Complex Trauma
Treatments
The Problem of Treating Complex Trauma
Need for intervention that:
Can address continuum of exposures (layers of
chronic and acute), including ongoing exposure
Is embedded in a social/contextual framework
Is sensitive to individual developmental
competencies and vulnerabilities, and flexible in
its approach
Addresses individual, familial, and systemic
needs and strengths
Hilary Hodgdon, Ph.D. – Complex Trauma in Children
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CORE Components
What are Evidenced Based Treatments?
Treatments
that have strong research support
Clinical trials & Randomized Controlled Clinical
Trials
Typically involve a manual, series of training and
consultation to learn the treatment model
Hilary Hodgdon, Ph.D. – Complex Trauma in Children
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EBT’s for Complex Trauma
TraumaTrauma-Focused
Cognitive Behavioral Therapy
(TF(TF-CBT)
ChildChild-Parent Psychotherapy (CPP)
Attachment, SelfSelf-Regulation and Competency
(ARC)
ParentParent-Child Interaction Therapy (PCIT)
Seeking Safety
Trauma Systems Therapy
And many more…
more….
EBT Training
Trauma EBT developers and experts believe in order
for a clinician to be considered trained the following
criteria are needed:
TwoTwo-day basic training, monthly consultation for 12
months by a certified EBT trainer
Weekly supervision by an agency EBT trained
supervisor who monitors clinician fidelity to the
model
Implementation of the model with a minimum of 3
families per year.
Hilary Hodgdon, Ph.D. – Complex Trauma in Children
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Trauma Focused Cognitive
Behavioral Therapy
(TF-CBT)
TF-CBT
Model
Developed by Cohen, Mannarino,
Mannarino, &
Deblinger
An EvidenceEvidence-Based Practice
A SAMHSA Model Program
One of Kaufman Best Practices
Hilary Hodgdon, Ph.D. – Complex Trauma in Children
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TFTF-CBT: A hybrid treatment model that integrates:
Trauma sensitive interventions
CognitiveCognitive-behavioral principles
Attachment theory
Developmental Neurobiology
Family Therapy
Empowerment Therapy
Humanistic Therapy
TF-CBT: The Evidence
Model initially tested:
Deblinger et al (1990). Journal of American Academy of Child and
Adolescent Psychiatry, 29, 5, 747747-752
Stauffer & Deblinger (1996). Child Maltreatment, 1, 6565-76.
Randomized controlled trials:
Deblinger et al, (1996). Child Maltreatment, 1, 4, 310310-321.
Cohen & Mannarino (1996). Journal of American Academy of
Child and Adolescent Psychiatry, 35, 1, 4242-50.
Cohen & Mannarino (1998). Child Maltreatment, 3, 1, 1717-26.
Deblinger et al (2001). Child Maltreatment, 6, 4, 332332-343.
Cohen & Mannarino (1997). JAACAP, 36, 9, 12281228-1235.
Cohen & Mannarino (1998). JAACAP, 37, 1, 4444-51.
Delbinger,
Delbinger, et al, (1999). Child Abuse and Neglect, 23, 12, 137113711378.
King, et al (2000). JAACP, 59, 1, 13471347-1355.
Hilary Hodgdon, Ph.D. – Complex Trauma in Children
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TF-CBT
TFTF-CBT maintains the following treatment focus:
PRACTICE
Psychoeducation and Parenting Skills
Relaxation
Affective Expression and Regulation
Cognitive Coping
Trauma Narrative Development and Processing
In Vivo Gradual Exposure
Conjoint ParentParent-Child Sessions
Enhancing Safety and Future Development
TF-CBT: Affect Expression
Hilary Hodgdon, Ph.D. – Complex Trauma in Children
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TF-CBT: SUDS
TF-CBT: Processing (8 yo)
Hilary Hodgdon, Ph.D. – Complex Trauma in Children
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Child Parent Psychotherapy
(CPP)
CPP
Targets children (ages 00-5 years)
and caregivers.
Heavy emphasis on dyadic work.
Developed by Alicia Lieberman, Ph.D.,
Patricia Van Horn, J.D., Ph.D.,
Chandra GhoshGhosh-Ippen,
Ippen, Ph.D.
UCSF Child Trauma Research Project
An EvidenceEvidence-Based Practice
A SAMHSA Model Program
Hilary Hodgdon, Ph.D. – Complex Trauma in Children
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CPP: The Evidence
Randomized controlled trials:
Cicchetti,
Cicchetti, D. et al, (2000). JOACP, 28, 135135-148.
Cicchetti,
Cicchetti, D. et al, (2006). Development and Psychotherapy, 18,
623623-650.
Cicchetti,
Cicchetti, D. et al, (1999). Attachment and Human Development,
1, 3434-66.
Lieberman, A.F. et al, (2005). JAACAP, 44(12), 12411241-1248.
