TF-CBT Test Study Guide QUESTIONS WITH COMPLETE 100% VERIFIED SOLUTIONS 2024/2025, Exams of Medicine

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TF-CBT Test Study Guide

QUESTIONS WITH COMPLETE 100%

VERIFIED SOLUTIONS 2024/

What is TF-CBT? evidence-based, conjoint child and parent/caregiver psychotherapy model for children and adolescents who are experiencing clinically significant emotional and behavioral difficulties related to traumatic life events they have experienced. TF-CBT is a relatively brief (typically 12-20 sessions). For ages 3-17 y/o and their parents. What are the goals? enable children and youth who have experienced serious traumatic events, and their supportive caregivers, 1) to learn effective skills to cope with trauma-related emotional and behavioral problems, 2) to face and resolve those problems in a safe and therapeutic way, and 3) to effectively integrate their trauma experiences and help them move on with their lives in a safe and positive manner. What are the characteristics of TF-CBT

• structured (not just pt talking and directing sessions)
• truama focused
• short term
• goal to address trauma related difficulties
• play therapy only sees child, family therapy sees them both together every time. CF-CBT will see child individually, parent individually, and then together for a few sessions. Whats the rationale for TF-CBT? If you develop fear, avoidance or other problems after trauma, you have to face your difficulties and develop coping mechanisms for those problems. You also need to realize the connection between your problems and the trauma in your past. By including a caregiver in the process you have some support through the different phases What are the phases?

1. Stabilization: Comprised of "PRAC" components with gradual exposure. You start applying new skills to trauma related sxs.

• Gradual exposure: develop skills while building on the connection between the trauma and the need to develop these skills. The caregivers skills are developed throughout as needed to help manage the childs behavior.

2. Truama narrative: "T" component. gradual exposure with caregiver and child processing their reactions.

• Trauma narrative: Once the skills are built, then a trauma narrative is done (talking about the trauma) in order to face the experience instead of avoiding it

3. Integration/ Consolidation: includes In Vivo Matery of trauma reminders, conjoint sessions, and enhacing future safety and development components ("ICE").

• Integrating: Integrate what you have done to face the truama and using those skills to move on. Length: 12-25 sessions, the sessions are split evenly between the phases (1/3 each) Goal: develop resiliency and move on Note: Gradual exposure and Parenting skills are taught and done throughout all sessions Who is TF-CBT for? 3 - 18 y/o, all children demograpics with any traumatic experience Note: if experiencing 4 or more PTSD sxs they will really benefit from TF-CBT. Can still benefit even after co-morbidities develop (ADHD, ODD, Conduct disorders etc.) Is a caregiver required for TF-CBT? No, but it is best if there is one. If one isn't there then substantial parts of tx aren't done. When would TF-CBT not be done? If a child isn't having truama related problems (highly resilient with good support systems) or if there are severe cognitive challneges (can be used with mild intellectual, cognitive or developmental problems if they can engage in cognitive therapy) such as autism because they cannot participate in cognitive therapy. What problems need to be addressed before starting TF-CBT? Imminent safety (active SI, abusive guardian etc.) Severe disruptive/agressive behavior problems Active problematic substance use (infrequent use wihtout interfening in daily functioning is okay) Guiding principles of TF-CBT CRAFTS:
• components based
• respectful of cultural values
• adapatable and flexible
• family focused
• therapeutic relationship is central
• self efficacy is emphasized How often is the pt and caregiver seen conjointly? About half the sessions, in order to improve the support for the child.

TF-CBT tx components PRACTICE:

• Psychoeducation/ Parenting skills: instill hope, normalize the truama and behaviors, teach skills to help parents with behaviors of child
• Relaxation: skills to help with fear and anxiety
• Affective Identification and Regulation: help understand and regulate negative feelings (both pt and caregiver)
• Cognitive coping: explain connections between thoughts, feelings, and behavior. Develop skills to generate alternative thoughts, important for later cognitive processing.
• Trauma narration and processing: guide child through trauma story to try and help manage related thoughts/feelings through gradual exposure (do this in small doses).
• In Vivo Mastery: means "real life", if fears from trauma are to non-dangerous things (e.g. rooms in house) then exposure activities are done to overcome fears.
• Conjoint Child-Parent Sessions: share truama with caregiver (beforehand, prep caregiver to ensure validating experience for child).
• Enhancing Safety and Future Development: enhance family communication and childs safety skills to minimize risk for future vicitmization and enhance self-competence. How is the TF-CBT delivery in respect to time spent with the child and caregiver? Both are involved in every session. Typically most sessions you will spend time with the child individiually, parent individually, then together. How often do you involve gradual exposure? At every session, however not constantly throughout the session. Some aspect of the truama is referred to and reviewed in every session. Then you teach relaxation skills and apply those skills to reduce tension while reviewing that aspect. Or during affect identification and regulation you identify emotions related to that aspect of the trauma and process through those emotions and try to manage those emotions. Whatever step you are on, you review a piece of the trauma narrative and involve another component to help process. Session frequency and length weekly tx sessions, 60-90 mins each (however, if not possible, it can also be done in 45-50 minutes and more frequently each wk [2 sessions/wk] but never less frequently [1 session/2-3 wks]). Found to be effective in 8-25 sessions but typically completed in 12-20 sessions Note: if caregiver isn't present then its not as effective, if not taken as often as its supposed to then its not as effective. This is because a significant part is taken out or you aren't intense enough to build up all the skills we try to teach in TF-CBT (weekly is needed). What is Tx fidelity?

