An Overview of Evidence-Based Assessment and Treatment

An Overview of Evidence-Based Assessment and Treatment

Among Traumatized and Grieving YouthK.I.T.S. Conference, June 22, 2017

Megan Mooney, Ph.D., Assistant Professor

Trauma and Grief Center for Youth

University of Texas Health Science Center

Overview of Presentation Overview of Trauma and Grief Center for Youth

What is trauma?

What is childhood bereavement?

How are trauma and bereavement different?

Overview of dimensions of grief

Trauma & Grief Component Therapy

When are trauma and/or bereavement-informed services needed?

© 2017 Julie B. Kaplow, Ph.D.

Trauma and Grief (TAG) Center for Youth

Primary Goals:Adapt, implement, and evaluate evidence-based treatments for traumatized and/or grieving youth, including Trauma and Grief Component Therapy (Saltzman et al., in press)

Provide training in “best practices” for grieving youth, including bereavement-informed assessment and intervention

Essential first steps:Theory: What does adaptive/maladaptive grief look like in children? How does grief differ from PTSD?

Assessment: How do we accurately measure grief in children?

Empirical Research: Can our research help to identify important

therapeutically modifiable risk and protective factors?


What is Trauma??

“A trauma is an exceptional experience in which powerful and dangerous events overwhelm the person’s capacity to cope.”

- Child Witness to Violence Project


Acute Trauma

car accident

natural disaster

death in the family

terrorist act

Chronic Trauma

domestic violence

child abuse and neglect

chronic illness

poverty

community violence

imprisoned parent

The Impact of Trauma


Depends on many factors such as...

The child

Age

Developmental Stage

Temperament

History of emotional problems

The social environment

Availability of primary care givers to help

Level of family stress and coping ability

Presence of family routine and stability

Availability of social supports in the community

The type of event

Acute vs. Chronic

Intensity of the trauma

Proximity of the child to the traumatic event

Loss or injury of primary caregiver

Extent of physical injury to the child

Relationship to perpetrator

Recognizing Signs of Traumatic Stress


Regression in developmental milestones or skills

Fear and worry about the safety of self, family, friends

Anxiety related to future possible trauma

Increased activity level

Decreased concentration and attention

Increased irritability

Changes in sleep or appetite

Withdrawal

Angry outbursts

Aggression

Aches and pains

Decline in grades

Problems with peers

Substance abuse, dangerous behaviors, unhealthy sexual behaviors


Impact of trauma on the Brain:

The traumatized brain “learns”:To be hyper-alert

To stay in “fight or flight” mode

To be anxious and afraid

To neglect higher level thinking and problem solving

Functional and Structural Changes:Decreased size in areas of Corpus Callosum in

children with PTSD

Significant memory impairments

Generally negative impacts in areas of the brain related to executive functioning, emotional regulation, and the ability to remember/learn from your mistakes


Attachment

Communication between mothers and infants is organized around the face, voice, gesture, and gaze

Secure attachment and communication directly influence and are influenced by brain development

Inconsistent care or neglect can lead to insecure attachments

Loss of caregiver can lead to anxiety about safety in future relationships

Abuse may make a child wary of all future relationships

Poor attachment related to later severe symptoms such as dissociation


Social & Emotional Deficits

Lower social competence

Less empathy for others

Difficulty recognizing others’ emotions

Difficulty recognizing their own emotional states

What is Bereavement? Grief?

Bereavement = the experience of deprivation or loss by death

Grief = psychological or behavioral responsearising from bereavement


Distinguishing PTSD from Grief

Grief does not = Posttraumatic Stress Disorder

Grief and PTSD can each contribute to different

forms of suffering; each require different

psychological resources

Their combination can make it more difficult to

function

Grief and PTSD differentially relate to different risk

factors (e.g., loss versus trauma reminders)

Grief and PTSD call for distinct methods of

assessment and distinct treatment components.

•The worldwide lifetime prevalence of children bereaved by the death of one or both parents was 151 million in 2011 (UNICEF, 2013).

•Death of a loved one identified as most common and most distressing form of trauma among adults and youth in general population (Breslau et al., 2004; Kaplow, Saunders,

Angold, & Costello, 2010).

•Efforts to help mental health service organizations and schools become “trauma-informed” may be insufficient.

