Trauma-Focused CBT for Children After Disasters

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Trauma-Focused CBT for Children After Disasters

• Judith Cohen, M.D.
• Allegheny General Hospital, Pittsburgh, PA
• Merritt Schreiber, Ph.D.
• University of California, Los Angeles

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Psychological Impact of Disasters on Children

• Initial emotional distress is common
• Most children are resilient
• Resilience depends on several factors including
• Genetic and personality factors.
• Coping style of child and family.
• Receiving timely and effective treatment.

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Risk Factors for Children Developing PTSD or
Depression Post Disaster

• Increased exposure to the event (e.g., death of
  family member)
• Feeling that ones own or ones familys lives
  were in danger
• Delayed evacuation
• Peri-traumatic panic symptoms
• Increased disaster-related television viewing in
  immediate aftermath
• Lack of parental support parental PTSD

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Immediate Aftermath (Hours-Days) What Do
Children Need?

• Reunion with parents or other family members.
• Age appropriate information about what happened
  and how we will keep them safe.
• Food, water, shelter, safety.
• For those whose parent/primary caretaker died
  immediate placement with a known adult.
• Psychological First Aid
• http//www.ready.gov/kids/_downloads/psychological
  _firstaid.pdf

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Available at http//www.ready.gov/kids/_downloads
/psychological_firstaid.pdf
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Intermediate Aftermath (Days to Weeks) What Do
Children Need?

• Return to normal as soon as possible
• Screening for psychological symptoms and risk
  factors (typically in school or community
  settings)
• PsySTART Triage System
• Local disaster systems of care
• UCLA PTSD Reaction Index
• available at www.nctsn.org

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Identifying Children at Risk

• Most common procedure is to screen children for
  current PTSD, depression or other symptoms
• Recent post-disaster studies have identified risk
  factors for developing future PTSD and depression

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Risk Factors Identified Through PsySTART (2- and
9- months post Tsunami)

• PTSD
• Delayed evacuation
• Perceived danger to own or familys life
• Extreme fear or panic at time of disaster
• Depression
• Older age
• Perceived danger to own or familys life

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Focus of Intervention by 1. Adherence to
directives 2. MUPS 3. Distress 4. High Risk
Disorders
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Triaged to General or Targeted Coping/
Information, Retriage/Clinical screening
Triaged to Behavior specific strategies
ie 1.Adherence, 2.MUPS 3.Surge
Triaged to EBTs
Source IOM, 2003 adapted by Schreiber,2006
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The PsySTART Concept

• Rapid triage linked to objective assessment of
• Traumatic Exposures
• Complex evacuation
• Traumatic Loss
• Post Event Adversities(home loss)
• Injury/illness(self/family)
• Chemical, Biological, Radiological, Nuclear
  Agents with unique agent specific
  impacts---changing definition of traumatic events
• Using short, simple, EMS type triage tags
• Bridges the gap between rapid field assessment
  and reach-back DMH assets across service delivery
  sites
• Common architecture / operationalization enables
  DMH ICS
• Common Operational Picture
• Linkage between ED,PH and DMH, disaster mental
  health (ARC)
• Establishes DMH ICS/NIMS foundation within/across
  systems
• Individual and population level risk projections
  of current need and long term planning
• Estimates MUPS for tailored risk communication
  strategies

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PsySTART Rapid Triage and Incident Management
SystemHow does it work?

• Impact of severe/extreme stressors or dose of
  exposure factors
• The PsySTART system measures a combination of
  acute exposure, traumatic loss and secondary
  stress
• Severe/extreme exposure) exposed to dead, dying
  or, mutilated bodies, hearing screams for help,
  delayed evacuation, trapped, separated from
  family members. Exposure to toxic agents or
  debris.
• In this model, those who witnessed the event(eg,
  mutilating death,, felt as if their own lives
  were in acute danger, and/or who lost loved ones
  would be at the highest triage levels) or became
  separated from family members during evacuation
• Traumatic Loss (inc. missing family members)
• Secondary Stresses (home loss, relocation, job
  loss)
• Injury/illness acute injury/illness, extended
  health risks ( i.e. BT,Pandemic events and
  associated medical treatments
• Event specific tag variants including CBRNE and
  Pan Flu versions
• Objective, yes/no
• Looks at what happened to the person, not their
• Symptoms or mental health per se
• Cultural validity (ie loss of loved one)

