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The Integration of Treatment Parent Training into the Treatment of Complex Trauma Paul Brylske, MSW, LCSW-C, Director Lauren Capel, MSW, LCSW-C, Senior Clinical Social Worker Paula Waller, MSW, LCSW-C, Program Manager/Supervisor

The Integration of Treatment Parent Training into the Treatment of Complex Trauma Paul Brylske, MSW, LCSW-C, Director Lauren Capel, MSW, LCSW-C, Senior

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The Integration of Treatment Parent Training into the Treatment of Complex TraumaPaul Brylske, MSW, LCSW-C, DirectorLauren Capel, MSW, LCSW-C, Senior Clinical Social WorkerPaula Waller, MSW, LCSW-C, Program Manager/Supervisor

Provides care for more than 16,000 children and adolescents annually with a focus on Disorders of the Brain & Spinal Cord:

Patient Care Research & Training Special Education Community Programs

Kennedy Krieger InstituteUnlocking the Potential of Children with Special Needs since 1937.

www.kennedykrieger.org22Autism spectrum disorders Behavioral & emotional disorders Brain injury Cerebral palsy Developmental disorders Feeding disorders Learning disorders Muscular dystrophy Spina bifida Spinal cord injury and paralysisChildhood Traumatic Stress

Kennedy Krieger InstituteAreas of Specialization

3The Family Center at the Kennedy Krieger InstituteThe Family Center OutpatientNCSTN category II and III site for over 8 yearsMultiple EBPs, psychiatry and specialty clinics 550 active case;19,000 visits 2013Trauma Training Academy Therapeutic Foster Care1986 -Licensed for 100 child/youth Complex trauma, developmental disabilities, medically fragile conditionsAdoptions & permanencyIndividual Family Care

4Learning ObjectivesBeginning understanding the Trauma Integration Model (TIM).

Beginning understanding of the Attachment, Regulation, and Competency (ARC) treatment framework.

Understanding of how the treatment parent training can be used effectively in the integrated treatment of complex trauma.

Apply tools which can be used in in training and practice with treatment parents in treating complex trauma.

Understanding the use of data and outcomes in the treatment of complex trauma5Research Findings on Treatment Care (TFC)M-TFC is evidence-basedTremendous variation in TFC in the real worldFew programs resemble evidence-based modelFactors associated with positive outcomeTraining and supervision of the treatment parent child relationship Supervision of childrenBehavioral interventions

NIMH (Farmer) / Maryland. Science to Service (Bruns et al 2004)

6Limitations of Training

7What effects sustainability/fidelity?Agency Readiness to Implement and Implement and ImplementIs there buy-in at all levels, especially leadershipDoes it fit agency cultureAre there necessary resource to supportCan it be integrated into current practice Can you measure adherence & outcomeIs there support to staff TrainingConsultationSupervision/Coaching

8Ongoing Consultation and Supervision/CoachingTeach effective practiceEnsure fidelity to practiceEnsure good judgment & decision makingInsure flexibility to meet needs of treatment parents & children/youth Increase staff & treatment parent satisfaction (value added) through support and skill acquisitionEnsure positive outcomes9KKI-TFC Trauma Integrative Model (TIM)TFC Program ElementsEvidence-based TFC(Chamberlain)Real World TFC (Farmer)(Bruns)Trauma Integrative Model (TIM) Service Coordination/Case ManagementYesYesYesTreatment Parents as key providers/change agentsYesYesYesTeam approach to treatmentYesYesYesRespiteYesYesYesWork with youths familyYesYesYesReduce association with deviant peersYesYesYesIntensive supervision/supportYesNoYesProactive approach to behavior problemsYesNoYesAddressing previous trauma (ARC)N/AN/AYesComprehensive Coordination of Somatic Care N/AN/AYesAddressing Developmental DisabilitiesN/ANoYesPreparing for transition to adulthood (TIP)Not systematicNoYesPermanency N/AN/AYesFamily and Youth VoiceN/AN/AYes10Farmer and Bruns research using FFTA standard developed a framework of program elements for developing Hybrid TFC models which we have used at KKI in developing our hybrid model the trauma integrative model or TIM. As you can see from their work components of in real world TFC models need to address and that are missing in the EBP model and we needed address in the development of our TIM Model. Farmer and Bruns identified preparing youth for Transition, and Addressing trauma. Based on our experience we added permanency, and inclusion of Family and Youth Voice . KKI-TFC Trauma Integrative Model contPrinciples/ Systems of Care & Safety/ Permanency/ Wellbeing Components of evidence based TFCRoles of clinical social worker and treatment parent with in the Focus of ChangeTreatment ofComplex trauma/neglectDevelopment disabilitiesMedically fragile conditionsCo-existing disorders (substance abuse & specialties)Needs of transition age youth Permanency and permanency planningMulti-generational complex traumaCommunity ServicesOut-patient Psychotherapy, Psychiatry, Medical, Educational, Vocational, Recreational, OT, PT, Nursing, OthersYouth, family, and stakeholders voice

