Treatment of Trauma in the Schools

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Treatment of Trauma in the Schools

• Ally Burr-Harris, Ph.D.
• Center for Trauma Recovery
• Child Traumatic Stress Program
• University of Missouri St. Louis
• Revised 11/8/04

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Greater St. Louis Child Traumatic Stress Program

• Free trauma-related assessment and treatment of
  children
• Cognitive-behavioral, family systems treatment
  orientation
• Consultation/training for professionals
• School-based group therapy for children/adolescent
  s exposed to violence
• National Child Traumatic Stress Network
  (NCTSN) www.nctsnet.org

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Types of Traumas

• Natural disasters
• Kidnapping
• School violence
• Community violence
• Terrorism/war
• Homicide
• Physical abuse

• Sexual abuse
• Domestic violence
• Medical procedures
• Victim of crime
• Accidents
• Suicide
• Extreme neglect or deprivation

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Protective Factors for Post-Trauma Adjustment

• Strong academic and social skills
• Active coping, self-confidence
• Social support
• Family cohesion, adaptability, hardiness
• High neighborhood/school quality
• Strong religious beliefs, cultural identity
• Effective coping and support by parents

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Risk Factors for Post-Trauma Adjustment Problems

• Severity of trauma
• Extent of exposure
• History of other multiple stressors
• Proximity of trauma
• Preexisting psychopathology
• Interpersonal violence
• Personal significance of trauma
• Separation from caregiver
• Extent of disruption in support systems
• Lack of material/social resources
• Parent psychopathology parent distress
• Genetic predisposition

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Trauma Symptoms in Preschool Children

• Regressive behaviors
• Separation fears
• Eating and sleeping disturbances
• Physical aches and pains
• Crying/irritability
• Appearing frozen or moving aimlessly
• Perseverative, ritualistic play
• Reenactment of trauma themes
• Fearful avoidance and phobic reactions
• Magical thinking related to trauma

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Trauma Symptoms inSchool-Age Children

• Sadness, crying irritability, aggression
• Nightmares
• Trauma themes in play/art/conversation
• School avoidance, failure
• Physical complaints
• Concentration problems
• Regressive behavior
• Eating/sleeping changes
• Attention-seeking behavior
• Withdrawal

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Trauma Symptoms in Adolescents

• Similar to adult response to trauma
• Feelings of shame/guilt
• Increased risk-taking behaviors
• Withdrawal from peers/family
• Pseudomature behaviors
• Substance abuse
• Delinquent behaviors
• Change in school performance
• Self-destructive behaviors

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School Assessment of Trauma Symptoms

• UCLA PTSD Index -Revised (Steinberg, Pynoos,
  Rodriguez, 2002) - screens for trauma exposure
  and trauma symptoms
• Youth (school-age) version, parent version
• Trauma Symptom Checklist for Children (TSCC,
  TSC/YC Briere, 1995) - assesses for PTSD and
  other trauma symptoms such as depression, anger
  problems, etc.
• Youth (school-age) version, parent version

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Common Trauma-Related Diagnoses

• Adjustment Disorder
• Acute Stress Disorder
• Posttraumatic Stress Disorder (PTSD)
• Depression (Dysthymic Disorder, MDD)
• Behavior Disorder (ADHD, ODD, Conduct Disorder)
• Anxiety Disorder (GAD, Panic Disorder, Specific
  Phobia)
• Reactive Attachment Disorder (RAD)
• Bereavement

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CBT Treatment Objectives

• Break associations between negative feelings and
  trauma cues
• Increase tolerance of trauma thoughts and
  memories
• Decrease reliance on maladaptive coping
• Facilitate processing of trauma
• Correct trauma-related distortions
• Model (therapist, parent) effective coping
• Reinforce (therapist, parent) positive coping and
  respond effectively to behavior problems

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Appropriate Clients

• Functioning at 3 years or higher
• PTSD symptoms
• Trauma-related confusion or misconceptions
• Substantiated abuse/trauma
• Parents (nonoffending) supportive of treatment

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Inappropriate Clients

• Psychotic symptoms
• Substance dependence/abuse
• Suicidal intent, high self-harm risk
• Questionable validity of abuse/trauma
• Extremely resistant after best sell
• High intensity trauma ongoing