PsySTART Tsunami Tag Version (Thai MoH/CDC)
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The PsySTART triage tag

• Objective, evidence informed exposure/loss(
• For use in a field settings such as evacuation
  centers, mass prophalxsis, ED,NDMS, mass vac.
• Minimal training using objective factors
• Centralized Incident management database
  Transmitted via FAX, web, or wireless device for
  automated processing and reporting integrated
  GIS to EOC incident management
• Can be event specific tailored in real time with
  changing events (i.e. natural vs biological vs
  radiological)
• Tied to community disaster systems of
  care(Pynoos, Steinberg, Schreiber, et.al.)
• Incident specific playbook compatibility(Schreiber
  ,in-press)

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An example...mental health and asthma
SOURCE GALEA,2007
Fagan J, Galea S, Ahern J, Bonner S, Vlahov D.
Relationship of self-reported reported asthma
severity and urgent health care utilization to
psychological sequelae of the September 11
terrorist attacks on the World Trade Center among
New York City area residents. Psychosomatic
Medicine 200365(6)993-996.
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• WHO Continuum
• of Care Model
• (Tsunami)

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Proposed Behavioral Health/ NRP Coordination
NIMS Role
Interagency Incident Management Group (IIMG)
Multiagency Coordination System
JFO Coordination Group

• Multiagency Coordination Entity
• Strategic coordination

• Multiagency Coordination Centers/EOCs
• Support and coordination

Joint Field Office (JFO)
RRCC
HSOC/NRCC
State Emergency Ops Center
Local Emergency Ops Center
Behavioral Health Incident Command with PsySTART
rapid triage

• Incident Command
• Directing on-scene emergency management

Role of regional components varies depending on
scope and magnitude of the incident.
An Area Command is established when needed due to
the complexity or number of incidents.
Area Command (AC)
Behavioral Health Incident Command with PsySTART
rapid triage
Incident Command Post (ICP)
Incident Command Post (ICP)
Source DHS,2004
Local Disaster Systems of Care
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Rationale National Impact Scope
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Estimating Special Health Care Needs Individuals
in States example of California Pediatric
Special Health Care Needs Children (about
1,000,000 Total SHCN Under 18)
Source CDC, 2006
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Stepped Care Approach to Universal Child
Screening and MH Intervention

• Being used in New Orleans post-Hurricane Katrina,
  all funded by Sisters of Mercy
• Initial screening of all consenting students in
  parochial, private and charter schools in New
  Orleans parish (gt22,000)
• Stepped care approach to MH intervention
• Least symptomatic receive in-class resiliency
  model Save the Children model (Macy et al)
• Moderately symptomatic receive break-out group
  therapy in school, Cognitive Behavioral
  Intervention for Trauma in Schools (CBITS)
• Most symptomatic receive clinic-based TF-CBT

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Ongoing Aftermath (Months-Years) What Do
Children Need?

• PTSD is associated with long-lasting, bad
  outcomes
• Impairments in academic performance
• Alterations in brain development (smaller
  intracranial volume and corpus collosum impaired
  limbic and HPA axis functioning)
• Depression, 6X completed suicides
• Substance abuse increased
• High risk sexual behaviors, HIV and other STDs
• Increased medical problems.
• Need effective treatment for PTSD symptoms and
  comorbid problems.

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Timing of Treatment for PTSD Symptoms

• No empirical studies have examined timing for
  children
• Shalev et al (2006) screened gt6500 adults
  affected by MVA, terrorism, accidents, medical
  trauma, in Israeli EDs
• Randomized 212 with significant PTSD to 12 weeks
  of early PE, CT, SSRI or WL
• At 5 months CAPS in CTPE, WL worse.
• Randomly assigned half still symptomatic in WL to
  late PE
• Early PE group better at 14 months than Late PE
  group
• Suggests that early CBT may be better than
  delayed for kids.

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What is TF-CBT?

• A hybrid model incorporating CBT, attachment,
  family, psychodynamic and empowerment principles
• Goals resolve PTSD, depressive, anxiety and
  other trauma-related symptoms in children and
  adolescents
• Optimize adaptive functioning, safety, family
  communication and future developmental trajectory

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Is TF-CBT the Right Treatment?

