1. Maryland Moves To Trauma-
Informed Care:
Be Part of It
Laurel J. Kiser, Ph.D., M.B.A.,
Kay M. Connors, LCSW, and
Angela Vaughn-Lee
2. Why Prioritize EBPs?
While the goal of increasing dissemination of
effective services to improve routine care is valid:
– implementation is not routine (Hoagwood, et al., 2001)
– implementation requires significant time and resources:
for creating change in system, provider, and clinician
practices,
adapting EBPs for local conditions, practice-related
exigencies, and specific populations,
providing extensive supervision during implementation and
afterwards
monitoring fidelity and outcomes
Since implementation is a resource intensive
activity, only a few can be implemented at a time.
3. Prioritizing Evidence-Based Practices
Number of youth Program cost
High risk population Funding mechanisms
Expensive population Grants
Family perception Demonstration projects
Provider perception Need Resources Community support
Agency perception Shared departments
Existing providers
On-going costs of EBP
replication & sustainability
Administrative & system
supports needed
Ease of
Evidence
Implementation
Buy-in
Competing interests
Training requirements Effect sizes
Cost of implementation Number of studies
Local vs. national resources
MH Focus Efficacy
EBP Name Effectiveness
Sole focus Cost effectiveness
High Medium Low
Primary, but shared focus Generalizability
Need Relevance (age,
Combined focus
Resources Secondary focus urban/rural, cultural)
DD/DA/LD interests Fidelity instruments
Evidence
Implementation
Score is the sum of the five ratings. High = 5; Medium
MH Focus
= 3; Low = 1. Midpoints can be used and scored as a
Total Score: 2 or 4.
4. Recommendations
Implement trauma-specific EBPs within a trauma-
informed statewide system of care in children’s mental
health.
Support ongoing efforts for implementing an effective EBP
TFC model
Support ongoing efforts to increase use of Family Treatment
EBPs
Improve practice-based evidence for Respite and Psychiatric
Rehabilitation Programs
Work in partnership with Early Childhood Mental Health,
School Based Mental Health, and Wraparound Initiatives to
disseminate the core competencies of these service delivery
frameworks and promote implementation of EBPs
5. Principles of Trauma-
Informed Practice
Goal is to reduce the adverse impact of trauma
exposure on children and adolescents
Trauma-informed principles of care
embedded within child serving systems
Strength-based, focus on resilience
Promote respect for child in all situations
Purposeful, therapeutic approach:
– Safety is first priority
– Arousal and self-regulation
– Conditions that cause arousal are minimized
6. Core Components of Effective
Trauma-Informed Practice
Identification
– increase public awareness of trauma’s impact
– risk screening and triage
– psychoeducation on trauma
– engagement in process
Assessment and Service Planning
– systematic trauma assessment
– conceptualization of intervention targets and intervention
planning
Intervention
– delivery of empirically supported trauma-informed treatment
– evaluation of intervention response and effectiveness
Adapted From: National Child Traumatic Stress Network
10. Screening
Exposure Instruments
– Traumatic Events Screening Inventory for
Children – Brief Form (TESI-C-Brief)
– Psychosocial Assessment of Childhood
Experience (PACE)
– Violence Exposure Scale for Children-
Revised (VEX-R)
Impact Instruments
– PTSD Checklist (PCL)
11. Psychoeducation
For all adults that interact with children and
adolescents:
– Understand behavior in context
– Developmentally appropriate expectations
– Normalization of traumatic response
– Impact of trauma
– Differentiation between reliving and
remembering
– Differentiating adult trauma history from child’s
experience
12. Engagement Goals
Open information sharing (duty to warn or report)
Clarify the helping process
Understanding the family’s expectations and
priorities
Empowering families
Advocacy and ongoing safety/risk reviews
Support parental coping
15. Assessment:
General Issues
No “gold standard”
Multisources needed
Multiscore instruments necessary to
measure subdomains
Across multiple areas of functioning
Developmental specificity
16. Challenges in Assessing
Children
Symptomotology may be transient or alternating
Symptoms may change as developmental functions
emerge
Caregiver disagreement on descriptions of
behaviors/symptoms
Current diagnostic criteria may not be appropriate
for children
Children may benefit from intervention even if they
do not meet specific diagnostic criteria
Ippen, 2002
17. Assessment:
Techniques and Instruments
Clinical Interview with Child and Parent
Semi-structured interviews
– K-SADS-PL
– Clinician Administered PTSD Scale, Child and Adolescent
version (CAPS-CA)
– Children’s PTSD Inventory
Observation
Parent Report
Self-Report
– UCLA PTSD Index for DSM-IV
– Trauma Symptom Checklist for Children
– Checklist of Child Distress Symptoms
– Children’s Impact of Traumatic Events Scale
22. Treatment:
General Considerations
For some children, cognitive-behavioral therapy (CBT) is
the one intervention with empirical support.
There is inadequate evidence of effectiveness for other
psychosocial treatments and for psychopharmacology.
There is a lack of empirical evidence and clinical support
for current models of treatment for children who have
experienced chronic trauma.
There is clinical consensus although limited data
supporting use of a combined treatment components.
(Perrin, et al 2000; Cohen, et al 2000a; AACAP 1998; Scheeringa 1999; Carr 2000)
23. Treatment for Traumatic Stress
Disorders in Youth
Assure the child’s safety
• Overarching Goals Return to normal developmental trajectory
Relief of symptoms
Coping skill development
Provide clear information to the child
• Child Therapy Prevent re-exposure or re-victimization
Restore trust in self and others
Renew sense of mastery and positive
meaning
Parent education
• Parent Therapy Developmental guidance
Differentiation
24. Treatment for Traumatic Stress
Disorders in Youth
Building representations or working models
• Parent - Child of trusting relationships
Coaching
Therapy Constructing joint understanding of trauma
Stabilizing family functioning
Connecting family members
• Family Therapy Developing a shared sense of meaning
Using coping/problem solving techniques
for minimizing additional stresses
• Community Fostering connections
Interventions Provide a safe haven
25. EBP Engagement
Protocols
Vanderbilt Study: Increase knowledge and
self-efficacy
Participation Enhancement Intervention
(Nock and Kazdin, 2005): Increase
attendance and adherence
26. Trauma Focus:
Overcoming Avoidance
PPT model
Anticipate parental and child patient
avoidance
Problem solve
Outreach and follow up
“The most symptomatic children almost
always have the most symptomatic
parent/families ( Scheeringa and Zeanah,
2001).”
27. Follow up: Overcoming
Avoidance
“Did you feel reluctant to come today like I
talked about last week?”
Rate reluctance 1-10
“Why did you feel reluctant?”
“What did you do to overcome it?”
PPT Scheeringa (2003)
28. Treatment of Single Event
Trauma and Childhood Sexual
Abuse
Trauma Focused – Cognitive Behavior
Therapy (TF-CBT)
– Most frequently used treatment for
childhood trauma
– Most commonly used in outpatient
therapy
– Manualized treatment
– Internet training available
29. TF-CBT: The Evidence
Multiple RCTs
Samples
– 3-17 years of age, mostly 8-12 years old
– racially mixed, but predominantly White
– sexual abuse; 1 sample of multiply traumatized children with sexual
abuse-related PTSD symptoms
Comparisons
– nondirective supportive therapy (NST)
– child centered supportive therapy (CCT)
– treatment as usual (TAU)
Results
– TF-CBT was significantly better than NST, CCT, and TAU
– improvements in children’s PTSD, internalizing, externalizing, and
sexual problems
– differences sustained up to 24 months