Lieberman, A.F. et al, (2006). JAACAP, 45(8), 913913-918.
Lieberman, A. F. et al, (1991). Child Development, 62, 199199-209.
Toth S.L. et al, (2002). Developmental Psychopathology, 14, 877877908.
Toth,
Toth, S. L. et al, (2006). Journal of Consulting and Clinical
Psychology,74(6), 10061006-1016
CPP
A hybrid treatment model that
identifies the following goals:
To support and strengthen the
caregivercaregiver-child’
child’s relationship as a
vehicle for restoring and protecting
the child’
child’s mental health.
Improve the caregivers’
caregivers’ and
children’
children’s maladaptive
representations of themselves and
each other and interactions and
behaviors that interfere with the
child’
child’s mental health.
Hilary Hodgdon, Ph.D. – Complex Trauma in Children
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CPP
ChildChild-parent interactions are
the focus of six intervention
modalities:
Promoting developmental progress through play,
physical contact and language.
Offering developmental guidance.
Modeling appropriate protective behavior.
Interpreting feelings and actions.
Providing emotional support/empathetic
communication.
Offering crisis intervention, case management and
concrete assistance with problems of living.
Attachment, Self-regulation
and Competency (ARC)
Hilary Hodgdon, Ph.D. – Complex Trauma in Children
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Where does ARC come from?
Translation of clinical principles across settings
(out(out-px,
px, residential, school, homehome-based)
“EvidenceEvidence-based practice”
practice”?
Or…
Or…what is it that we actually do?
Or…
Or…how to fit real kids into scientific boxes
Staying true to the inner clinician
Or…
Or…keeping the art in trea tment
r
Protocol vs. Component based
Interventions
Clinical Objectives
Focused
Developmentally Tailored
Context Specific
Individual Targets
MenuMenu-Driven
Hilary Hodgdon, Ph.D. – Complex Trauma in Children
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ARC: A Framework for Intervention
with Complexly Traumatized Youth
Core
principles of understanding:
understanding:
Trauma derails healthy development
Trauma does not occur in a vacuum, nor
should service provision
Good “intervention”
intervention” goes beyond individual
therapy
mic
ste
Sy
ARC:
ARC:
A Framework
For
Intervention
with
Complexly
Traumatized
Youth
F am
l
ilia
iv id
Ind
ual
TRAUMA EXPERIENCE
INTEGRATION
COMPETENCY
REGULATION
ATTACHMENT
Primary Components
•Executive functions
•Self development
•Affect Identification
•Modulation
•Affect Expression
•Caregiver affect management
•Attunement
•Consistent response
•Routines and Rituals
Hilary Hodgdon, Ph.D. – Complex Trauma in Children
Blaustein & Kinniburgh, 2010;
Kinniburgh & Blaustein, 2005
12
ARC - 10 Building Blocks
Trauma
Experience
Integration
Competency
Executive
Functions
Affect
Identification
Caregiver
Affect
Mgmt.
Attunement
Self Dev’t
& Identity
Modulation
Consistent
Response
Affect
Expression
SelfRegulation
Routines
and
Rituals
Attachment
Who does ARC target?
Designed to target the needs of children,
families, and systems impacted by complex
trauma
Core domains translate across children/ families/
systems; applications and goals will vary
Crucial importance of:
Keep an eye on the clinical objective, rather than the
technique
Pay attention to relative goals and relative successes
Have a plan, but catch the moments
Hilary Hodgdon, Ph.D. – Complex Trauma in Children
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Programs Applying ARC Principles
Anchorage CMHC (Out(Out-px)
px)
Beth Israel NY (Out(Out-px,
px, schoolschool-based)
B.C. Children’
Children’s Hospital (In(In-px)
px)
Bethany Christian Services (Out(Out- px)
px)
Butler Center (DYS residential)
Calgary Public Schools (Classroom /
wholewhole-school)
Children’
Children’s Hospital L.A. (High(High-risk
youth programs)
The Children’
Children’s Guild (Therapeutic
foster care)
Cohannet Academy (DMH IRTP)
Crittenton Children’
Children’s Services (Multiple
programs – outout-px,
px, Head Start, Group
Home)
DV Crisis Center (DV Shelter and
Advocacy)
GatewayGateway-Longview (Child Welfare
Agency)
Glenhaven Academy (Residential
School)
Harmony Hill (Residential treatment)
Hertfordshire County Council
(Adolescent programs)
House of Mercy (Domestic Violence
shelter program)
Kennedy Krieger (Therapeutic Foster
Care Program)
La Rabida Children’
Children’s Hospital (Out(Out-px)
px)
Lower Naugatuck Valley PCRC (DV
Resource Center)
Mosaic Children’
