The Child and FamilyTraumatic Stress Intervention:

Implementing an Evidence-BasedEarly/Acute Intervention

in Child Advocacy Centers

PRESENTERS

Steven Marans, MSW, Ph.D.‒ Harris Professor of Child Psychiatry and Professor of

Psychiatry‒ Director, Childhood Violent Trauma Center,

Yale Child Study Center‒ Yale University School of Medicine

Carrie Epstein, LCSW-R‒ Assistant Professor‒ Director of Clinical Services and Training,

Childhood Violent Trauma Center, Yale Child Study Center‒ Yale University School of Medicine‒ Consultant, Safe Horizon, Inc.

Nancy Arnow, LMSW‒ Vice President‒ Child Advocacy Centers and Mental Health Treatment

Programs‒ Safe Horizon, Inc.

CFTSI: What Is It?

Brief (4-8 session) evidence-based early intervention model for children following a range of potentially traumatic events (PTE)– After exposure– After disclosure of earlier sexual or physical

abuse

Children aged 7-18 years old

Goals of CFTSI

CFTSI aims to:

Reduce traumatic stress symptoms and prevent chronic PTSD

Improve screening and initial assessment of children impacted by traumatic stress

Assess child’s need for longer-term treatment

Mechanisms of CFTSI

CFTSI works by:

Increasing communication between caregiver and child about child’s traumatic stress reactions

Providing skills to family to help cope with traumatic stress reactions

Assessing concrete external stressors (e.g. housing issues, systems negotiation, safety planning, etc.)

CFTSI: Filling a Gapin Available Interventions

CFTSI:

Fills a gap between acute responses/crisis intervention and evidence-based, longer-term treatments designed to address traumatic stress symptoms and disorders that have become established

Capitalizing on Protective Factors

Family and social support are best predictors for good post-trauma outcomes– Primary caregiver/s are central to CFTSI

Improves support through improving communication:– Helps child communicate about reactions and

feelings more effectively – Increases caregiver’s awareness and

understanding of child’s experience

CFTSI provides skills to help children and families cope with and master trauma reactions

Recovery through Regaining a Sense of Control

CFTSI:

Replaces chaotic post-traumatic experience with:– Structure– Words– Opportunity to be heard by caregiver

Uses standardized assessment instruments to:– Structure discussion about symptoms– Increase symptom recognition and communication

about them

Provides skills and behavioral interventions

Increases control through symptom reduction

The CFTSI Model

CFTSI: What and How?

Session 1 – Meeting with Caregiver• Provide psychoeducation about trauma and trauma symptoms• Assess caregiver’s and child’s trauma symptoms• Address case management and care coordination issues

Session 2, Part A: Meeting with Child• Provide psychoeducation about trauma and trauma symptoms• Assess child’s symptoms

Session 2, Part B: Family Meeting - Key part of intervention• Begin discussion by comparing caregiver and child’s reports about trauma symptoms

• Identify the specific trauma reactions to be the focus of behavioral interventions and introduce coping skills

CFTSI: What and How?

Session 3: Family Meeting• Praise and support communication attempts• Re-administer measures to assess levels of distress and increased awareness• Practice coping skills(s), support efforts

Session 4: Family Meeting/Case Disposition• Follow same format as Session 3• Review progress made and identify any additional case management or treatment needs

Possible Additional Sessions• May require 1 or 2 additional individual sessions with caregiver(s) or child due to a range of issues

CFTSI: An Evidence-based ModelListed in:

NCTSN list of evidence-based treatments

California Evidence-based Clearinghouse for Child Welfare

NREPP (National Registry of Evidence-based Programs and Practices (soon)

Randomized Control Trial: Results

CFTSI versus 4-session psychoeducation/supportive comparison intervention

Sample size = 112

Participants recruited from:– Forensic Sexual Abuse Program– Pediatric Emergency Department– New Haven Department of Police Service

Funded by SAMHSA

Sample Demographics(Sample Size = 106)

Intervention N=53

24 Boys 29 Girls Mean Age=12; SD=2.8 Mean # Traumas=6.1;

SD=2.7

Comparison N=53

21Boys 32 Girls Mean Age=12; SD=2.7 Mean # Traumas=6.6;