1111Focus of Change

1212Attachment, Regulation, Competency (ARC) Treatment FrameworkComponent-based vs. manualized protocolGrounded in theory and research on complex traumaRecognizes core effects of complex trauma: AttachmentSelf-regulationCompetenciesUnderstands importance of intervening within the context of the child (family and system)Components inform treatment choicesRecognizes the need for individual tailored trauma interventionsRecognizes each practitioners skill levelBlaustein & Kinniburgh13Caregiver Affect ManagementAttunementConsistent ResponseRoutines & RitualsAffect IdentificationAffect ModulationAffect ExpressionDevelopmental TasksExecutive FunctionsSelf Devt& IdentityTrauma Experiences IntegrationARC Building BlocksBlaustein & Kinniburgh1414(Kinniburgh, Blaustein, Spinzola, Van der Kolk, May 2005)

ARC Model15ARC ImplementationCollaborationThe Trauma Center at Justice Resource InstituteConsultationClinical ProgrammaticTraining staffInitial / OngoingTraining Treatment ParentsCurriculum DevelopmentDevelopment of ToolsStaff & parent toolkitsProgrammatic toolsFidelity, Measurement & OutcomesManuals/Clinical ProtocolsMapping ARC & CANSOther Measures (Youth Connection Scale, Trauma Symptom Index)16Core Principles of Training17Treatment Parent TrainingPhase OneRecruitmentOrientationpre-service traininghome study process

Phase TwoFollowing approval/matching training to particular child & their needs

Phase Three Following placement of child in the homeformal presentations, support groupin home/child specific training

Phase Four Development of Professional Development Plan Annual review of performance and training needs1818Goals of Treatment Parent TrainingAcquisition of KnowledgeAcquisition of SkillSupport Problem Solving19Professional Development PlanEach treatment parent identify goals which can improve their effectiveness as a treatment parent.

Goals are related to child(ren) in their home and training needs of treatment parent.

Treatment parent progress is assessed routinely by clinician and evaluated yearly with clinician, program manager/supervisor & director through the annual re-licensure.20Role of Professional Development Committee Oversees every aspect of parent trainingDevelops the yearly training schedule Trains and Supervises child life staffProvides food and resources Monitors RSVP and attendees lists (internal and external)Maintains curriculum of each trainingReviews and maintain training evaluations.21Structure of Training22Staff Integration

23Staff Integration in Training24Staff Integration in Practice25Supervision and Integration26Parallel process with clinician26Case PresentationDemographicsParent44 year old treatment parentEducatorFoster parent for 5 yearsExperienced treatment parent for youth with complex trauma and sexual predatory behaviors.Client13 year old male with history of physical abuse, neglect, homicidal and suicidal ideation.Multiple placements including several hospitalizations, diagnostic center and RTC. First TFC placement27Presenting IssueYouth exhibits poor self-regulation skills.Youth has limited capacity to attach to foster parentTreatment parent triggered by youths behavior.Integration of Trauma Tools in Practice

CANS/ARC Assessment: Self-RegulationKisiel & Blaustein- NCSTN NumbingDissociationAttention Deficit Impulse Control Behavioral Regression Affect Dysregulation DepressionOppositionalInterpersonal FamilySocial FunctioningAttachment Difficulties28Explain under ARC Domains rather than CANS scores. Importance of treatment planning around entire team to address.28Training Topic Example

REGULATION

WHAT DO YOU SEE?

