National Crime Victims Research and Treatment Center Best Practices to Treat Abused Children and Their Families -Why Don’ Don’t We Use Them? 1979 in Review Jimmy Carter is President. In a ceremony at the White House, President Anwar Sadat of Egypt and Prime Minister Menachem Begin of Israel sign a peace treaty. The Shah of Iran flees to Egypt. Egypt. Ayatollah Ruhollah Khomeini returns to Tehran and sets an Islamic state. 52 American embassy workers are taken hostage in November. Iraqi President Hasan alal-Bakr “resigns” resigns” and Vice President Saddam Hussein replaces him. him. The Soviet Union invades Afghanistan. Benjamin E. Saunders, Ph.D. Professor and Director, Family and Child Program National Crime Victims Research and Treatment Center Department of Psychiatry and Behavioral Sciences Medical University of South Carolina Charleston, South Carolina USA Presentation at the 5th Annual Eastern Conference on Child Sexual Abuse Treatment, March 23, 2006, Arlington, VA. 2 1979 in Review Psychological and Behavioral Impact of Childhood Victimization Abuse and victimization in childhood correlated with: ● Anxiety disorders (PTSD, social phobia, generalized anxiety ESPN starts broadcasting. The Susan B. Anthony $1 coin is introduced in the US. The first fully functional space shuttle orbiter, Columbia, is delivered to the John F. Kennedy Space Center to be prepared for its first launch. A nuclear power plant accident at Three Mile Island, Island, Pennsylvania releases radiation. Kramer vs. Kramer wins Best Picture. Dustin Hoffman and Sally Field (Norma (Norma Rae) Rae) win Best Actor and Best Actress awards. Saunders treats first case of sexual abuse. disorder) ● Affective disorders (major depression) Sexual disorders (dysparunia, dysparunia, vaginismus, vaginismus, inhibited sexual desire) Substance use/abuse/dependence (drug, alcohol, tobacco) Delinquency and criminal behavior Violent behavior (peer aggression, dating violence, spouse/partner ● Other problems (future victimization, selfself-esteem, guilt, shame, selfself- ● ● ● ● violence) blame, relationship difficulties, academic performance, occupational achievement) ● Comorbid problems 3 4 Wanted: Effective Treatments Effective interventions are needed for common proximate The Problem: Problem: All sorts of “interventions” interventions” are available out there. victimizationvictimization-related mental health problems. ● ● ● ● ● PTSD, fear, anxiety Depression Behavioral difficulties Aggression Guilt, shame, stigmatization, difficulty with trust Effective treatments are needed to prevent the development of future future problems. ● ● ● ● ● Substance use/abuse/dependence Physically or sexually aggressive behavior Delinquency, criminal behavior Sexual disorders Relationship difficulties 5 6 1 Questions to ask of any Practice or Treatment A Good Question... Is it based on a solid conceptual and theoretical framework? How can we sort out the good from the poor or even harmful interventions? ? ● ● Is the theory upon which it is based widely accepted? Is there a logic model that makes sense? How well is it supported by practice experience? Does is have an acceptable benefit vs. risk for harm ratio? Can it be used by the average clinician? ● ● ● Are books, practice manuals, and procedure descriptions available? available? Is training, supervision, and consultation available? Is there any reason the practice cannot be used with the clients you work with? How well is it supported by scientific research? ● ● ● How many evaluations have been conducted? How rigorous were the research designs? How strong are the results? 7 8 Many Terms Used to Describe Treatment Support The Clinical Science Process Evidence Based Practice Use in Practice Setting Proven Practice Demonstrated Effective Practice Best Practice Conduct Efficacy Studies Conduct Effectiveness Studies Evidence Informed Practice Disseminate Intervention to the Field Evidence Supported Treatment Empirically Supported Treatment Emerging Practice Develop Intervention Approach Promising Practice Blah, blah, blah… blah… 9 10 What is an “Evidence Supported Treatment” Treatment” or EST? Problems in the Child Abuse Field in the U.S. Empirical evidence of efficacy has not been a common criteria for for Treatment or intervention protocol that has at least some scientific, scientific, empirical research evidence for its efficacy with its intended target target problems and populations. Evidence may be based on a variety of research designs. ● Randomized Clinical Trial (RCT) ● ● ● treatment selection in the child maltreatment field. Lack of outcome research for many commonly used interventions. Ready willingness among some to use, embrace, promote, and Controlled studies without randomization Open trials, prepre- postpost-, or uncontrolled studies Multiple baseline, single case designs The degree to which we are persuaded that the treatment is effective effective will vary by the quality of empirical support. ● ● ● Number of RCT’ RCT’s Replication by researchers other than the treatment developers Sampling, sample size used, comparison treatment, effect size Various methods have been developed for classifying the level of of empirical support enjoyed by treatment approaches 11 staunchly defend practices that have no evidence for their efficacy efficacy and questionable theoretical bases. Poor dissemination of the significant clinical outcome research that has been done. Ineffective approaches to continuing education. Poor adoption of empirically supported treatments in real world clinical settings. Disconnection between current scientific knowledge and practice in the field. 