assessment-based treatment for traumatized children: a trauma assessment pathway model (tap)...

Assessment-Based Assessment-Based Treatment for Traumatized Treatment for Traumatized

Children: A Trauma Children: A Trauma Assessment Pathway Assessment Pathway

Model (TAP)Model (TAP)

Presented by:Presented by:

Alicia Gilbert, PhDAlicia Gilbert, PhD

Robyn Igelman, PhDRobyn Igelman, PhD

Chadwick Center forChadwick Center for Children and Families Children and Families

Chadwick Center ProgramsTrauma Counseling

Forensic and Medical ServicesFamily Support

Professional Education

Research Linkage Child & Adolescent Services Research Center

(funded by the NIMH)

Trauma Counseling ProgramTrauma Counseling Program

Assessment-based individual, group and family Assessment-based individual, group and family therapy for children who have experiencedtherapy for children who have experiencedtraumatic events. traumatic events.

Therapy and advocacy to domestic violence Therapy and advocacy to domestic violence victims and their children at the Family Justice victims and their children at the Family Justice Center.Center.

School-based counseling services.School-based counseling services. Parent-child interaction therapy.Parent-child interaction therapy. Medication & psychological assessments. Medication & psychological assessments. Crisis intervention, advocacy, information and Crisis intervention, advocacy, information and

referrals.referrals.

TAP Model OverviewTAP Model Overview

A treatment manual for traumatized A treatment manual for traumatized children ages 2 to 18 yearschildren ages 2 to 18 years

Incorporates assessment data, clinical Incorporates assessment data, clinical interview, and observation to create a interview, and observation to create a Unique Client PictureUnique Client Picture

Includes specific components of trauma-Includes specific components of trauma-specific treatment described by the specific treatment described by the Trauma WheelTrauma Wheel

Draft completed and undergoing Draft completed and undergoing revisionsrevisions

What Is Assessment Based What Is Assessment Based Treatment (ABT)?Treatment (ABT)?

Development of clinical assessment-based Development of clinical assessment-based treatment refers to the “development of an treatment refers to the “development of an integrated plan of integrated plan of prioritized interventionsprioritized interventions, , that is based on the diagnosis and that is based on the diagnosis and psychosocial assessment of the client, to psychosocial assessment of the client, to address mental, emotional, behavioral, address mental, emotional, behavioral, developmental and addictive disorders, developmental and addictive disorders, impairments and disabilities, reactions to impairments and disabilities, reactions to illnesses, injuries, and social problems.” (Social illnesses, injuries, and social problems.” (Social work, consolidated laws, effective Sept. 1, work, consolidated laws, effective Sept. 1, 2004)2004)

Clinical PathwaysClinical Pathways

• A sequence or path that clinicians follow in making A sequence or path that clinicians follow in making assessment, triage, and clinical decisions.assessment, triage, and clinical decisions.

• Found increasingly useful within the medical field.Found increasingly useful within the medical field.• Evaluation of UCLA’s Asthma Pathway showed Evaluation of UCLA’s Asthma Pathway showed

substantial cost effectiveness and adherence to substantial cost effectiveness and adherence to medical standards (Chest, 1998)medical standards (Chest, 1998)

• Rady Children’s Hospital developed over 40 Rady Children’s Hospital developed over 40 pathways, starting with Asthma in 1994, domestic pathways, starting with Asthma in 1994, domestic violence in 2001, and TAP in 2005.violence in 2001, and TAP in 2005.

• TAP includes a pathway that directs triage, TAP includes a pathway that directs triage, assessment, referrals, and clinical interventions.assessment, referrals, and clinical interventions.

The therapeutic goal is to resolve the The therapeutic goal is to resolve the impact of a single or series of traumatic impact of a single or series of traumatic experiences to the child and their family. experiences to the child and their family.

Therapeutic decisions emerge from clinical Therapeutic decisions emerge from clinical and standardized assessment.and standardized assessment.