3030PerspectiveIs defined asa particular attitude toward or way of regarding something; a point of view

3131

Whos Perspective?3232What It Takes To Set Your Story/Perspective Aside?Reflect on your story/perspectiveIdentify your feelingsReflect on your feelingsSeparate fact from fiction (story & feelings)Willingness to set story aside (not the same as giving it up)

33

33What It Takes To Set Your Story/Perspective Aside? contdBe CalmBe and Act CuriousBe Attentive (especially to non-verbal cues)Be Open to ListenKnow the Right Time and Right Place

3434Benefits of Therapeutic Listening Helps to clarify informationKeeps you talking about problems and feelings (affect identification & expression)Helps you to solve problemsTalking out problem prevents acting out problems (affect modulation)Builds trust and relationshipMinimizes judgment and triggers

3535

What Does Our Story Have to Do With Competency & Regulation?If were caught in our story we cant hear the child's story?If we cant hear the child's story we cant...get under the behavior...get to the emotions...to understand the emotions...to understand and change thinking and behavior

3636

Cognitive Behavioral TriangleAggressive Driver- Angry Driver vs. Preggie Lady3737What is most important may be source of your triggerHow do we know we are being trigger?How do we respond?Do you have a plan to step-back?

Trigger Protection Plan Tool

38

Deep breathingMuscle RelaxationDistractionSelf SoothingTime outsWhat are your strategies?Self-Care Strategies39Putting the Pieces Together: Work in Progress40How It All Comes Together

41

Outcomes42Training Pre-Post Evaluations Establish objectives Clarify areas of knowledge & skill Program/trainers/treatment parentsAssess baseline knowledgeAssess effectiveness knowledge & skill acquisition Identification of future training needsProgram/trainer/treatment parents43

44Domain Items

Case-Specific Score ComparisonCANS Scores Over Time 45

Item-Specific Counts and PercentagesDomain: Child Behavioral EmotionalDomain Items: Count & Percentage

46

Domain-Specific PercentagesDomain: Child Behavioral Emotional

Domain Total Percentage47

Percentage

DomainTotal PercentagesAll Domains

Domain: Child Behavioral Emotional48

49CANS Domain Score Comparison: Statistical Significancet1: Admission, t2: Discharge, n=104 201350

CANS/ARC Score Comparison

Percentage of Actionable CANS Items/ ARC Domains & Self Regulation Block 51

CANS/ARC Component Measurement T1, T2 & Overtime

Measure outcomes of child/youth functioning at youth & program level over time Measures outcomes of trauma treatment (ARC) at youth & program level over timeCan be used at case level to measure effectiveness of interventions/toolsAt program level can be used to assess training needs of treatment parents Because measures of ARC components are reliable and valid measures can be used in research

CANS AssessmentARC Components RegulationIntervention of ARC ToolsTherapeutic listingTrigger protection planSelf-Care strategiesCognitive triangleCANS OutcomesARC OutcomesAdditional InterventionsIdentification of training needsIndividual Tx ParentProgram

Integration of Assessment/Treatment Intervention/Outcomes/Training53

n=138Prior Placement %Discharge Placement %RESTRICTIVENESSENVIRONMENTMore RestrictiveInpatient Psych HospitalResidential Tx CenterGroup Home/Shelter11.20%16.00%32.00%12.98%3.90%18.18%Total59.20%25.06%Equally RestrictiveTFC2.40%2.60%Total2.40%2.60%Less RestrictiveRegular Foster CareRelativeIndependent LivingAdoption32.00%6.40%0%0%9.09%23.37%14.29%15.59%Total38.40%60.14%OtherArmed ServicesRunaway0%0%1.30%1.30%Total0%2.60%Restrictiveness of PlacementJamora, Brylske et al 201054PermanencyFiscal YearTotalPercentage2010201120122013Adoption1591064028%Reunification1371133425%Transition841042620%Year Total3620311310073%Outcomes55Placement StabilityMean (S.D.)

Placement Changes Prior to TFC

3.7 (3.6)

*Placement Changes While in TFC

1.7 (0.8)

Comparison of placement changes before & during TFC, t-statistics 4.8, p