Children’s Services (Group
Home)
MGH Chelsea (Group/Out(Group/Out-px)
px)
New England Counseling & Trauma
Center (Out(Out-px)
px)
Safe from the Start (Community(Community-based
agencies)
Southern Trust (Residential / group
homes)
SutterSutter- Yuba Mental Health (Out(Out- px)
px)
The Trauma Center at JRI (Out(Out- px)
px)
UCSF/CASARC (Out(Out-px)
px)
Vermont Department of Mental Health
(Outpatient programs)
Youth on Fire (Adolescent dropdrop- in
center)
Treatments Utilized in the NCTSN
17.4
TF-CBT
ARC
2.5
3.5
CPP
4.5
PCIT
SPARCS
8.3
63.8
Other /
Unknown
Total n=966
NCTSN FY 2010 Annual Progress Report – Executive Summary
Hilary Hodgdon, Ph.D. – Complex Trauma in Children
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Restraint Reduction
Monthly Restraint Totals 2006-2007
50
45
40
35
30
25
20
15
10
5
0
Jan Feb Mar Apr
May Jun Jul
Aug Sept Oct Nov Dec Jan Feb Mar Apr
May Jun Jul
2006
Aug Sept Oct Nov Dec
2007
butler
7
18
2
9
8
5
8
1
6
4
3
4
4
0
3
2
1
1
7
7
cohannet
28
20
44
44
31
42
19
15
20
15
8
8
6
5
10
0
6
4
14
15
4
glenhaven
41
22
33
24
22
23
19
13
11
11
8
12
7
15
13
5
3
6
5
3
14
6
Restraint Reduction
Percent Reduction in Restraints Per
Bed Capacity
Average Percent Reduction in Restraint Per Bed Capacity
FY 06 - FY 07
100%
80%
60%
54%
40%
20%
0%
-20%
Glenhaven, Cohannet, Butler
Other JRI Residential Treatment Programs
-20%
-40%
Hilary Hodgdon, Ph.D. – Complex Trauma in Children
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6-Month Change in CBCL Scores
68
67
66
65
64
63
62
61
60
59
58
57
56
55
54
TF-CBT
ARC
SPARCS
Baseline
3 Months*
6 Months*
NCTSN FY 2010 Annual Progress Report – Executive Summary
*Significant
decreases
on CBCL
scores; no
significant
differences
across
interventions
6-Month Change in UCLA PTSD-RI
Scores
29
27
25
TF-CBT
ARC
23
21
19
17
15
Baseline
3 Months*
6 Months*
NCTSN FY 2010 Annual Progress Report – Executive Summary
Hilary Hodgdon, Ph.D. – Complex Trauma in Children
*Significant
decreases
on CBCL
scores; no
significant
differences
across
interventions
16
ARC Treatment Outcomes to Date
PTSD Symptom Reduction (Outpatient,
Residential)
Child Behavior Improvement (CBCL)
(Outpt/Resi)
Outpt/Resi)
Outpatient (85%percentile to 50% percentile)
Residential (sig reduction Externalizing Problems;
positive trend Internalizing)
Significant Restraint Reduction (JRI)
Significant increase in Placement Permanency
(92% vs. under 50%) (ACMHS)
Increased staff perceived competence, reduced
staff burnout and turnover (VT(VT-DMH)
ARC Intervention Components
Integration into clinical work (structured and
unstructured); individual and/or dyadic
application
Caregiver support
Caregiver training workshops
Group treatment
Milieu training, consultation, and staff support
Milieu interventions and initiatives
CommunityCommunity-based applications
Importance of building an internal team to
support integration goals
Hilary Hodgdon, Ph.D. – Complex Trauma in Children
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Attachment: The Big Picture
Overarching:
Overarching:
Develop safety and positive
capacities within the child’
child’s caregiving
system
How?
Supporting caregivers
Increasing knowledge and skills
Creating positive relationships
Increasing predictability
Self-Regulation: The Big Picture
Overarching:
Overarching: Increase child/adolescent capacity
to manage emotional and physiological
experience
How?
Build a language for emotions, energy, and body
states
Build capacity to recognize these states in self and
other
Explore and support use of tools (individual as well as
external and systemic) to better manage experience
Increase communication resources, and capacities to
use those resources effectively
Hilary Hodgdon, Ph.D. – Complex Trauma in Children
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Competency: The Big Picture
Overarching:
Overarching: Support key reflective capacities,
including ability to make active choices and
sense of self
How?
Notice choices, assist with problemproblem-solving, link
actions and outcomes, and reflect on causecause-andandeffect
Tune in (and support child in tuning in) to attributes,
experiences, values, goals, opinions, etc.
Pay attention to the range of areas in which a child
may build developmental mastery
Trauma Experience Integration:
The Big Picture
Overarching:
Overarching:
Support selfself-reflective
capacities, and ability to understand the
self and act in the present,
present, while taking
into account the context of the past.
How?