Chadwick’s Philosophy ofChadwick’s Philosophy ofTrauma TreatmentTrauma Treatment

3 Components of TAP3 Components of TAP

1.1. AssessmentAssessmentCreating a Unique Client PictureCreating a Unique Client Picture

2.2. TriageTriage

3.3. TreatmentTreatment

Assessment:Assessment:

Is the client appropriate for your Is the client appropriate for your Center and for the TAP Model?Center and for the TAP Model?

To get the full rich unique client To get the full rich unique client picture, gather information via:picture, gather information via:

Clinical InterviewsClinical Interviews Behavioral ObservationBehavioral Observation Standardized MeasuresStandardized Measures

Standardize your Assessment ChoicesStandardize your Assessment ChoicesWhat measures exist to help you know your client?What measures exist to help you know your client?

Domain Informants

Child Caretaker Clinician

Trauma History UCLA PTSD Index Caretaker Trauma- TSI

Clinical Interview

Symptom Presentation Trauma SymptomsTSCC, UCLA PTSD Index

Other Symptoms: YSR, CDI, BAIC

Trauma Symptoms CSBI, CDC, UCLA PTSD IndexOther Symptoms:CBCL

Clinical Interview/Observation

* Teacher can complete TRF

Relevant Contextual History

Family Dynamics FAM-III, FRI, FACESPeers YSR

Family Dynamics FAM-III, FRIParenting: PSIPeersCBCL

Clinical Interview/Observation

Developmental History Clinical InterviewIQ:WISC,KBIT, Stanford Binet

Clinical InterviewITSEA, BITSEA, ASQ

Clinical Interview/ ObservationDenver, Bayleys

Measurement ConsiderationsMeasurement Considerations

Psychometric Psychometric PropertiesProperties

Reliability and ValidityReliability and Validity Clinical CutoffsClinical Cutoffs

Sensitivity to ChangeSensitivity to Change

Feasibility IssuesFeasibility Issues Time to administerTime to administer Staff trainingStaff training Costs of using measuresCosts of using measures

LanguageLanguage

Multiple vs. Single Multiple vs. Single InformantsInformants

Real World ValidityReal World Validity

Clinical UtilityClinical Utility

Assessment Pathway ProcessAssessment Pathway Process

1.1. Core measures administeredCore measures administered

2.2. Problem areas identifiedProblem areas identified

3.3. Other measures are Other measures are administered to probe more administered to probe more deeplydeeply

Guiding Therapists via Assessment

Pathways integrated into assessment measures

Therapists’ Use of Therapists’ Use of Assessment Assessment Measures:Measures:

Guiding the assessment Guiding the assessment and providing feedback.and providing feedback.

How to make sense ofHow to make sense ofassessment results:assessment results:

Know what each measure assesses and Know what each measure assesses and applicable populationsapplicable populations

Have a general understanding of each Have a general understanding of each subscalesubscale

Examine the validity scales (if any)Examine the validity scales (if any) Use assessment results as an adjunct to your Use assessment results as an adjunct to your

clinical interviewclinical interview Clarify inconsistencies between assessment Clarify inconsistencies between assessment

results and clinical impressionsresults and clinical impressions

How to make sense of How to make sense of assessment results (cont.):assessment results (cont.):

Involve the parents and children in your Involve the parents and children in your interpretive processinterpretive process

Integrate results with clinical Integrate results with clinical impressions & think about how the impressions & think about how the results can be used to plan treatmentresults can be used to plan treatment

Don’t discount your clinical judgment!!Don’t discount your clinical judgment!!

Problem Solving: What Happens When the Problem Solving: What Happens When the Measures & Clinician Don’t Agree?Measures & Clinician Don’t Agree?

Critical Items

How do you discuss How do you discuss feedback with your feedback with your

clients?clients?

Parent and client feedback:Parent and client feedback:Dos & Don’tsDos & Don’ts

DODO:: Allow one therapy session to discuss results Allow one therapy session to discuss results

and give feedback and give feedback Elicit client feedback and impressions Elicit client feedback and impressions

regarding assessment resultsregarding assessment results Discuss results with parent and child to Discuss results with parent and child to

confirm clinical impressionsconfirm clinical impressions Address areas of concern not initially Address areas of concern not initially

revealed through clinical interviewrevealed through clinical interview Most important: Engage them in the process!Most important: Engage them in the process!