• Target symptoms PTSD, depression, anxiety, and
  behavioral symptoms secondary to trauma.
• Children presenting with mainly behavioral
  problems probably need different treatment.
• TF-CBT treats all types of traumas
• TF-CBT treats children ages 3-18, with and
  without parental participation, in schools, group
  home, foster home and in-home settings
• Most commonly provided to child and parent in
  clinical settings.

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Evidence That TF-CBT Works

• Six randomized controlled trials completed for
  gt500 sexually abused/multiply traumatized
  children, 3-17 years old, comparing TF-CBT to
  other active treatments.
• PTSD symptoms consistently improved significantly
  more in the TF-CBT groups.
• Depression, anxiety, shame, parenting also
  improved more in TF-CBT groups.
• Differential gains maintained at follow-up
  assessments (up to 2 years post-treatment).

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TF-CBT for Children Exposed to Disasters

• CATS Following 9-11 in NYC, significantly
  greater improvement in PTSD among children
  receiving TF-CBT than those receiving usual
  treatment.
• Two open studies of TF-CBT for Childhood
  Traumatic Grief (CTG) show promise of adding
  grief-focused module to TF-CBT for children with
  CTG (Cohen et al, 2004 2006).
• Current ongoing randomized trials for children
  with PTSD symptoms secondary to domestic violence
  and Hurricane Katrina

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TF-CBT Components PRACTICE

• Psychoeducation
• Parent Component includes parenting skills
• Relaxation
• Affect identification and regulation
• Cognitive coping
• Trauma narration and cognitive processing of
  traumatic experiences
• In vivo mastery of trauma reminders
• Conjoint child-parents sessions
• Enhancing safety and future development

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Psychoeducation

• Provide information about PTSD or other
  disorders/symptoms the child has
• Provide information about the childs traumatic
  experience/s
• Normalize the childs and parents reactions
• Provide hope for recovery

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Parent Component

• Parents receive parallel interventions for all of
  the PRACTICE components
• Parenting skills to enhance child-parent
  interactions including
• Optimal use of praise
• Selective attention
• Time out procedure
• Contingency reinforcement schedules

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Relaxation

• Develop individualized relaxation strategies for
  child and parent which may include
• Focused breathing
• Progressive muscle relaxation
• Exercise
• Yoga
• Songs, dance, blowing bubbles, reading, prayer,
  whatever is relaxing to them

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Affective Identification and Modulation

• Exercises to identify a variety of feelings
• Individualized strategies to modulate upsetting
  affective states including
• Problem solving
• Anger management
• Present focus
• Obtaining social support

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Cognitive Coping

• Cognitive Triangle connections among thoughts,
  feelings and behaviors
• Cognitive restructuring replacing thoughts with
  more accurate/ more helpful ones
• Learning optimism being your own cheerleader,
  recognizing what you are doing well right now

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Trauma Narration and Cognitive Processing

• Gradually develop a detailed narrative of the
  traumatic event/s the child has experienced
• Process these events using the cognitive
  strategies learned earlier (changing
  inaccurate/unhelpful thoughts about the traumatic
  events)

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In Vivo Mastery of Trauma Reminders

• To be used only if the feared reminder is
  innocuous (NOT if it is still dangerous)
• Gradual exposure to innocuous reminders which
  have been paired with the traumatic experience
  (similar to overcoming school refusal)

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Conjoint Parent-Child Sessions

• Joint sessions with the child and
  parent/caretaker
• Activities may include sharing the childs trauma
  narrative developing a family safety plan for
  future disasters discussing healthy sexuality
  (sexual abuse) safety plan for DV What Do You
  Know game, etc.

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Enhancing Safety and Future Development

• Individualize additional components as needed for
  each child
• Safety plans continued for individual situations
• Social skills, problem solving, drug refusal,
  etc.
• Public Service Announcement allows child to see
  progress from past, demonstrate altruism for
  other children.

