© 2015 center for family development 646-389-6550 716-810-0790 complex trauma: assessment and...

© 2015 Center For Family Development www.Center4FamilyDevelop.com 646-389-6550 716-810-0790

Annual APSAC-NY State Conference: “Trauma and

Adolescence”COMPLEX TRAUMA:

ASSESSMENT AND TREATMENT OF ADOLESCENTS

Arthur Becker-Weidman, Ph.D.

Emily Becker-Weidman, Ph.DCenter For Family Development

Child Study Center at NYU Langone Medical Center (1 Park Avenue, 7th Floor New York, NY)

29 April 2015


Overview

What is Complex Trauma?Three session model of assessmentA brief summary of an Attachment-Focused Treatment approach: an evidence-based treatment.


What is Complex Trauma?

Complex Trauma (aka Developmental Trauma Disorder):

EARLYCHRONICMALTREATMENT IN A CARE-GIVING RELATIONSHIP


Domains of ImpairmentAttachmentBiologyEmotional RegulationDissociationBehavioral RegulationCognitionSelf-Concept

Domains of ImpairmentAttachment. Traumatized children feel that the world is uncertain and unpredictable. They can become socially isolated and can have difficulty relating to and empathizing with others.

Biology. Traumatized children may experience problems with movement and sensation, including hypersensitivity to physical contact and insensitivity to pain. They may exhibit unexplained physical symptoms and increased medical problems.

Mood regulation. Children exposed to trauma can have difficulty regulating their emotions as well as difficulty knowing and describing their feelings and internal states.


Domains of Impariment

Dissociation. Some traumatized children experience a feeling of detachment or depersonalization, as if they are “observing” something happening to them that is unreal.

Behavioral control. Traumatized children can show poor impulse control, self-destructive behavior, and aggression towards others.

Cognition. Traumatized children can have problems focusing on and completing tasks, or planning for and anticipating future events. Some exhibit learning difficulties and problems with language development.

Self-concept. Traumatized children frequently suffer from disturbed body image, low self-esteem, shame, and guilt.



Affect

Dys

regu

lation

Attent

ion/C

once

ntra

tion

Negat

ive S

elf-Im

age

Impu

lse C

ontro

l

Aggre

ssion

/Risk

-takin

g

0%

15%

30%

45%

60%

75% 61.5%59.2% 57.9%

53.1%45.8%

Complex Trauma: Most Frequent Behaviors

Affect Attention/ Negative Impulse Aggression

Dysregulation Concentration Self Image Control Risk-taking


Relationship between adverse childhood experiences and lifetime risk of attempting

suicide

Dube, SR, et al., (2001), JAMA, Dec 26, 286(24): 3089-96.

http://www.sciencenews.org/view/download/id/345845/name/UPPED_RISK


Effects on Child DevelopmentDevelopmental delaysDifficulty identifying feelingImpairments in various domainsFear & Shame based behaviors

Lies-shameStealing-lack of trustIntimacy difficulties



Impairment in Several AreasDevelopmental age < Chronological ageReaction to peers.Control of impulses.Problem solving abilities.Ability to defer gratification.Capacity to transition.Ability to persist at problem solving.Thinking.


Basic Model for AssessmentThree session model

Consider the 7 domains affected by complex trauma

ParentsChildParents


Outline for a Thorough EvaluationReview of all recordsSession One: Session with Parents (Carers) regarding child.

Evaluation of Parents: pattern of attachment, insightfulness & reflective function, commitment.

Use of various tests and questionnairesSession Two: Assessment of ChildSession Three: Session to review assessment and treatment recommendations.


Outline for a Thorough Evaluation

Seven Domains that may be affected by Complex Trauma aka Developmental Trauma Disorder.Assess for various mental health conditions: Bipolar Disorder, ADHD, etc.Screen for neuro-psychological issues caused by early maltreatment

(Executive functions)

Sensory-IntegrationARND

Alcohol Related Neurodevelopmental Disorder


Parent SessionClinical meeting with caregivers

Child’s current functioningQuestions asked.