12 2 Why Use Evidence Supported Treatments? The race is not always won by the swift, nor the contest by the strong, but the smart man bets that way. Why should we worry about using Evidence Supported Treatments? Treatments? Damon Runyon 13 14 Responsibilities of Practitioners Practitioners have a duty to be familiar with available interventions and their supporting literature. Practitioners have a duty to be trained, knowledgeable, and skilled in the use of proven interventions. If they are not, they have a duty to refer clients to practitioners practitioners who are. When they exist, practitioners should use proven interventions with appropriate clients as their firstfirst-line practice. A clinical decision to use an alternative, unsupported approach when a empirically supported intervention exists must be considered an ethical issue. Practitioners should refrain from using experimental or potentially dangerous interventions. Costs of NOT using EST’ EST’s? 15 16 Finding Evidence Supported Treatments on the Web A Question... =1192 http://modelprograms.samhsa.gov/template.cfm?CFID http://modelprograms.samhsa.gov/template.cfm?CFID=1192 92&CFTOKEN=55491051 http://ebmh.bmjjournals.com ttp://ebmh.bmjjournals.com// How can the average frontfront-line practitioner locate Evidence Supported Treatments for cases of child abuse? ? www.cochrane.org www.campbellcollaboration.org www.colorado.edu/cspv/blueprints/model/overview.html 17 www.strengtheningfamilies.org/ www.strengtheningfamilies.org/ www.ncptsd.va.gov/topics/treatment.html www.nctsn.org 18 3 OVC Guidelines Project: OVC Guidelines Project Criteria for Judging a Treatment Theoretical basis (sound, novel, reasonable, unknown) Clinical/anecdotal literature (substantial, some, limited) General acceptance/use in clinical practice (accepted, some, limited) Risk for harm/benefit ratio (little, some, significant) www.musc.edu/cvc/ Level of empirical support (randomized controlled trials, nonrandom controlled trials, uncontrolled trials, single case studies, none) Download the full report 19 20 21 22 OVC Guidelines Project: Classification Results 1. 2. 3. 4. 5. 6. WellWell-supported, efficacious treatment Supported and probably efficacious treatment Supported and acceptable treatment Promising and acceptable treatment Innovative or novel Experimental or concerning treatment 1 1 14 8 0 1 24 EST’ EST’s for abused children are available! 16 protocols had at least some empirical support. ParentParent-Child Interaction Therapy (PCIT) (HembreeHembree-Kigin & McNeil; Urquiza & McNeil) ` Specific goal is to change parentparent-child interaction, not specific child behavior. Increase positive parentparent-child interactions. Therapist as coach of the parent, use of oneone-way mirror and “bug in the ear” ear” with parent to direct interaction with child. Parent taught PRIDE skills ● ● ● ● ● Praise Reflect Imitation Description Enthusiasm Behavioral Parent Training Multiple trials primarily with oppositional younger children find find improvements in child behavior. Two trials with abused children and their families. Find improvements in behavior of children and reduction in physically physically abusive behavior by parents. 23 24 4 Abuse Focused Cognitive Behavioral Therapy for Child Physical Abuse Cognitive Processing Therapy (Resick & Schnicke) Schnicke) (Kolko & Swenson) Psychoeducation Write impact statement, explore the meaning of the trauma Assessment of family structural roles and interaction Reframing to enhance cooperation Identify negative effects of the use of physical force Learn ABC model, ABC Worksheets Exposure description No violence contract Problem solving skills Communication skills ProblemProblem-solving family routines as alternatives to physical punishment Behavior management skills Identification of “stuck points” points” Challenging Questions, Faulty Thinking Patterns, Challenging Beliefs Worksheet Modules covering safety, trust, power and control, selfself-esteem, intimacy Affect regulation to manage abuseabuse-specific triggers Combination of child, parent, and family components Two RCT’ RCT’s with adult sexual assault victims demonstrated One randomized controlled trial Recommended as a best practice for adolescent sexual assault improvement in PTSD and depression victims 25 26 TraumaTrauma-Focused Cognitive Behavioral Therapy (TF(TF-CBT) TFTF-CBT Treatment Outcome Research (Deblinger & Heflin; Cohen & Mannarino) Mannarino) Developed for children with symptoms of PTSD, fear, and anxiety due to sexual abuse or other traumatic event. With developmental adjustments, appropriate for use with children as young as 4 up to adolescents. Approach is focused on building in children and parents the necessary skills to reduce current symptoms and to manage problems that may occur in the future. Based upon CognitiveCognitive-Behavioral Therapy principles. TFTF-CBT has been rigorously tested. Multiple randomized controlled trials with sexually abused children and their families by different research groups. Results indicate: ● ● ● ● Improvement in PTSD, depression, and behavior problems compared to no treatment PTSD improves more with direct child treatment, working with parents is not sufficient. Improvement in depression and social competence compared to nonnon-specific treatment Improvement in parental distress, support and perceptions compared to nonnon-specific treatment 27 28 TFTF-CBT Components Structure of TFTF-CBT (Parent and Child) Treatment follows a structured approach with specific procedures done in sequence. Considerable creativity is needed to apply the procedures. Psychoeducation about childhood trauma, trauma reactions, PTSD Stress and anxiety management skills Treatment includes individual child and parent sessions, and conjoint (parent(parent-child) sessions. Usual session comprised of 45 minutes with child and 45 minutes with parent alone or with parent and child. Child is taught a skill, then teaches it to the parent. Protocol ends with a series of conjoint sessions. Protocol set up for 1212-16 sessions. Emotional identification and expression Cognitive triangle and cognitive coping Constructing the Trauma Narrative Identifying and altering maladaptive cognitions Behavior management 29 30 5 TFTF-CBT Components TFTF-CBT Components (Parent and Child) (Parent and Child) Psychoeducation about childhood trauma, trauma reactions, PTSD ● ● ● ● ● Emotional identification and expression ● Information provision Normalization of reactions to traumatic event Body awareness; sex education Risk reduction Provide hope and promote expectation of improvement ● ● ● Cognitive triangle and cognitive coping Stress and anxiety management skills ● ● ● ● Developing a vocabulary for feelings Understanding sensations associated with different affective states Correctly labeling feelings Developing skills for appropriately expressing feelings ● Controlled Breathing Progressive Muscle Relaxation Thought Stopping Other Relaxation methods ● Understanding the connections between events, thoughts, feelings and behavior. Methods for changing thoughts to alter feelings and behavior. 31 32 TF-CBT Components TF-CBT Components (Parent and Child) (Parent and Child) Constructing the Trauma Narrative ● ● ● ● ● Identifying and altering maladaptive cognitions Based upon principles of gradual exposure. Goal is to repeatedly expose the child to the traumatic event, reminders of the event, and related feelings in real time in order order to help them habituate to those feelings, reducing their intensity, and help develop positive and longlong-lasting coping skills. Child constructs a detailed story of the trauma, including what happened, thoughts, and feelings at the time. Creative methods are often used to construct the Trauma Narrative, including developing a book with chapters, including poetry, writing a song, recording a rap, drawing or constructing pictures, etc. Child shares the Trauma Narrative with the parent. ● ● Basic cognitive restructuring techniques Exposure of inaccurate or maladaptive thinking, challenge and dispute the thoughts, replace with accurate, appropriate, and enhancing thoughts. Behavior management ● Parent is taught and practices basic behavioral management techniques Reduce negative attention through active ignoring of nondanger misbehavior Praise and positive reinforcement of desired behavior Teach appropriate, nonviolent logical consequence techniques for misbehavior 33 A Question... 34 Treatment Manuals Deblinger, Deblinger, E. & Heflin, A.H. (1996). Treating sexually abused children and their nonoffending parents. parents. Sage Publications: Thousand Oaks, CA. Where can I learn more about TFTF-CBT. ? Cohen, J.A., Mannarino, Mannarino, A.P., & Deblinger, Deblinger, E. (in press). Treating Trauma and Traumatic Grief in Children and Adolescents. Adolescents. New York: Guilford Publications, Inc. (to be released June, 2006). 35 36 6 TF-CBTWeb TF-CBTWeb www.musc.edu/tfcbt www.musc.edu/tfcbt •WebWeb-based learning •Learn at your own pace •Learn when you want •Learn where you want •10 hours of CE •Return anytime TFTF-CBTWeb is an InternetInternet-based, distance education training course for learning TraumaTraumaFocused CognitiveCognitiveBehavioral Therapy (TF(TF-CBT). TFTF-CBTWeb is offered free of charge. 