SD=2.4

Nature of Trauma

Sexual Abuse21%

Assault20%

MVA24%

WV/Threats22%

Animal Bite5%

Injury8%

Children Who Received CFTSI Were 73% Less Likely

to Meet Partial or Full Criteria for PTSD

8872

93

44

0

20

40

60

80

100

Baseline 3 Mos FU

Perc

ent o

f you

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ComparisonCFTSI

*

*p<.05

Adapting CFTSIfor Child Advocacy Centers (CACs)

Implementation of CFTSI with sexually and physically abused children seen in CACs

Initial collaboration with Safe Horizon in New York City

Further dissemination to additional CACs nationally

Overview of Safe Horizon

Safe Horizon is the nation’s leading victim assistance organization, moving thousands of victims of violence and abuse from crisis to confidence each year

Our mission is to provide support, prevent violence, and promote justice for victims of crime and abuse, their families and communities

We have 35 years of experience in expert service delivery

Safe Horizon’sChild Advocacy Centers

Safe Horizon is the only organization in the country to operate four and soon to be five fully co-located, nationally accredited CACs in an urban setting

Each year, our CACs investigate and respond to over 4,000 cases of sexual abuse and/or severe physical abuse

Where We Were: 2006-2007

Environmental Factors: – 148% increase in CAC volume following a tragic, highly

publicized child fatality– Flat and diminishing CAC funding

Organizational Factors:– Strategic Plan: Move to standardize service delivery and

implement evidence-based practices whenever possible – CAC Vision: To provide immediate, expert victim

advocacy & therapeutic services to every child victim and impacted family walking through the doors of our CACs

CAC Practice:– Eclectic CAC services in response to complex and

multiple needs of clients

Safe Horizon-Yale Partnership:

National search for a trauma-focused, brief, evidence-based treatment

Development of a flow chart illustrating how a potential CFTSI case progresses through a CAC

Development of inclusion/exclusion criteria

Development of scripts for introducing CFTSI to families

Translation of CFTSI into Spanish

Creation of audio versions of informational handouts

Where We Are Now:

Have successfully adapted and sustained CFTSI at our four CACs for over 5 years

Have completed over 730 CFTSI cases– Children feel better; Caregivers have learned

skills to help their children feel better– Staff feel more effective & reduced burnout– MDT partners feel more hopeful – Funders are very interested in reduction of

trauma symptoms- importance of data!

Sustaining CFTSI Over Time:

Importance of data-evaluation results

Strong organizational leadership & agency-wide support

Recruitment changes & Ongoing training

Expert Monthly Consultation Calls– Rotating case presentations with all CFTSI

providers & leadership– With Clinical Directors

Monthly tracking of key CFTSI metrics

Evaluation of CFTSI in CAC Setting

Evaluation Results

Results from 12-month evaluation conducted in Safe Horizon’s Child Advocacy Centers

Sample Size = 134

Trauma type: sexual and physical abuse

Statistically significant reductionsin symptoms (p<.001)

Symptom severity goes from

clinically significant levels to below clinical levels

Change in PTSD Symptoms Following CFTSI (N=134)

Pre-Tx Parent Post-Tx Parent Pre-Tx Child Post-Tx Child0

5

10

15

20

25

17.57

9.58

21.68

10.87

PT

SD

Sym

pto

m S

ever

ity

Caregiver Satisfaction Survey

Completed with caregivers following final CFTSI session

N=63

If you had a friend dealing with a similar situation, would you suggest

that s/he try CFTSI?

Did you learn about trauma and how it may affect your child and

family?

Did you and your child learn about ways/skills to help your child feel better and make the problems and/or reactions your

child was having happen less often?

Future Directions

CFTSI Treatment Applications

Current:–CAC setting–Children in foster care

In development:–Domestic violence shelter setting–Young children (aged 3-6 years)–Physically injured children–Military families

CFTSI:Dissemination and Spread

National trainings

Learning collaboratives

Train-the-Trainer program

Implementation of CFTSIin a CAC Setting:

A Brief Case Presentation