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Additional Grief-Focused Components for
Childhood Traumatic Grief (CTG)

• Grief psychoeducation
• Grieving the loss (what I miss) and resolving
  ambivalent feelings about the deceased (what I
  dont miss)
• Preserving positive memories of the deceased
• Redefining the relationship with the deceased and
  committing to present relationships
• Treatment closure issues

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TF-CBTWeb
www.musc.edu/tfcbt
TF-CBTWeb is a web-based, distance education
training course for learning Trauma-Focused
Cognitive-Behavioral Therapy (TF-CBT).
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TF-CBTWeb
www.musc.edu/tfcbt

• Web-based learning
• Learn at your own pace
• Learn when you want
• Learn where you want
• Return anytime
• 10 hours of CE

TF-CBTWeb is offered free of charge.
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TF-CBTWeb
www.musc.edu/tfcbt

• Each module has
• Concise explanations
• Video demonstrations
• Clinical scripts
• Cultural considerations
• Clinical Challenges

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TF-CBTWeb
www.musc.edu/tfcbt
TF-CBTWeb is sponsored by
TF-CBTWeb was developed and is maintained through
grant No. 1-UD1-SM56070-01 from the Substance
Abuse and Mental Health Services Administration.
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First Response Teams and TF-CBT

• Help local professionals (MH and non-MH)
  identify at-risk children post-disaster
• Educate local MH professionals about evidence
  based treatments such as TF-CBT
• Educate local MH professionals about resources
  for training in TF-CBT and other EBTs
• Encourage them to start using these treatments
  with appropriate children.

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Ways of Introducing Local MH Providers to TF-CBT

• Introduce TF-CBTWeb (some providers may already
  be familiar with this resource)
• Provide introductory talks using the slides in
  this presentation
• Show them the treatment book, Treating Trauma
  and Traumatic Grief in Children and Adolescents
• Introduce providers to www.NCTSN.org
• Provide TF-CBT treatment outcome studies if
  desired (not all providers are interested in
  research).

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Assisting Local Professionals in Identifying
Children in Need of Services

• Types of professionals MH, pediatric,
  educational, child protection, spiritual,
  bereavement, parents, undertakers, military,
  others
• Education can include information about
  screening for symptoms or identifying children
  with known risk factors (some listed above)
• Instruments PsySTART tag UCLA PTSD Reaction
  Index (available at www.NCTSN.org typical cutoff
  score 23

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Typical Issues Encountered in Treating Children
Affected by Disasters

• Trauma-focused treatment or not? Assess whether
  trauma issues/symptoms are central, versus
  behavioral/other symptoms
• Which trauma is causing symptoms? For multiply
  traumatized children the disaster may not be the
  worst experience. Assess PTSD symptoms in
  reference to the worst trauma as reported by the
  child.

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Issues in Treating Children Affected by
Disasters2

• How to engage overwhelmed or traumatized parents?
  Provide education about child PTSD symptoms,
  potential negative effect on childrens learning,
  brain development, and MH outcomes
  (www.NCTSN.org) , and positive impact of
  trauma-focused treatment

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Treatment Issues for Children Impacted by
Disasters3

• When to provide treatment? Optimal timing is
  unknown, but many children remain symptomatic
  many months later, when federal funding is no
  longer available and public attention has
  diminished.
• This emphasizes the importance of first response
  teams efforts to build capacity of local child
  professionals to optimally treat traumatized
  children

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Obtaining TF-CBT Training Post-Disaster

• TF-CBT Developers Judy Cohen Tony Mannarino,
  Allegheny General Hospital jcohen1_at_wpahs.org
• TF-CBT Train the Trainer Institute has 15
  trainers who can provide post-disaster training.
  Contact jcohen1_at_wpahs.org
• First Response Contact Chip Schreiber, PhD
• e-mail mschreiber_at_mednet.ucla.edu

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SUMMARY

• Screening is critical for identifying traumatized
  children post-disaster
• TF-CBT is an EBT for traumatized children,
  including disaster-related PTSD symptoms.
• First response teams provide critical
  post-disaster information to parents and local
  professionals regarding identification of
  traumatized children and optimal treatment.
• Encourage local professionals to use TF-CBT/ EBT
  to treat traumatized children.

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SUMMARY

• Provide resources to local professionals
• www.NCTSN.org
• Introductory training
• TF-CBTWeb www.musc.edu/tfcbt
• Treating Trauma and Traumatic Grief in Children
  and Adolescents treatment book
• The Courage To Remember CD and print curriculum
• Live TF-CBT training

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SUMMARY

• For more information
• www.musc.edu/tfcbt (TF-CBTWeb)
• www.pittsburghchildtrauma.org
• www.NCTSN.org
• E-mail mschreiber_at_mednet.ucla.edu
• Thank you for all you do for traumatized children
  and families!