Diagnostic interview to screen for various mental health difficulties and trauma-attachment difficultiesParent’s state of mind with respect to attachment. (Use of AAI)Insightfulness AssessmentParent Commitment Assessment


Parent SessionQuestions asked/areas covered

Presenting problem; why here now?Pediatrician, eating, sleeping, meds, medical issuesSchoolFriendsRelationships within home

AffectionSiblingsCompliance


Specific testsChild Behavior Checklist (CBCL; Achenbach, 1991) ** (Parent & Teacher versions)Trauma Symptom Checklist for Young Children **Symptom checklist screener **Sensory-integration screener **Behavior Rating Inventory of Executive Function (Parent & Teacher) **Vineland Adaptive Rating Scales – II (Parent &Teacher) **Sensory Profile **Parent Stress Index **Connors Rating ScalesChild Problems ChecklistDevelopmental History form

Outline of Child SessionOrientation & Mental StatusHTP – achromaticHeart DrawingChromatic HTPASCTQuestions interspersed between



TopicsSchool & gradesFriendsIf hurtLikesRelationships with family membersHistory




Clinical Interview with ChildDiagnostic Interview

Mental StatusProcess of interview to assess state of mind with respect to attachment.

House-Tree-Person

Heart Drawing4 key questionsAssessing for indications of other conditions:

Mental Health issuesSensory-IntegrationExecutive Function/Neuropsychological issuesFASD

Attachment Story Completion Test


Third Meeting with Caregivers

Review Assessment and DiagnosesMental Health ConditionsAttachmentWhat is causing the difficulties: what is driving the behavior: what is going on in the family & why.

Other issues requiring further evaluationSensory-Integration Disorders -OTNeuro-psychological assessment – Board Certified NeuropsychologistEducational testing for LD


Final Meeting with CaregiversOther issues requiring further evaluation

Developmental ScreeningDevelopmental PediatricianDevelopmental neurologist

Treatment Recommendations: Treatment follows directly from assessment.ParentingTreatment

Child at home?


TREATMENT:Attachment-Focused Treatment


Forming & Maintaining Alliance

Without an alliance there can be no secure base. Without a secure base there can be no exploration. Without exploration there can be no integration. Without integration there can be no healing.


PARENTINGThe “best” predictor of treatment outcome is often not how “disturbed” is the child, but, rather, parent capacity:InsightfulnessState of mind with respect to attachment

SensitivityReflective capacityCommitment

COMPONENTS OF DYADIC DEVELOPMENTAL PSYCHOTHERAPY

1. Therapist Use of self2. It’s about connections not compliance: process

focus3. PACE & PLACE4. Intersubjectivity5. Reflective Capacity6. Affective/Reflective dialogue7. Commitment8. Insightfulness



COMPONENTS OF DYADIC DEVELOPMENTAL PSYCHOTHERAPY

9. Coherent Autobiographical Narrative10. Co-regulation of Emotions11. Co-creation of Meanings12. Follow-lead-follow13. Interactive Repair14. Nonverbal-verbal dialogue




Phases of Treatment1. Creating the Alliance2. Maintaining the Alliance – Safe

Base3. Exploration4. Integration5. Healing


Effective TreatmentGoals of treatment include:

resolution of early losses, development of trust, modulation of affect, development of internal control,development of reciprocal relationships,learning appropriate responses to external structure and societal rules, correcting distorted thinking patterns, developing self respect.


Attachment Facilitating ParentingCauses not symptomsKind attributionsIt’s about connections not complianceDevelopmental age not chronological ageCreate a healing PLACE

Time togetherDoing for, with, then independence


PARENTS ARE CENTRAL

Parents are central to treatment success: the keystone.Whatever you wish the parent to do with the child the therapist must be able to do with the parent.The best predictor of treatment outcome and success is the parents capacity.




ResearchBased on Craven & Lee (2006) (using Saunders et al. 2004) Dyadic Developmental Psychotherapy meets criteria as an evidence-based category 2 treatment, “Supported and probably efficacious.”

Based on two outcome studies (n=64 in each) using control/usual care groups over 1 and 4 years.82 % of treatment group and 83% of control group has received previous treatment; 3.2 prior treatment episodes.100% of usual care group received ongoing other treatments during the four years.