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OutpatientIndividual TF-CBT

• Short-term (Average 3 assessment sessions plus
  12 treatment sessions)
• Divided individual sessions for child and parent
  initially
• Joint sessions begin once parents symptoms have
  decreased and coping skills are improved

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School-Based TF-CBT

• Screen for trauma exposure/symptoms
• Assess for treatment appropriateness
• 10 to 12 individual sessions with parental
  involvement strongly encouraged for elementary
  age
• 10 to 12 week group therapy with option of 2
  individual sessions and 2 parent feedback
  sessions if possible

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Trauma-Focused CBT Components

• Psychoeducation
• Ensuring Environmental Safety
• Stress Inoculation Training (coping skills)
• Gradual Exposure
• Affective and Cognitive Processing
• Safety Skills
• Parental Involvement
• Behavior Management Skills Training
• Family Sessions

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Psychoeducation

• Common reactions to trauma (parent, child)
• PTSD in children
• Accurate trauma-related information
• Self-care after trauma supporting child
• Purpose, rationale, estimated length, typical
  course of treatment
• Splinter or wound analogy
• Ensuring safety
• Healthy discipline Healthy sexuality
• Appropriate developmental expectations

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Stress Inoculation Training (SIT)

• Techniques for reducing physiological stress
  reactions in response to trauma reminders
• Life Saver vs. Swim Lesson analogy

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SIT Techniques

• Deep breathing
• Belly breathing, pinwheel
• Mindfulness, visual imagery
• Safe place
• Progressive muscle relaxation
• Tin soldier/Raggedy Ann
• Raw/Cooked noodle
• Developmentally appropriate script

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SIT Techniques (cont.)

• PMR examples
• Ollendick, T. H., Cerny (1981). Clinical
  behavior therapy with children. New York Plenum
  Press.
• Koeppen, A.S. (1974). Relaxation training for
  children. Elementary School Guidance and
  Counseling, 9, 17-20.
• Forman (1993). Learning to Relax

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SIT Techniques (cont.)

• Thought-stopping/replacement
• Stop sign, Change your channel
• Cognitive coping skills (positive focus)
• Mantra coaching
• Im safe nowI can do thisHes locked up
  nowIt wasnt my fault

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Gradual Exposure (GE)

• Purpose is to gradually expose child to thoughts,
  memories, and other reminders of the trauma until
  child can tolerate those memories without
  significant emotional distress and no longer
  needs to avoid them.
• Techniques used to disconnect cues of traumatic
  event from overwhelming negative emotions.

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Gradual Exposure

• Hierarchical exposure starting from moderate
  distress (e.g., facts about trauma) and working
  toward extreme distress (e.g., worst moment)
• Modalities play, art, visualization, narratives,
  drama, in vivo exposure (for feared but safe
  situations)
• Reduce arousal through reprocessing and
  elaboration across sessions
• Can use SIT skills during exposure phase

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Exposure Examples

• Writing anonymous book about trauma advising
  others who face similar situations
• Playing out trauma with toys and gradually
  incorporating positive resolution
• Drawing pictures of trauma images and later
  shredding them
• Getting rid of upsetting thoughts or images
  (thought funeral)
• Writing rap song about impact of trauma
• Sharing trauma narrative

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Affective and Cognitive Processing (CP)

• Feeling Identification and Expression
• Feeling charades Polaroid feeling chart Feeling
  identification race
• Cognitive Triangle
• Thoughts, Feelings, Behaviors
• Practice generating helpful thoughts
• Train game

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Affective and Cognitive Processing (cont.)

• Identify trauma-related inaccurate or unhelpful
  thoughts using open-ended inquiry, impact
  statement, narrative, observation, or self-report
  measures
• Why do you think this happened to you?
• What caused it?
• How trusting were you of other people?
• How about now?
• Why do bad things happen to good people?
• What would keep it from happening again?

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Common Trauma-Related Cognitive Distortions

• Self-blame
• Guilt, survivor guilt
• Shame/embarrassment b/c of trauma or symptoms
• Hero fantasies related to trauma
• Overgeneralization of danger/risk
• Minimization of trauma
• Omen formation
• Foreshortened future
• Magical thinking
• Revenge fantasies

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Affective and Cognitive Processing (cont.)

