How Prepared are MFT Trainees to work with Child Sexual Abuse?

Colleen Friend, PhD & Vasavi Charathram, MS(Counseling) - California State University

4 Broad Themes of the MFT Trainees’ Qualitative Study

• Theme 1. Inadequacy of course work• Theme 2. Availability and inadequacy of

practical training • Theme 3. Preference for specific techniques• Theme 4. Recognition of need to have

experience in working with CSA at different stages of MFT trainees’ development and education.

Key pointsChildren with developmental disabilities are more at risk of sexual and physical abuse than the general public

– Studies vary, but consistently show that there is a link between children with disabilities and abuse (Sobsey, 1991)

– 1 in 3 children with an identified disability for which they receive special education services are victims of some type of maltreatment.

Developmentally Sensitive Applications of Trauma Focused-Cognitive Behavioral Treatment

Set ground rules at the onset and modify as needed - and have the child practice!

Short, simple sentencesAvoid shifting words (pronouns & unclear references)Do not finish sentences for the childEnsure a clear transitionRepeat what victim says to clarify what was saidSexual knowledge inventory

Visual, Auditory & Kinesthetic Stimulation Parents need to become Co-Regulating Agent for

child’s behavior Vigilance Symptom - safety can be a trigger too! Watch for responses that ‘aimed to please’ Avoid “yes/no” questions if possible First try open-ended questions to see if child can

respond in narrative If the child does not seem to understand questions

or is unable to provide narrative, then proceed to direct questions, multiple choice, or yes/no questions

Use of sensory focus questions How did that make you feel? Tell me what you heard? Tell me what you saw? Tell me what you felt?

Developmentally Sensitive Applications of Trauma Focused-

Cognitive Behavioral Treatment

Soft tone of voice and face

Organize (time management, regularity)

Offer choices

Touch and physical proximity

Hear what child is anxious about

End and let go!

The Interview

• Use of tools: drawings, dolls, photographs, mood charts

• Pace the interview• Allow for long pauses -

processing issues• Be careful not to interrupt• Be aware of interview stress -

use breaks• Shorten interview - focus on

questions to essential information rather than peripheral details

• Consider multiple interviews - scaffolding

Forensic Interviewing with Pre-School Childrenby Jackie Block-Goldstein,MSW

Shift your goal from

Prosecution

to Protection !

1 in 4 girls is

victim of sexual

abuse

1 in 6 boys

is a victim of

sexual abuse

At 27 months and younger, the

child is unable to express the

narrative verbally

At 36 months and older, the

child is able to give a

narrative

Forensic Interviewing with Pre-School Childrenby Jackie Block-Goldstein,MSW

2 Types of

Memory

Procedural

Explicit

Free Drawing - best because it

aids the narrative

Anatomical drawings, 2-3 years and older

Anatomical dolls - endorsed by APRI when used properly, 4 years old and older

Forensic Interviewing with Pre-School Children

‘Good’ touch vs. ‘Bad’ touch, now ~ ‘Touch’ Inventory

Picture Test no longer used because it is time consuming

Prepare the young child before the interview, do your work in familiarizing yourself with the details

Rapport building with the child

Developmental screening of the child

Forensic Interviewing with Pre-School Children

• Scaffolding Procedure

• Explore Alternative Hypothesis

• Standard Structural Protocol

National Children’s Advocacy Center [NCAC] Model Extended Forensic Evaluation, since 1990s

– Philadelphia Model very similar

What is Project Kariñu?

¥ Kariñu is an early childhood initiative usinga Public Health approach that will servechildren age’s birth through five years.

¥ Kariñu will provide screening, assessment,mental health promotion and consultation,family education, and individualized servicesand supports.

Assessment: Ages & Stages

Questionnaire 3rd Edition

21 Questionnaires used to assist with screening and monitoring children

from 1 thru 66 months of age.

Designed to screen young children for

developmental delays

Assessment: Ages & Stages Questionnaire -

3rd Edition

Each questionnaire contains 30 developmental items written in simple and straight-forward language.