Prevalence and Significance of Bereavement


How Do Children Typically Respond to the

Loss of a Loved One? “Typical” grief reactions hard to define

Very few large studies of bereaved children… even fewer studies of bereaved children followed over time and even fewer have targeted underserved minority youth

Grief reactions influenced by:– developmental level– previous life experiences– relationship to deceased– culture– religious/spiritual beliefs– family – social environment– circumstances of death


Multidimensional Grief TheoryLayne, Kaplow, & Pynoos (2011)

Kaplow, Layne, Saltzman et al. (2013)

Adaptive/Normative Maladaptive

Separation Distress

Existential / Identity Distress

Circumstance-Related Distress

© 2017 Julie B. Kaplow, Ph.D

A multidimensional framework is important because…Kaplow & Layne (2014) American Journal of Psychiatry

Distinct dimensions of grief may:

– be more prominent at certain developmental stages

– differentially relate to specific risk or protective

factors (e.g., loss versus trauma reminders)

– differentially relate to causal consequences

– may not be present in all bereaved populations

– may require different treatment components


Trauma and Grief Component Therapy:

An Assessment-Driven Intervention


Trauma and Grief Component TherapySaltzman, Layne, Pynoos, Olafson, Kaplow, & Boat, in press

Group-based, evidence-based intervention for traumatized and/or grieving youth

MODULE I Group Cohesion Psycho-Education Basic Coping Skills

MODULE II Trauma Processing

MODULE III Grief Processing

MODULE IV Resuming Developmental Progression Moving Forward

TGCT Overview

Pre-treatment assessment – Combination of Interview and Standardized MeasuresGather information to determine if this treatment is

appropriate

Gather information to determine whether group or individual therapy will be more helpful

Gather information r.e. trauma and bereavement experiences and rank according to severity and impact

Provide FeedbackBegin providing psychoeducation

Building trust and therapeutic rapport


TGCT Overview


TGCT Overview

Module I: Foundational Knowledge & SkillsDeveloping group rules, norms, and procedures

Developing group cohesion

Identifying and normalizing traumatic stress reactions

Identifying and developing coping strategies

Identifying trauma and loss reminders


TGCT Overview

Module II: Working Through Traumatic or Loss ExperiencesReview of copings skills

Selecting and systematically “revisiting” a traumatic experience = construction of trauma narrative

Individual pull-outs as needed

Sharing the narrative

Challenging of Problematic Thoughts & Beliefs


TGCT Overview

Module III: Working Through Grief ExperiencesAim to reduce distressing grief reactions and cope in

adaptive ways with the death of a family member or close friend

Addresses 3 domains of grief: separation, identity, and circumstance-related distress

Psychoeducation on grief

Connections between loss reminders and thoughts, feelings, behaviors, and consequences

Identification of intense negative emotions that contribute to maladaptive grief

Address any ambivalence about the deceased

Finding healthy ways to connect with the deceased

Support-seeking skills


Example of Intervention Objectives for Grief Module, Session 2

• Provide psychoeducation regarding loss reminders as understandable, predictable, and manageable.

• Link loss reminders to bereavement-related feelings, hurtful thoughts (inaccurate or unhelpful), and related behaviors and their consequences. (Choose relevant grief reactions based on assessment results).

• Learn how helpful thoughts can lead to more positive

feelings, behaviors, and consequences.


TGCT Overview


Module IV: Preparing for the Future Integrated sense of personal identity – help kids to learn

ways to move forward in important life domains, integrating traumatic experiences and focusing on positive plans for the future

Shifting from past-focus to present and future-focus Help detect danger and seek safety in responsible ways

Discriminate between age-appropriate adolescent thrill-seeking and risky behaviors that may be dangerous

Shifting from focus on self to focus on others Identify any disruptions in normal development and attempt

to remedy Preparing for termination

Evidence of TGCT’s Effectiveness(Grassetti et al., 2015; Layne et al., 2001; 2008; Saltzman et al., 2006)

Results of effectiveness studies have demonstrated:reductions in PTSD

reductions in depression

reductions in maladaptive grief reactions

improved school behavior

enhanced classroom rule compliance

enhanced school performance

enhanced positive peer relationships

increased school interest

decreased school anxiety/withdrawal


When Does A Child Need More?

Most children are naturally resilient and with appropriate supports in place may not need professional services after a trauma or loss

A child may need professional help that is trauma and/or bereavement informed if you notice significant changes:In developmental skills

Regression

Decline in progress

In mood

In appetite

In sleep

In relationships with family, friends, daycare workers, etc.

Grades or behavior ratings

These changes last more than a few weeks


Megan A. Mooney, Ph.D.,Assistant Professor, Trauma and Grief Center for Youth University of Texas Health Science Center at Houston

[email protected]

For additional information on trainings, please contactJulie B. Kaplow, Ph.D.,

Director, Trauma and Grief Center for YouthUniversity of Texas Health Science Center at Houston

[email protected]

https://med.uth.edu/psychiatry/research/tag/

Contact Information

mailto:[email protected]

mailto:[email protected]

https://med.uth.edu/psychiatry/research/tag/

Documents

An Overview of Evidence-Based Assessment and Treatment