Doing all of those things we’
we’ve just talked
about…
about…..the integration of many different
skills to manage, tolerate, explore, and
understand personal experience,
relationships, and systems of meaning
Hilary Hodgdon, Ph.D. – Complex Trauma in Children
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Attachment
SelfRegulation
Competency
Trauma
Experience
Integration
Attachment
Main / Overarching Domain Concept:
Build safe / trauma-informed caregiving
systems and safe relationships that
support children / adolescents
Attunement: Core Target / Goal
Help caregivers to better
understand children / adolescents
Key Sub-skills/Clinical Objectives:
-Build active curiosity
-Build reflective listening skills
Techniques:
i.e., Dyadic
check-ins,
feeling
charades, etc.
-Use attunement skills in support of
youth regulation
-Build pleasure / positive engagement
Hilary Hodgdon, Ph.D. – Complex Trauma in Children
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ATTACHMENT
Caregiver
Affect
Mgmt.
Attunement
Consistent
Response
Routines
and
Rituals
Caregiver Affect Management
The
Main Idea: Support the child’
child’s
caregiving system – whether parents or
professionals – in understanding,
managing, and coping with their own
emotional responses, so that they are
better able to support the children in their
care.
Caregiver
Affect
Mgmt.
Hilary Hodgdon, Ph.D. – Complex Trauma in Children
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Trauma Cycle
The Breakfast Club: Eat my Shorts
An example of poor caregiver affect
management.
The Trauma Cycle
Cognitive
Youth
Caregiver / Staff
Provider
I am bad, unlovable,
damaged.
I am ineffective.
I am ineffective.
This kid is causing trouble.
He’
He’s making things chaotic
for everyone.
This family/ this parent is
so difficult. They need to
just do what I ask them to
do.
People are
dangerous. I can’
can’t
trust anyone.
Emotional
Shame, Anger,
Fear, Hopelessness
Frustration, Anxiety,
Helplessness
Frustration, anger,
burnout, loss of empathy
Behavior
(Coping
Strategy)
Avoidance,
aggression, prepreemptive rejection
and selfself-protection.
OverOver-reacting, Controlling,
Shutting down /
Disconnecting emotionally.
Reactivity, control,
punitive responses
The Cycle
“I’m being
controlled; I have to
fight harder.”
harder.”
“He keeps fighting me; I
better dig my heels in.”
in.”
“This provider doesn’
doesn’t get it
– I’m not going to bother.”
bother.”
“I have to up the ante or
this family will never do
the right thing.”
thing.”
Hilary Hodgdon, Ph.D. – Complex Trauma in Children
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A1 – How do we increase our
ability to regulate? Primary Targets
(1) Validation, psychoeducation and depersonalization
Normalizing caregiver responses and depersonalizing youth
behaviors / reactions
(2) Identifying difficult situations
Building awareness of challenging situations
(3) SelfSelf-monitoring skills
Increasing capacity to “tune in”
in” to our own reactions
(4) SelfSelf-care and support
Building coping strategies and support systems that facilitate
caregiver selfself-care
Attunement
The
Main Idea: Support the child’
child’s
caregiving system – whether parents or
professionals – in learning to accurately
and empathically understand and respond
to children’
children’s actions, communications,
needs, and feelings.
Attunement
Hilary Hodgdon, Ph.D. – Complex Trauma in Children
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A2 - Attunement: Key Concepts
Children often communicate emotions and internal experience via
behavior, rather than words; traumatized children, in particular,
particular, may
lack the capacity to communicate their needs or even to know what
what
those needs are
Difficult behaviors are often fronts for unmet needs or unregulated
unregulated
affect; a key attunement challenge is therefore to identify the function
of youth behavior
Attunement is an ongoing process, and involves perception as well as
response
Accurate attunement in the caregiving system provides the foundation
foundation
for youth selfself-regulation; link these explicitly. The more the system is
ACTIVE in its attunement efforts, the more reflective this process
process will
be (and the less reactive!)
Consistent Response
The
Main Idea: Support the caregiving
system, whether familial or programmatic,
in building predictable, safe, and
appropriate responses to children’
children’s
behaviors, in a manner that acknowledges
and is sensitive to the role of past
experiences in current behaviors.
Consistent
Response
Hilary Hodgdon, Ph.D. – Complex Trauma in Children
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An alternative approach:
Two primary goals
(1) Incorporate the system’
system’s understanding of
youth behavior into their response to the
behavior (i.e., incorporate attunement into youth
management strategies, ideally reducing the
need for limits)
(2) Build responses to behavior that are
consistent, appropriate, and sensitive to trauma
influences on youth responses (i.e., building
consistent responses that increase,
increase, rather than
decrease,
decrease, felt safety)
Building Consistent Response
Support caregivers in understanding their own
emotional / physiological / cognitive / behavioral
responses in the face of child behaviors
Support attunement efforts: what is the function
of the child’
child’s behavior? Is this a regulation
moment, or a limitlimit-setting moment? (Or both?)
Provide support, education, and coaching in
parenting strategies, as needed. Build slowly.
