowledge the experience of

trauma:

 Traumatic reenactments

 Avoidance of trauma reminders

 Dysregulation of biological rhythms

 Symbolize, verbalize, enact feelings and

behaviors related to the trauma in emotional holding environment

 Decrease developmental anxieties: fear of

separation, loss of love, self-blame

 Create a joint narrative of what happened to the

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 Therapeutic relationship / Parallel process

 Collaborative exploration / inquiry

 Empathic attunement and parallel process

 Provision of psychoeducation and developmental anticipatory

guidance

 Therapist as play translator: expand on child’s play to bring

increased:

 narrative coherence to fragmented and disorganized aspects of child’s

experience

 Promote self regulation, co-regulation, and affect modulation  Enhance self-reflection

 Decrease trauma-related symptoms by strengthening the

attachment relationship

 Coping through play: Reenactments, movement towards mastery of trauma,

exploration of cause and effect, experimentation with roles

 Create a safer and more protective caregiving environment.  Increase age-appropriate capacity of caregiver and child to be

accurately attuned to each other's needs and motivations.

CPP: P

 Negative or unbalanced representation of child

 Limited attunement

 interactive mismatch without repair

 Challenges to self-regulation, co-regulation

 Inappropriate developmental expectations

 Unresolved trauma, “ghosts of he nursery”

 Challenges to “goodness of fit”

PCIT:

 Conjoint therapy focused on restructuring parent

child interactional patterns.

 Two phase model: CDI and PDI utilizing coaching of

the parent child dyad.

 Use of standardized pre/post treatment measures

 Inclusion of PRIDE skills and selective

attention/ignoring concepts and weekly Homework

 Ages 2-8. Children exhibiting externalizing behaviors

and who live with their caregiver or have liberal visitation and/or will be returned to the caregiver within 8-10 weeks of beginning therapy.

 Neither caregiver or child have a diagnosis that

C

:

 Negative or unbalanced representation of child

 Interactive mismatches without repair

 Low parental self-efficacy

 Challenges to dyadic co-regulation

 Multigenerational / unresolved trauma

 Poor “goodness of fit”

 Low skill set as adult play partner

 Developmental expectations that are too high or

PCIT C

:

 Strengths of the Model:

 Effectively addresses behavioral concerns  Short term model

 Improves parent child relationship  Family model

 Limitations of the Model:

 Does not directly address the trauma  Must have consistent caregiver

 Adaptations for younger children

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PCIT

 Improve parent child relationship

 Decrease externalizing behaviors

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-B

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 Development of an integrated plan of prioritized

interventions, that is based on the diagnosis and bio-psychosocial assessment of the child to

address wide range of areas.

 Using the information gathered in a thorough

assessment to inform which treatment model to use.

Components of a Thorough Trauma Assessment:

• Gather collateral information/history (Social Worker, Bio Parent, Foster Parent, school, etc.)

• Administer wide range of standardized assessment measures for

caregiver(s) and child (CBCL, TSCYC, ECBI, PSI, ASQ, Angels in the Nursery, Life Stressors Checklist, TSI, CESD, etc.)

• In-Depth Social-Emotional-Developmental Assessment of child and family

• Observations of child in a variety of settings and with relevant caregivers (assessment of the “relationship”)

• Assess family resources and readiness (visitation schedule, transportation, caregiver able to participate in treatment, etc.)

CPP: Ages 0-6 • Appropriate caregiver • Attachment/Relational difficulties • Traumatic Experience (including separation from primary attachment figure) • Treatment goals:

Trauma Processing for parent and child, parent to understand child’s experience of trauma TF-CBT: Ages 4-18 • Appropriate Supportive Adult • Identified Traumatic Experience • PTSD symptoms • Treatment Goals: Reduce PTSD, Process/Resolve Trauma PCIT: Ages 3-8 • Appropriate Caregiver • Behavioral Concerns • Parent-Child relationship difficulties • Treatment Goals: Enhance relationship with caregiver, reduce negative/acting out behaviors

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#1

 Brandon, age 4

 B was removed from the home after witnessing a DV incident in which Dad attacked Mom and she

sustained injuries. Dad was arrested, and has not had any contact with the family in over 6mo. B was placed in Polinsky Children’s Center and was in 2 different foster homes before being placed back with Mom.

 B presents with high anxiety and trauma symptoms, hypervigilence, avoidance. Mom reports he has some regressive behaviors (baby talk and thumb sucking), and has a great deal of separation anxiety. He fears losing Mom and is afraid something bad will happen to her. Has recently displayed school refusal.

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#2

 The Smith Family:

 Bio Mom: Stella

 Foster Mom: Brenda  Sammi, age 5 ½

 Bobby (Jr.), age 3

 Please read through case example, paying close

attention to information gathered in the family assessment

 Begin thinking about how you would treat this family in your clinic

Q

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E

:

 Is there more information that you need or more

assessment that needs to be done?

 Which modality would you start with and why?

 Is there a clear cut best modality? Why or why

not?

 Who will be involved in the therapy and why?

 What do you see as the Treatment goals for each

child?

 If more than one modality could be used, discuss

the process of choosing and how/when you might switch modalities.

R

:

 Chadwick Center for Children and Families. (2009). Assessment Based Treatement for Traumatized Children: A Trauma Assessment Pathway (TAP). San Diego, CA: Author

 Cohen, J. A., Mannarino, A. P., & Deblinger, E. (2006). Treating trauma and traumatic grief in children and adolescents. New York, NY: Guilford Press.

 Lieberman, A., & Van Horn, P. (2005). Don't hit my mommy!: A manual for child-parent

psychotherapy for young witnesses of family violence. . Washington, D.C. : Zero to Three Press.

Lieberman, A., & Van Horn, P. (2008). Psychotherapy with Infants and Young Children: repairing the effects

of stress and trauma on early attachment. New York: NY: Guilford Press.

 Rae, T., & Zimmer-Gembeck, M. (2011). Accumulating evidence for parent-child interaction therapy

in the prevention of child maltreatment. Society for Research Child Development, 82(1), 177- 192.

 Urquiza, Ph.D, A. (2007). Child trauma and the effectiveness of pcit. In PCIT Training Center Sacramento, CA: UC Davis.

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 Thank You!

 Leslie Peterson, LCSW, RPT

 [email protected]  (858) 966-5803, x.7319

 Ashley Rambeau, ASW

 [email protected]  (858) 966-5803, x. 3342

 Susan Gordon, LCSW

 [email protected]