37 38 TF-CBTWeb TF-CBTWeb www.musc.edu/tfcbt www.musc.edu/tfcbt TFTF-CBTWeb is sponsored by: Each module has: has: •Concise explanations •Video demonstrations •Clinical scripts •Cultural considerations •Clinical Challenges TFTF-CBTWeb was developed and is maintained through grant No. 11-UD1UD1-SM56070SM56070-01 from the Substance Abuse and Mental Health Services Administration. Administration. 39 40 Characteristics of Child Treatments with Empirical Support Characteristics of Child Treatments with Empirical Support Goal directed. Treatment has specific target problems. Use a protocol or structured phasephase-oriented approach composed of specific procedures. Not much “freefree-styling.” styling.” More focused, less distracted by COW’ COW’s over the course of treatment. Treatment procedures are matched to specific presenting problems. Therapist is active and directive in treatment. Treatment involves both the child and the parents or caregivers. Tend to be behavioral or cognitivecognitive-behavioral theoretically. Focus on skillskill-building and building competencies within individuals, relationships, and families to replace maladaptive strategies. Use of practice and feedback methods. ● ● 41 Role play Homework 42 7 It’s NOT 1979 any more Good News!!!! 27 years of research and practice have given us a good understanding of the… the… ● ● ● ● ● ● We know a lot about child abuse and how to treat its consequences! Prevalence and incidence of child abuse in the U.S. Risk factors for child abuse. Mental health impact of child abuse, immediate and longlong-term. Resilience of most victims of child abuse. Risk factors for mental health impact. Bad News!!!! Evidence supported treatments for many mental health problems experienced by victims of child abuse and their families. We know a lot about child abuse and how to treat its consequences, but we are not using that knowledge effectively in front-line practice. 43 44 A Logical Question… Question… If they are so great, why have EST’ EST’s not spread more widely and more quickly in the U.S.? ? 45 Admiral Dom Vasco de Gama 46 Captain James Lancaster In 1601 he conducted a RCT of lemon juice for scurvy. 1 ship’ ship’s crew given 3 tsp of each day, crew members on 3 other ships were given a standard diet. At the halfway point of the trip 110 (40%) of 100 of the crew of 160 died of scurvy 47 the 278 sailors on the three “control group ships had died of scurvy vs. none on the lemon juice ship. Replicated 146 years later by Dr. James Lind. 264 years after the first definitive trial, the British ordered proper diets on merchant marine vessels in 1865. Change is hard! 48 8 How can we describe those who adopt new technologies? Challenges for Clinical Science How do we discover what interventions are effective for what problems with what people in what settings? What is the best way to disseminate theoretically sound and empirically supported interventions? How can frontfront-line practitioners best be trained in their use? How can clinicians, supervisors, administrators, and intervention systems be motivated to use theoretically sound and empirically supported interventions? How can we identify and overcome the barriers that inhibit the use of empirically supported practice? Innovators Early Late Majority Majority Early Adopters Traditionalists 49 50 Three Treatments Selected as Clear “Best Practices” Practices” in Child Abuse Cases Kauffman Best Practices Project Final Report TraumaTrauma-Focused Cognitive Behavioral Therapy for child sexual abuse Abuse Focused Cognitive Behavioral Therapy for child physical abuse ParentParent-Child Interaction Therapy for child physical abuse Download at: www.musc.edu/cvc/ 51 52 Why Have These EST’ EST’s Not Spread Widely in the U.S.? Why Have These EST’ EST’s Not Spread Widely in the U.S.? Tradition in the field and acculturation of practitioners art vs. a Poor connection between research and practice ● ● View of mental health treatment as primarily an ● Most therapists classify themselves as “eclectic” eclectic” in approach and are used to picking and choosing techniques to use based upon interest. Few practitioners were trained in the use of proven treatments or or protocols. Empirical support has not traditionally been a criteria practitioners practitioners use in treatment selection. Primary reliance on previous training and clinical experience rather rather than new scientific breakthroughs for treatment selection. Resistance to the notion of structured treatment protocols or standardized standardized procedures. Lack of accountability for outcomes. Payment for time spent rather rather than outcomes achieved. ● ● ● ● ● . science 53 ● ● ● ● ● ● Segregation of researchers and clinicians and research and practice classes in primary training programs. Researchers can’ can’t seem to say anything works or apply it to the real world. Research findings are always overly qualified to the point of seeming to be useless or not applicable to many clients. Not enough outcome research with commonly used treatments. Little effectiveness research. No or ineffective dissemination efforts by developers of EST’ EST’s. Inadequate continuing education system. Lack of demand for EST’ EST’s by consumers of services. 