Explore the caregiver’
caregiver’s personal / cultural beliefs
about appropriate parenting and their own
historical parenting experiences.
Hilary Hodgdon, Ph.D. – Complex Trauma in Children
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Building Consistent Response
Actively
engage youth in setting / defining /
understanding household / milieu /
contextual rules, as appropriate
Explore values underlying rules, and find
common ground
Solicit youth input on ways adults can
support them in following established
structures; anticipate / collaborate on
building success
Routines and Rituals
The
Main Idea: Build predictability through
use of individual, familial, and systemic
routines and rituals.
Routines
and
Rituals
Hilary Hodgdon, Ph.D. – Complex Trauma in Children
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A4 – The role of routines:
Key Concepts
Trauma is often associated with chaos and loss of
control; predictability helps build feelings of safety in
traumatized children
When children feel safe, they are able to shift their
energy from survival to healthy development
Repetition is an important way that children gain skill;
children often notice routines more in their absence than
in their presence
Routines should be part of the daily fabric, as well as
targeting areas of vulnerability or difficulty
A4 – The role of ritual:
Key Concepts
Rituals (traditions, celebrations, patterns of experience)
offer felt coherence among members of a family, culture,
or community, and may repeat across generations
Shared rituals may provide a sense of belonging; feeling
disconnected from dominant culture rituals may highlight
a feeling of difference
Exploration and celebration of ritual may include both
establishment and celebration of wholewhole-system rituals,
as well as exploration, sharing, and celebration of many
individual rituals
Hilary Hodgdon, Ph.D. – Complex Trauma in Children
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Domain 2:
SELF-REGULATION
Affect
Identification
Modulation
Affect
Expression
Affect Identification:
The Main Idea: Work with children to build an
awareness of internal experience, the ability to
discriminate and name emotional states, and an
understanding of where these states come from.
Affect
Identification
Hilary Hodgdon, Ph.D. – Complex Trauma in Children
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Considerations
Pair attunement with affect identification:Caregiver
identification:Caregiver attunement
skills can be used to support the child in affect identification.
identification.
Consider doing the work simultaneously.
Be mindful of cultural influences:
influences: Culture and context impact our
language for emotion, as well as our experience of it. Be cautious
cautious of
making assumptions.
Use your own imagination and creativity to create feelingsfeelingsrelevant activities.
Work with all caregivers to incorporate basic feelings identification
into their own interactions with the child.
Choose your moments:
moments: Much of this work happens in the
moment, and in conversation. Tune into opportunities to explore
affect in the material children are already bringing in.
Affect Identification - Basic
Hilary Hodgdon, Ph.D. – Complex Trauma in Children
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Affect Identification - Basic
Modulation
The Main Idea: Work with children to develop
safe and effective strategies to manage and
regulate physiological and emotional
experience, in service of maintaining a
comfortable state of arousal.
Affect
Modulation
Hilary Hodgdon, Ph.D. – Complex Trauma in Children
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Modulation
Little Girl Throwing a Tantrum
R2 - Modulation
Modulation Involves Multiple Skills:
Skills:
Ability to identify initial emotional/physiological state
Ability to identify and connect to subtle changes in state.
A note about connection:
connection: This is the ability to tune into,
into,
tolerate,
,
and
sustain
connection
to
tolerate
emotional/physiological states.
Ability to identify what it feels like in the body to
experience subtle changes in state
Ability to identify and use strategies to manage those
state changes
Hilary Hodgdon, Ph.D. – Complex Trauma in Children
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R2 - Modulation
Specific Targets / Skills:
Skills:
Build understanding of comfortable and effective states
Build an understanding of degrees of feelings and
energy
Support children in exploring arousal states, and in
developing a sense of agency over tools that allow them
to manage emotions and energy (build a “feelings
toolbox”
toolbox”).
Support and facilitate strategies which effectively and
comfortably lead to state changes
Modulation: Safe Place
Hilary Hodgdon, Ph.D. – Complex Trauma in Children
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Affect Expression:
The
Main Idea: Help children build the
skills and tolerance for effectively sharing
emotional experience with others
Affect
Expression
R3 – Key Skills and Targets
Exploration
of the goals of expression;
build comfort and safety in relationship
Identifying resources for safe expression
Effectively using resources
Initiating communication
Effective nonverbal communication skills
Effective verbal communication skills
Building and supporting forums for
selfself-
expression
Hilary Hodgdon, Ph.D. – Complex Trauma in Children
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Domain 3: Competency
Executive
Functions
Self Dev’t
& Identity
Dev’tal Tasks
Developmental Competencies
Each developmental stage builds on the learning and
experience of the previous stage
Competency and mastery of tasks at each stage lead to
construction of an internal sense of efficacy and
achievement;
achievement; in turn, this increases confidence in
approaching new tasks
When children are exposed to chronic trauma, energy
that is normally invested into development of
competencies is instead invested in survival
Hilary Hodgdon, Ph.D. – Complex Trauma in Children
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Executive Functions
The
Main Idea: Work with children to act,
instead of react, by using higherhigher-order
cognitive processes
to solve problems and
Executive
Functions
make active choices in service of reaching
identified goals
Self and Identity
The
Main Idea: Support children in
exploring and building an understanding of
self and personal identity,
including
Self Dev’t
& Identity
identification of unique and positive
qualities, building of coherence across
time and experience, and support in the
capacity to imagine and work toward a
range of future possibilities
Hilary Hodgdon, Ph.D. – Complex Trauma in Children
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Considerations
Consider group as well as individual identity goals for all
domains; i.e.:
Unique self:
• What characteristics does each child contribute?