The items are organized into five areas:

1. Communication 4. Problem Solving2. Gross Motor 5. Personal-Social3. Fine Motor

“ Sample “

Assessment : Mental Health

Ages & Stages Questionnaire : Social-Emotional

Used in conjunction with ASQ-3

Seven Behavioral Areas:

1. Self-Regulation 5. Autonomy 2. Compliance 6. Affect and3. Communication 7. Interaction4. Adaptive with

Functioning People

“ Sample “

Human

Figure

Drawing

Female, 5 yrs

Additional Inferences ~

ChildSexual

BehaviorInventoryQuestionnaire

9 Domains of CSBI:- Boundary Problems- Exhibitionism- Gender Role Behavior- Self-stimulation- Sexual Anxiety- Sexual Interest- Sexual Intrusiveness- Sexual Knowledge- Voyeuristic Behavior

Developmentally Related Sexual Behavior - Reflects level of age- and gender-appropriate behavior

Sexual Abuse Specific Items- SA Hx after controlling for effects of maternal education and family income.

ChildSexual

BehaviorInventoryQuestionnaire

Child Sexual Behavior Inventory Score Sheet

[CSBI]

*Developmentally Related Sexual Behaviors***

**Sexual Abuse Specific Items

59 and below Nonsignificant

Trauma Symptom Checklist for Young Children

TSCYC

TSCYCQuestionnaire

TSCYCQuestionnaire

The Application of Parent Child Interaction

Therapy (PCIT) for Traumatized Children

• Designed to treat children age s 2 through 7 years exhibiting disruptive behaviors

• Work with caregiver and child together

• Intervention done in ‘real’ time

The Application of Parent Child Interaction Therapy (PCIT) for Traumatized Children

Two Phases:1. Relationship Enhancement

2. Strategies to Improve Compliance

PCIT Phase One: Relationship Enhancement

The focus is on enhancing the parent-child Interaction, also known as the Child-Directed Interaction, or CDI

– Shift attention to child’s desired behavior– Focus on recognizing and praising positive child

behavior– Avoid controlling and negative parent behaviors– Shape child behavior through selective attention

PCIT Phase 2: Strategies to Improve Compliance

The focus is on improving child compliance, often described as Parent-Directed Interaction, or PDI- Focus on giving clear and direct commands- Make sure parent follows through with commands- Structure child consequence for non-compliance-Teaching an effective time-out sequence- Develop a mastery of skills related to managing child’s non-compliance- Mastery of PDI skills signals end of treatment

Trauma-Focused Cognitive Behavioral Therapy (TF-CBT)

for Traumatized Children & their Families

Cognitive Triangle : Thoughts, Feelings & Behaviors

Doing

Feeling

Thinking

Trigger

Trauma-Focused Cognitive Behavioral Therapy (TF-CBT)for Traumatized Children and their Families

PRACTICE Components - Skill-building - The Narrative Unfolds - Personal and Body Safety

‘Pair positive, healthier emotions with traumatic memory

to make it more approachable.’

(TF-CBT)

P sycho Education & Parenting Skills

R elaxationA ffective Expression & Regulation

C ognitive CopingT rauma Narrative Development & Processing

I n vivo Gradual ExposureC onjoint Parent-Child SessionsE nhancing Safety & Future Development

A Pilot Study Comparing TF-CBT to TF-Integrated Play

Therapy

3 components of PTSD : Re-Experiencing, Avoidance, Hyperarousal

Are certain children better matched to certain kinds of therapy?

Trauma-Focused Integrated Play Therapy TFIPT

Combination of

directed & nondirective approaches

to advance structured,

goal-oriented therapy

Attends to developmental needs

of young children

Post traumatic play

appears to be child’s natural way to introduce gradual exposure, narrative formation and

trauma processing

DiagnosticReferences

Diagnostic and Statistical Manual, Version IV, Text Revised [DSM-IV-TR] [DSM-V, May 2013]

Diagnostic Classification of Mental Health & Developmental Disorders of Infancy and Early Childhood: Revised Edition [DC:0-3R]

DSM-IV-TR Multi-axial Assessment

Axis I Clinical DisordersOther Conditions That May Be a

Focus of Clinical AttentionSexual Abuse of Child (Victim)

Axis II Personality DisordersMental Retardation

Axis III General Medical ConditionsAxis IV Psychosocial & Environmental ProblemsAxis V Global Assessment of Functioning

Diagnostic Classification

of Mental Health & Developmental

Disorders of Infancy and Early Childhood: Revised

Edition

[DC:0-3R]

DC: 0-3R Multi-axial Assessment

Axis I: Clinical DisordersOther Relationship

DisturbancesAxis II: Relationship ClassificationAxis III: Medical & Developmental

Disorders and ConditionsAxis IV: Psychosocial StressorsAxis V: Emotional & Social Functioning

Thank you for helping us to heal!