California Evidence-Based Clearinghouse for Child Welfare rated Dyadic Developmental Psychotherapy 3, “Promising Research Evidence”: http://www.cebc4cw.org/program/dyadic-developmental-psychotherapy/

No case date suggesting a risk of harmThe practice has a manual that specifies the components of practice and how to administer it.At least one study utilizing some form of controlStudy reported in published peer-reviewed literature.Reliable and valid outcome measures

http://www.cebc4cw.org/program/dyadic-developmental-psychotherapy/

http://www.cebc4cw.org/program/dyadic-developmental-psychotherapy/


STATISTICAL ANALYSIS OF TREATMENT GROUPPre-test Post-test 2nd post

testMeasureCBCL

Mean

SD Mean SD t-value

P-value

Mean SD t-test prob.

Withdrawn 65 11.8 54 6.0 4.897 <.0001 56 6 .008

Anxious/Depressed

62 10.5 58 8.1 2.665 .006 58 5 .006

Social 67 9.7 59 5.5 4.376 <.0001 56 5 .001

Thought 68 9.5 65 3.9 6.133 <.0001 60 8 .02

Attention 72 12.5 57 6.1 5.836 <.0001 57 6 <.0002

Rule-breaking

69 6.9 53 3.8 12.181 <.0001 52 3 <.0001

Aggressive 71 9.1 55 4.5 10.576 <.0001 54 4 <.0001© 2015 Center For Family Development www.Center4FamilyDevelop.com

646-389-6550 716-810-0790

STATISTICAL ANALYSIS OF USUAL CARE GROUPPre-test Post-test 2nd post

testMeasureCBCL

Mean

SD Mean SD t-value

P-value

Mean SD t-test prob.

Withdrawn 65 10.5 63 9.45 1.427 .16 71 49 .18

Anxious/Depressed

62 10.6 60 10.3 1.060 .30 70 10 .03*

Social 64 11.1 65 11.25 -0.854 .40 65 2 .5

Thought 63 8.6 62 8.1 0.948 .33 67 8 .02*

Attention 68 11.9 66 10.8 0.927 .36 77 9 .02*

Rule-breaking

67 7.4 66 9.6 1.8691 .07 81 4 .02*

Aggressive 70 10.3 68 9.4 0.919 .37 81 4 .02*© 2015 Center For Family Development www.Center4FamilyDevelop.com

646-389-6550 716-810-0790


ReferencesBecker-Weidman, A., (2006). “Treatment for Children with

Trauma-Attachment Disorders: Dyadic Developmental Psychotherapy,” Child and Adolescent Social Work Journal. Vol. 23 #2, pp. 147-171.

Becker-Weidman, A., (2006). “Dyadic Developmental Psychotherapy: A multi-year Follow-up”, in, New Developments In Child Abuse Research, Stanley M. Sturt, Ph.D. (Ed.) Nova Science Publishers, NY, 2006, pp. 43 – 60.

Becker-Weidman, A., (2006) “Attachment Facilitating Parenting: Effective Methods for Parenting Children with Trauma and Attachment Disorders,” Three DVD set, Williamsville, NY: Center For Family Development.

Becker-Weidman, A., (2007) “Treatment For Children with Reactive Attachment Disorder: Dyadic Developmental Psychotherapy,” http://www.center4familydevelop.com/research.pdf

http://www.center4familydevelop.com/research.pdf


ReferencesBecker-Weidman, A., (2007). “Assessing Children with

Complex Trauma and Disorders,” 2-DVD set, Williamsville, NY: Center For Family Development, ASIN: 0982288301 2007.

Becker-Weidman, A., (2009) “Effects of Early Maltreatment on Development: A Descriptive study using the Vineland,” Child Welfare, 88 (2)137-161.

Becker-Weidman, A., (2010), Dyadic Developmental Psychotherapy: Essential Practices & Methods, Lanham, MD: Jason Aronson.

Becker-Weidman, A., (2010), "Assessing Caregiver Reflective Capacity, Commitment, Insightfulness, and Sensitivity," 2-DVD set. Williamsville, NY: Center For Family Development.

Becker-Weidman, A., (2011), The Dyadic Developmental Psychotherapy Casebook, Lanham, MD: Jason Aronson.


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