• What makes this setting unique? (Group values, goals, etc.)
Positive self:
• Support and reinforce child successes
• Establish community pride; set collaborative group goals
Coherent self:
• Notice and normalize differences in child presentation and
experience across moments and setting
• Notice coherence and fragmentation among group members
Future self:
• Support individual youth in setting and working toward future goals
goals
• Set programmatic / community goals, and support members of the
system in working toward these
Trauma Experience Integration
Trauma
Experience
Integration
The Main Idea: Work with children to actively
explore, process, and integrate historical
experiences into a coherent and comprehensive
understanding of self in order to enhance
children’
children’s capacity to effectively engage in
present life.
life.
Hilary Hodgdon, Ph.D. – Complex Trauma in Children
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Children are not simply a composite of their
deficits, but are whole beings, with
strengths, vulnerabilities, challenges, and
resources.
ARC provides a framework that seeks to
recognize factors that derail normative
development, and to work with children,
families, and systems to build or rere-build
healthy developmental pathways.
Sensory Motor Arousal
Regulation Therapy
(SMART)
Hilary Hodgdon, Ph.D. – Complex Trauma in Children
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The Modulation Model©
High
High Activation
Activation
Hyperarousal
Hypervigilant
Hyper-defensive
Intrusive images
Emotional reactivity
Obsessive/Cyclical Cognitive Processing
A
A
R
R
O
O
U
U
S
S
A
A
LL
Optimal Arousal Zone
Optimal Arousal Zone
“inside our Window of Tolerance”
(D. Siegel 1999)
Low
Low Activation
Activation
Hypoarousal
Collapsed
Disabled defensives responses
Flat Affective
Numbing
Cognitively Disabled
with Permission of the Sensorimotor Psychotherapy Institute, © Ogden and Minton (2000)
Extreme Stress: Triggered to fight / flee, out of control fear or rage / “Panicky”…
Panicky”…..
”…..
Going to “jump out of my skin”
skin” / Coping resources really hard to engage, alone /
Enraged and out of control / “ I’ve got to get out of here”
here”
Increased Stress: More “ Reactively ACTIVE
ACTIVE””, agitated, anxious, angry but able to
control self and “ be present”
present”
CONTAINED, CALM, ALERT,
FEELS PRESENT / FEELS SAFE
Increased Stress: More “ Reactively INACTIVE
INACTIVE””, depressed, spacey, but able to
control self and “ be present”
present”
Extreme Stress: Triggered to engage automatic survival responses of freezing,
numbing/ Not feeling “ here”
here”, not feeling “ me”
me” / Coping resources are really hard to
engage alone / Really low energy, doesn’
doesn ’t seem really present.
Adapted from Candace Saunders, LICSW and based on Pat Ogden’s “Windows of Tolerance”, Trauma and the
Body
Hilary Hodgdon, Ph.D. – Complex Trauma in Children
38
Sensory Motor Arousal Regulation
Training (SMART)
SMART
Self-Regulation through 3 types of input:
• Vestibular input: the kid who lies on the
couch upside down.
• Proprioceptive input: the kid who is
roughhousing with others, or jumping
around.
• Tactile input: the kid who seems to seek
restraints, or needs lots of stuff on him to
sleep
Hilary Hodgdon, Ph.D. – Complex Trauma in Children
39
Why SMART for trauma?
A treatment aimed at subcortical as well as
cortical systems:.
systems:.
Begins with movement and sensation, exploration and
curiosity as routes to better regulation.
Does not rely on language as entry point.
Allows integration of affect through engagement of the
whole body.
Cognitive understanding or a coherent narrative emerges
as the consequence of full engagement of the subcortical
systems (sensory, motor, limbic/emotional, and autonomic
arousal).
Uses present moment new experience to expand and
create new capacity for attachment through coco- and selfselfregulation.
Neurofeedback (NFB)
Hilary Hodgdon, Ph.D. – Complex Trauma in Children
40
State of Arousal and EEG Wave Patterns
Neurofeedback (NFB)
EGG biofeedback.
Brain activity measured and
interpreted by the computer.
Visual and auditory feedback
in form of simple computer
games.