• Model helpful thoughts
• Correct distortions
• Younger children Insert mantras
• Coloring book example
• Narrative Its not your fault
• Older children Help to reprocess

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Methods for Challenging Distortions

• Identify feelings, behaviors, outcomes related to
  negative thought and generate more helpful
  thought instead
• One-down Columbo style approach
• Mirror distortions in the extreme and push child
  to amend distortion
• Progressive logical questioning
• Cartoon bubbles
• Role plays, talk shows, peer counseling
• Books/narratives

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Safety Skills

• Recognize dangerous situations
• Good touch/bad touch (SA cases)
• Problem-solving skills
• Support-seeking skills
• Calming skills if risk of self-injury
• Present carefully so as not to blame
• Develop safety plan

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Parental Involvement in Individual Treatment

• Assessment feedback
• Psychoeducation
• Parallel work in areas of SIT, GE, and CP
• Parenting Skills Building, Behavior Mgmt.
• Joint parent-child sessions
• Continuation of GE and CP jointly
• Parent models positive coping with trauma
• Parent assumes role of therapist as childs
  supporter related to trauma

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Helping Parents of Traumatized Children

• Communicate with parents frequently about child
• Encourage parents to listen to child closely
• Encourage parents to set aside special time for
  child
• Recommend maintenance of normal routine
• Encourage parents to remain calm and to get help
  for themselves if needed
• Normalize childs emotional/behavioral
  difficulties after trauma
• Model soothing behaviors with child
• Assist in developing plan for behavior management

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Guidelines for Parents

• Comforting Traumatized Children
• reinforce ideas of safety and security
• allow child to be more dependent temporarily if
  needed
• follow childs lead (hugs, listening, supporting)
• use typical soothing behaviors
• use security items and goodbye rituals to ease
  separation with younger children
• distract with pleasurable, normally occurring
  activities
• let child know you care

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Guidelines for Parents

• Discussing Trauma with Child
• Encourage child to express feelings about trauma
  but dont pressure
• Remain calm when answering questions and use
  simple, direct terms
• Dont soften information for child
• Help child develop realistic understanding of
  what happened
• Gently correct trauma-related distortions
• Be willing to repeat yourself
• Normalize bad feelings

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Guidelines for Parents

• Controlling Childs Environment
• Maintain normal routines
• Avoid exposing child to further trauma or to
  unnecessary trauma reminders (e.g., media)
• Minimize contact with others who upset child
• Guide others in supporting child

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Guidelines for Parents

• Listening skills
• Children need to have their feelings accepted and
  respected
• Listen quietly and attentively
• Acknowledge their feelings with a word or two
• Give their feelings a name
• Give them their wishes in fantasy
• Show empathy
• How to Talk So Kids Will Listen
• and Listen So Kids Will Talk
• By Adele and Faber

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Guidelines for Parents

• Listening No-Nos
• Denial of feelings
• Philosophical response
• Advice
• Too many questions
• Defense of the other person
• Pity
• Amateur psychoanalysis
• How to Talk So Kids Will Listen
• and Listen So Kids Will Talk
• By Adele and Faber

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Behavior Management

• Caregiver interventions
• Anger control skills with child
• Skills training (problem-solving, social skills,
  communication)
• Specific behavior plans (sleep problems, sexual
  behavior problems)
• Intervene in relevant systems

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Caregiver Interventions for Behavior Management

• Create predictability for child
• Make expectations clear
• Reasonable developmental expectations
• Dont personalize childs behavior
• Avoid power struggles
• Emotionally unplug when disciplining
  Emotionally plug in when rewarding

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Caregiver Interventions for Behavior Management

• Identify triggers that upset child and plan ahead
• Expect angry outbursts
• Address aggressive/self-destructive behaviors
  quickly and firmly
• Model self-control
• Be patient and calm

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Caregiver Interventions for Behavior Management

• Consistent limit-setting
• Predict increase in negative behavior
• Reward positive behavior
• PRIDE skills (from PCIT)
• Naturally occurring reinforcers
• Jump start material reinforcers when necessary
• Ignore negative behavior
• Give effective instructions
• Time-out, removal of privileges

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Anger Control Skills

• Identify triggers or high-risk situations and
  plan ahead
• Red button exercise
• Increase awareness of physiological and cognitive
  components
• Teach/rehearse management strategies
• Counting, breathing
• Relaxation (turtle technique)
• Leave situation, SCAR
• Exercise
• Thought-stopping replace with mantra