54 9 Barriers to Use Survey: Barriers to Use Survey: TraumaTrauma-Focused Cognitive Behavioral Therapy AbusedAbused-Focused Cognitive Behavioral Therapy Respondents identified 118 barriers including: including: Funding/Reimbursement Issues Lack of Advocacy Lack of Awareness/Understanding of TFTF-CBT Entrenched Status Quo/Lack of Tradition of Adopting EBT/Implications EBT/Implications of Change for Current Practice Few Organizational Role Models Belief Their Population is ‘Different” Different” Training/Supervision Lack of Incentive or Link of Rewards to Outcomes Misperception About Model (Art vs. Science of Therapy) Respondents identified 115 barriers including: including: Funding/Reimbursement Issues Lack of Advocacy Lack of Awareness/Understanding of AFAF-CBT Entrenched Status Quo/Lack of Tradition of Adopting EBT/Implications EBT/Implications of Change for Current Practice Few Organizational Role Models Training/Supervision Lack of Incentive or Link of Rewards to Outcomes Misperception about model and Manualized Treatment (Art vs. Science of Therapy) Lack of Appreciation of Trauma Issues in Physical Abuse Intervention Intervention Lack of Appreciation in Clinical Approach to Parenting/Conflict (vs. Parenting Education 55 56 Strategies for Overcoming Barriers Barriers to Use Survey: Parent Child Interaction Therapy Respondents identified 98 barriers including: including: Funding/Differential Payments for Best Practices (include Funding/Reimbursement Issues, Lack of Advocacy, Lack of Awareness/Understanding of PCIT, Entrenched Status Quo/Lack of Tradition of Adopting EBT/Implications of Change for Current Practice, Few Organizational Role Models, Training/Supervision Lack of Incentive or Link of Rewards to Outcomes Room and Equipment Costs Community Stakeholders may see PCIT as Insufficient Treatment Resentment by NonNon-PCIT Therapists or Teams for the Special Attention (expense, space and equipment) and Perception of Inequities PCIT may not be Perceived as Providing the Traditional Therapeutic Relationship Satisfaction – some may miss the more open discussion format of their traditional approach PCIT may feel more like training or coaching than therapy and some therapists may resist on that basis family work) Training (Payment for retooling training time) Professional education/marketing Trained Clinical Supervision/Consultation Create Tool Kits Develop Parental engagement strategies Create peer support networks Teach EBT in graduate schools Recruit national and state advocates at political level Professional society endorsements Create clinical decision making aides (assessment tools) linked to EST 57 Common Continuing Education Dissemination Model 58 Institute for Healthcare Improvement Model Environmental Context One day workshop Therapist Use Tx with appropriate clients Organizational Context Microsystem Book Patient and Community Community, Government, Funders Organizations Departments and Programs Within Organizations Social Workers, Therapists, Medical Professionals and Families 59 60 10 Supportive Implementation Model IHI Breakthrough Series Model Administrative Leadership and Support for EBT Technical Assistance Expert Consultation Therapist Training www.ihi.org Obtain client feedback Supervision Use EST with appropriate clients Materials Community/Consumer Support for EBT 61 62 Conclusions We know a lot about child abuse in the U.S., e.g., prevalence and and incidence, incident characteristics, risk factors, immediate impact, impact, long term consequences We use very little of this knowledge in our everyday, frontfront-line interventions. Empirical research support has not been a primary factor in treatment treatment selection for many frontfront-line therapists. Practical, evidence supported treatments exist for many problems often encountered in cases of child abuse. When they exist, therapists should use evidence supported treatments treatments as their first choice. Not to do so should be considered an ethical ethical issue. Better methods of training, continuing education, and dissemination dissemination of EST’ EST’s are needed. 63 Time to Dive into Evidence Supported Practice 64 Contact Information Download reports and handout from: www.musc.edu/cvc/ www.musc.edu/cvc/ E-mail: [email protected] 65 66 11 Treatment Manuals for EST’ EST’s Deblinger, Deblinger, E. & Heflin, A.H. (1996). Treating sexually abused children and their nonoffending parents. parents. Sage Publications: Thousand Oaks, CA. Kolko, Kolko, D. & Swenson, C.C. (2002). Assessing and treating physically abused children and their families. families. Sage Publications: Thousand Oaks, CA. HembreeHembree-Kigin, Kigin, T. & McNeil, C.B. (1995). ParentParent-Child Interaction Therapy. Therapy. New York: Plenum. Resick, Resick, P. & Schnicke, Schnicke, M. (1993). Cognitive processing therapy for rape victims: A treatment manual. manual. Sage Publications: Thousand Oaks, CA. 67 12