Uses operant conditioning to
“train the brain”
brain” to perform at
an optimal level.
“Top down”
down” approach to
quiet the brain and body.
Shown to improve attention,
concentration, selfself-regulation
and depression, as well as
reduce irritability and anger.
Hilary Hodgdon, Ph.D. – Complex Trauma in Children
41
NFB Trauma Protocol
T4T4-P4 placement.
Training focused on
inhibiting slow wave
(Delta and Theta) and
high wave (High Beta)
activity, while rewarding
Alpha activity.
Protocol designed to
increase selfself-regulation
and reduce
hypersensitivity to stimuli.
Case Example
Hilary Hodgdon, Ph.D. – Complex Trauma in Children
42
Case Example: “Katie”
16 year old adopted, African American female.
Treatment at VDK for 8 months.
Incoming Diagnoses: Reactive Attachment Disorder,
Bipolar, PTSD, ADHD, ODD, R/O Borderline IQ.
Presentation at intake:
High levels of dysregulation and reactivity.
Regressive, “primitive”
primitive” and selfself-harm behaviors when
dysregulated.
dysregulated.
Easily overwhelmed, leading to becoming shut down.
Needed almost constant attention from adults.
Developmentally immature (i.e. childlike) interpersonal
interactions.
Active PTSD symptoms.
Angered easily, often perceived hostile intent from others.
Negative self concept.
Limited ability to engage in school.
Difficulty making friends.
Individual Context
Severe and chronic neglect by parents.
Physical and sexual abuse by father.
Sexual exploitation by father.
Severe emotional and behavioral
difficulties (sleep difficulties, aggression,
hyperactivity, oppositional &
sexualized behaviors).
Supervised visit with father where she
“went limp and blank.”
blank.”
Symptoms – impulsivity, aggression,
defiance, nightmares, flashbacks,
avoidance, etc., etc.
Severe attachment difficulties.
Dissociative response – “space out or go
to sleep when stressed.”
stressed.”
Multiple instances of running away.
Sexual assault by unknown male in the
community.
Reemergence of memories of early
sexual and physical abuse by father.
Self harm behaviors increase in
frequency and severity.
Serious suicide attempt.
Age
Birth - 4
3-5
6-12
12-16
Hilary Hodgdon, Ph.D. – Complex Trauma in Children
Environmental Context
Bio mom: severe and persistent
mental illness.
Exposure to domestic violence.
Father leaves family.
NonNon-compliance with mental health
services for Katie.
Removed from mother’
mother’s care.
8 placements, including first
psychiatric hospitalization.
Adopted by current family.
Multiple transitions between schools.
Good motivation and ability in school if
highly structured.
Estimated 1515-20 psychiatric
hospitalizations.
3 stays in residential treatment.
43
“Medical Model/Diagnostic Lens”
Assumptions
Bipolar: Chemical imbalance in the brain.
ADHD: Dysfunctional frontal lobe leading to poor
inhibition.
RAD:
Unable to love or feel empathy for others.
Behavior driven by need to control and manipulate.
Borderline IQ: Cognitively impaired, limited
ability to learn.
Conduct/Oppositional Behaviors: aggression,
defiance, and inability to follow directives.
“Trauma Lens”
Complex PTSD/Developmental Trauma Disorder Framework:
SelfSelf-regulation is impaired:
Dissociative coping response:
Push/pull in interpersonal relationships.
Poor social skills.
Limbic system highjacks the neocortex:
neocortex:
Persistent negative sense of self.
Feelings of depression and hopelessness.
Disorganized attachment style.
“State dependent”
dependent” presentation shown by vacillation between periods of
stability and extreme instability.
Low SelfSelf-Esteem:
Highly dysregulated and impulsive.
Frequent and severe self harm and regressive behaviors.
Executive functioning deficits.
Poor attention and concentration.
Worldview shaped by early environment:
Hostile attribution bias.
Preoccupation with threat (i.e. hypervigilence).
hypervigilence).
Hilary Hodgdon, Ph.D. – Complex Trauma in Children
44
CORE Battery Measures
UCLA PTSD Reaction Index (Steinberg, Brymer,
Brymer, Decker, Pynoos,
Pynoos,
2004):
Exposure to traumatic events (baseline only).
PTSD Symptoms:
• Intrusive: flashbacks, nightmares, intrusive thoughts.
• Avoidance: cognitive and/or behavioral avoidance.
• Arousal: hyperarousal,
hyperarousal, sleep difficulties.
Novaco Anger Scale and Provocation Inventory (NAS(NAS-PI;
Novaco,
Novaco, 2003):
Cognitive: anger justification, rumination, hostility, and suspicion.
suspicion.
Arousal: Anger intensity, duration, somatic tension, and irritability.
irritability.
Behavior: Impulsive reaction, verbal aggression, physical confrontation,
confrontation, and
indirect expression.
Anger regulation.