Parent and client feedback:Parent and client feedback:Dos & Don’ts (cont.)Dos & Don’ts (cont.)

DON’TDON’T:: Avoid discussing results with your clientsAvoid discussing results with your clients Act like the assessments are a waste of Act like the assessments are a waste of

time (because your clients will too!)time (because your clients will too!) Be afraid to share written feedback and Be afraid to share written feedback and

printouts with parents and childrenprintouts with parents and children Underestimate the ability of your clients to Underestimate the ability of your clients to

understand and appreciate your feedbackunderstand and appreciate your feedback

How to form your clinical How to form your clinical hypothesishypothesis

Consider all assessment feedbackConsider all assessment feedback Which family members need to be Which family members need to be

included in treatment? What are the included in treatment? What are the dynamics in the family?dynamics in the family?

Family and client buy inFamily and client buy in Consider the cause of distressConsider the cause of distress

Heuristics of Using theHeuristics of Using theClinical PathwayClinical Pathway

One skill builds upon another. One skill builds upon another. All spokes of the Trauma Wheel will be All spokes of the Trauma Wheel will be

addressed at some point during addressed at some point during treatment. treatment.

The length of time and intervention type The length of time and intervention type depend upon the unique client picture. depend upon the unique client picture.

The wheel is fluid – you move back and The wheel is fluid – you move back and

forth between spokes of the wheel.forth between spokes of the wheel.

Trauma Integration

Systemic DynamicsSkill Building

&Psychoeducation

Addressing Maladaptive Cognitions

AffectRegulation

Relationship Building

Culture

Child Development

The Trauma Wheel

Case Example:Case Example:

•Referral InformationReferral Information•Interview with Child & FamilyInterview with Child & Family•Standardized Assessment Results Standardized Assessment Results •Consider family buy-in & needs before Consider family buy-in & needs before making treatment decisionsmaking treatment decisions•Re-Assess Re-Assess

On-going Re-assessmentOn-going Re-assessment

Weekly interviews/updated goalsWeekly interviews/updated goals Progress notesProgress notes Supervision Supervision Follow-up standardized measuresFollow-up standardized measures

Must use the same measures for each time period Must use the same measures for each time period (to measure change over time)(to measure change over time)

Can add measures over time (once added must Can add measures over time (once added must continue to administer added measure to assess continue to administer added measure to assess change over time).change over time).

Symptom Change

Over Time

Trauma Assessment Pathway Model (TAP): At a Glance

Initial Screening Process

Triage

Assessment:Clinical Interview and Standardized Measures

Integrate Assessment InformationForm Unique Client Picture

Narrow the Clinical Focus Select Symptom Domains

Hypotheses/Prioritize

Treatment PathwayGuides treatment decisions and the use

of the Trauma Wheel

Reassess:Weekly interviews, update goalsSupervisionFollow-up standardized measures

Continue TreatmentFollowing the Treatment

Pathway

Refer out

Refer to a specialized program if needed

Termination

Trauma Wheel

Establish Treatment Goals

You’re the ExpertsYou’re the Experts

What are some basic assumptions you What are some basic assumptions you may have about traumatized clients?may have about traumatized clients?

How have you validated those How have you validated those assumptions?assumptions?

What is your experience with using What is your experience with using assessment measures?assessment measures?

ResourcesResources

www.ChadwickCenter.orgwww.ChadwickCenter.org (Chadwick) (Chadwick) www.nctsn.netwww.nctsn.net (National Child Traumatic (National Child Traumatic

Stress Network)Stress Network) www.musc.edu/cvc/www.musc.edu/cvc/ (TF-CBT on-line and (TF-CBT on-line and

OVC guidelines)OVC guidelines) www.cachildwelfareclearinghouse.orgwww.cachildwelfareclearinghouse.org

Contact InformationContact Information

Alicia Gilbert, PhDAlicia Gilbert, PhD

858-966-8682858-966-8682

agilbert@rchsd.orgagilbert@rchsd.org

Robyn Igelman, PhDRobyn Igelman, PhD

858-576-1700, ext. 3211858-576-1700, ext. 3211

rigelman@rchsd.orgrigelman@rchsd.org