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Problem-Solving Skills

• Name problem
• Practice perspective-taking
• Generate total possible solutions (w/out
  evaluation)
• Evaluate and discard non-feasible solutions
• Choose solution (within childs control)
• Try it out
• Check back and reevaluate

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Managing Sexual Behavior Problems

• Help parents communicate openly and clearly about
  appropriate/inappropriate sexual behavior
• Examine behavioral patterns and identify
  motivators/positive reinforcers of behavior
• Alter parental responses by establishing negative
  consequence for behavior
• Identify and shape positive replacement behaviors
  so child can achieve desired consequence
  appropriately

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Managing Sleep Problems

• Establish consistent bedtime routines and
  schedules
• Gradually transition child back to own bed and
  fade out check-ins fade out rewards for
  successful nights.
• Relaxation tape or exercises
• Restructuring nightmares to bring resolution
• Visual imagery of peaceful place

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Traumatic Bereavement

• PTSD in the case of traumatic loss often impedes
  the grieving process. The person focuses on the
  traumatic death rather than the loss.
• After exposure, additional treatment components
  include recognition/acceptance of the loss,
  positive reminiscing, coping with future loss
  reminders, and addressing conflicting thoughts
  about the deceased.

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Group CBT of PTSDin Children and Adolescents

• Same components as Individual CBT
• Members need to have similar level/type of trauma
  exposure
• Provides opportunity for social skills-building,
  peer feedback, and stigma reduction
• Advantageous if large-scale trauma or school
  setting with high violence rate
• School-wide trauma exposure/symptom screening
  yields best referrals
• Modules include traumatic bereavement

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School TF-CBT group outline

• How violence affects youths
• Self assessment of symptoms
• Psychoeducation
• Recognizing/managing feelings
• Positive coping strategies (SIT)
• Coping with trauma cues
• Challenging hurtful thoughts
• How the violence affected me - GE
• Individual session, group sessions
• Challenging stuckpoints - CP
• Traumatic bereavement, positive reminiscing

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School TF-CBT GroupOutline Continued

• Changing problem behaviors
• Support-seeking
• Anger management, emotional control
• Communication skills, problem-solving
• Building healthy relationships
• Feeling good about myself
• Positive self-esteem
• Goal-setting
• Group closure

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Empirical Support for PTSD Treatment in children

• TF-CBT (individual, group) - 13 randomized
  trials, mostly with SA samples - treatment
  effects for PTSD, depression, behavior problems,
  social competence, parental distress, and
  parental support
• School-based TF-CBT (treatment effects for GPA,
  PTSD, school attendance and behavior)
• CBT gt Nondirective Supportive Therapy
• Parent involvement in CBT improved childs
  symptoms, even when child not involved in tx
• SIT, EMDR

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TF-CBT References

• Deblinger, E., Heflin, A. H. (1996). Treating
  Sexually Abused Children and Their Nonoffending
  Parents A Cognitive Behavioral Approach. Sage
  Publications, Inc. Thousand Oaks, CA.
• Cohen, J. A., Mannarino, A. P., Deblinger, E.
  (2001). Child and Parent Trauma-Focused Cognitive
  Behavioral Therapy Treatment Manual. Allegheny
  General Hospital, Center for Traumatic Stress in
  Children and Adolescents.

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School-Based TF-CBT References

• Burr-Harris, A. (Sept, 2004). School-Based
  Trauma-Focused Cognitive-Behavioral Group Therapy
  Manual (7th -12th grades). Greater St. Louis
  Child Traumatic Stress Program, University of
  Missouri-St. Louis
• Layne, C. M., Saltzman, W. R., Pynoos, R. S.
  (2002). Trauma/Grief-Focused Group Psychotherapy
  Program. UCLA Trauma Psychiatry Service.
• Jaycox, L. (2004). Cognitive Behavioral
  Intervention for Trauma in Schools. Longmont, Co
  Sopris West Educ. Services. (ages 11-15).

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Were Done!

• For additional questions, references, or
  referrals, contact Ally Burr-Harris, Ph.D.
• Phone [phone]
• Email Burrharrisa_at_msx.umsl.edu