Provocation: sensitivity to disrespectful treatment, unfairness, frustration,
annoying traits of others, and irritations
Child Behavior Checklist (CBCL; Achenbach & Rescorla,
Rescorla, 2001):
Internalizing symptoms.
Externalizing symptoms.
So
cia
l
Th
ou
gh
t
At
te
nt
io
Ru
n
le
-B
rk
in
Ag
g
gr
es
si
ve
In
te
rn
al
iz
Ex
in
g
te
rn
al
izi
ng
100
90
80
70
60
50
40
30
20
10
0
An
x/
W
De
it h
p
dr
wn
/D
ep
So
m
at
ic
CBCL T-Score
CBCL at Intake
Hilary Hodgdon, Ph.D. – Complex Trauma in Children
45
eg
u
la
tio
n
ve
nt
or
y
An
ge
r
R
In
n
Pr
ov
oc
at
io
NA
S
To
ta
l
io
r
Be
ha
v
Co
gn
i ti
Ar
ou
sa
l
80
70
60
50
40
30
20
10
0
ve
NAS-PI T-Score
NAS-PI at Intake
PTSD Reaction Index at Intake
70
PTSD-RI Score
60
50
40
30
20
10
0
Total Score
Crit. B:
Reexperiencing
Hilary Hodgdon, Ph.D. – Complex Trauma in Children
Crit. C:
Avoidance
Crit. D:
Hyperarousal
46
mic
ste
Sy
ARC:
ARC:
A Framework
For
Intervention
with
Complexly
Traumatized
Youth
F am
l
ilia
iv id
Ind
ual
TRAUMA EXPERIENCE
INTEGRATION
COMPETENCY
REGULATION
ATTACHMENT
Primary Components
•Executive functions
•Self development
•Affect Identification
•Modulation
•Affect Expression
•Caregiver affect management
•Attunement
•Consistent response
•Routines and Rituals
Blaustein & Kinniburgh, 2010;
Kinniburgh & Blaustein, 2005
ARC Approach
SelfSelf-Regulation:
Neurofeedback (NFB): “Top down”
down” regulation.
Sensory Motor Arousal Regulation Therapy (SMART): “Bottom
up”
up” regulation.
Integration of sensory motor tools in the milieu and school
contexts.
Individualized planning in milieu to encourage translation of self
self-regulation skills (ex. settling plan) in day to day.
Attachment:
SMART: Build attachment with individual therapist.
Milieu interventions focused on building positive relationships
(Ed and Res advocates) and getting needs for nurturance and
affection met in a positive way (ex. hug plan).
Focus on routines, rituals, consistent responding and caregiver
affect management across the board.
Hilary Hodgdon, Ph.D. – Complex Trauma in Children
47
SMART Session
Restraint Data
Number of Restraints
6
5
4
3
2
1
0
1
2
3
4
5
6
7
8
Month
Hilary Hodgdon, Ph.D. – Complex Trauma in Children
48
PTSD Symptom Change
PTSD-RI Score
70
60
50
Intake
40
3 Months
30
Discharge
20
10
al
e
yp
er
a
.D
:H
C
rit
.C
:A
C
rit
ro
us
vo
id
an
c
ng
nc
i
er
ie
.B
:R
ee
xp
C
rit
To
ta
lS
co
re
0
CBCL Symptom Change
100
90
CBCL T-Score
80
70
*
60
*
*
*
50
Intake
3 Months
40
Discharge
30
20
10
A
W nx/
D
ith
ep
dr
w
n/
D
ep
So
m
at
ic
S
oc
ia
Th l
ou
gh
At
t
te
nt
R
io
ul
n
eBr
k
A
gg ing
re
ss
In
iv
e
te
rn
al
E
iz
xt
in
er
na g
liz
in
g
0
* Indicates clinically significant improvement.
Hilary Hodgdon, Ph.D. – Complex Trauma in Children
49
80
70
60
50
40
30
20
10
0
Intake
3 Months
P
An
ge
r
R
eg
ul
at
io
n
In
ve
nt
or
y
n
To
ta
l
or
ro
vo
ca
tio
NA
S
eh
av
i
B
Ar
ou
Co
gn
i
sa
l
Discharge
t iv
e
NAS-PI T-Score
NAS-PI Symptom Change
Treatment Summary
Treatment approach was individualized and integrated
across contexts.
Initial focus on building selfself-regulation skills through both
“top down”
down” and “bottom up”
up” approaches (SMART, NFB).
Attachments across the program and with family played
in integral role.
Underlying capacity was revealed once extreme
dysregulation had stabilized.
Significant clinical improvement in PTSD, somatic, and
externalizing symptoms over 8 months.
Competency piece of ARC has continued beyond
residential treatment – such as returning to her parent’
parent’s
home to live, getting her drivers license, etc.
Hilary Hodgdon, Ph.D. – Complex Trauma in Children
50