• skillfully delivered
• as it was designed
• 2 components: adherence and competence Note: the higher the level of fidelity, the better the outcomes. Adherence: children with trauma and PTSD sxs, involve caregiver, meet weekly, follow PRACTICE components, spned 1/3 of sessions on each phase, complete in 12-20 sessions Competence: do procedures correctly Note: you need to measure fidelity and outcomes at begining, half way, and at end. What do you provide information about during psychoeducation?
• Different types of trauma
• trauma sxs
• the course of TF-CBT Note: psychoeducation is the first module and you come back to it as needed Why is psychoeducation important for the child? They often believe inaccurate things because they've been deliberately given incorrect information. Psychoeducation is one of the best ways to help detraumatize because they will receive correct information. How does psychoeducation get the child to open up? When you talk about the type of traumatic experience and normalize it by using general terms there is less anxiety related to talking about the trauma and they often will start to talk about their own experience. This is how gradual exposure starts in psychoeducation. How do you do psychoeducation?

1. Review your assessment findings: go over what was revealed about the childs functioning (with the parent, without the child present, unless they are older children). Focus more on how the child's behavior has been affected and not on the diagnosis. This helps you form a goal/focus for therapy and connects the child's sxs to the experience of trauma.
2. Provide an overview of Tx: Explain what will happen during tx, even if they've had other kinds of therapy before. Explain that they will learn ways to cope with the sxs and problems they've been experiencing, that the caregiver will be involved as well, and if everything goes according to plan tx will be 3 - 4 months (invite to commit to 12-18 sessions). Then convey optimism for recovery.

3. Neutral Narrative/ Baseline Trauma Narrative: get a baseline at start of tx to see what the child can share about the trauma, to do this get the child to give a narrative from a non-trauma (neutral or positive) event (B-day party, soccer game etc.). Assess the level of detail given (try to get them to tell you as much as they can about it). Then ask about the trauma, if they're reluctant that's okay (don't push them). You just want to know what their baseline is at with sharing the truama.
4. General education about abuse and trauma: give common reactions to trauma (tailored to child by first asking what the child knows about their type of trauma). A question and answer game format is best where the child gets points for answering questions right (be generous and praise for partially correct responses), correct and add developmentally appropriate information to answers.

• Examples: What is sexual abuse? How often do things like this happen? Why does this type of truama happen? Why do you think it happened to you?

5. specific information about the traumatic events: provide information about the trauma (this is how gradual exposure starts with psychoeducation)

• example with sexual abuse: Explain that often abusers have sexual feelings for children which most people don't have so they choose to do something wrong and they may use tricks or fear to get children.
• example with physical abuse: explain what appropriate parental disciple is, explain psychological abuse (excessive yelling, ignoring, or name calling) is commonly apart of physical abuse but this isn't an indication of their worth as a person.
• example with witnessed violence: explain its not their fault their parents were violent with each other and its not okay to hand disagreements in that way. Tips for engaging family during psychoeducation Ask about pt/family's perspective" does the family see it as a private matter? Something to be ashamed of? If its traumatic grief, what do they believe abotu what happens when you die? What they think about mental health tx: What do they think is causing the childs sxs? Do they think tx lasts for years or 1-2 sessions to fix? How active do caregivers need to be? How open to trying new things will they be? Instill hope: many think they will never overcome this, project confidence that childs future won't be contrained by whats happened. General principles: keep language simple and direct, don't use psychological jargon, include family members in tx planning and psychoeducation activities, use pictures for complex ideas. If dealing with younger pts (3-4) psychoeducation is geared towards parents and kids are mostly just reassured that their reactions are normal. For middle childhood be careful not to teach too much, because they can only

sit and listen for so long. For adolescents they will have the most questions about prevalence rates, sxs ect. When things go bad:

• sometimes just psychoeducation causes severe anxiety, in these situations start with stress management tx and skills before doing psychoeducation.
• If parents don't want you to talk about sex you should:

1. provide a rationale for discussing it
2. find basis for their concerns
3. explain you will respect their value system and only provide information thats developmentally appropriate that falls within their comfort zone and include the parents in the education sessions.
4. If they still refuse respect their wishes.

• If children tells you you're wrong with the content you've shared, don't battle. Address their questions/ concerns, if they continue to argue let it go, you'll have other opportunities. What is important in the parent psychoeducation?
• make connections between childs truama and sxs and interventions
• explain what truama cues are and how they produce sxs
• explain the goal of TF-CBT is to reduce effects of truama cues
• give overview of tx model to get parents on board
• note the importance of early tx to prevent long term problems and the importance of talking directly about the trauma to help cope with their experiences
• explain the child will be taught skills to cope with discomfort and talking about trauma is done slowly then explain the parents role and that the tx model emphasizes them working together as a team
• at any time they can ask questions and make suggestions
• also educate them about the specific type of trauma and its prevalence, directly addressing parents fear of long term damage due to trauma (especially with sexual abuse)
• with sexual abuse involve the parent in education so the child gets accurate info about healthy sexuality and also parents get communication about sexual issues and can implement their values. Child behaviors related to Trauma exposure
• anxiety
• nightmares
• poor sleep
• avoidance behavior
• distruptive, aggressive, or non-compliant behaviors Note: these problems may be present before trauma but may worsen after trauma due to reactions to

trauma cues or as a result of learning inappropriate ways of expressing strong emotions from perpetrators. Behaviors may also be due to sxs of trauma like poor sleep. What is a common mistake parents make with children who have had trauma? They feel they can't discipline their children because they feel guilty that they experienced the trauma or they feel guilty for disciplining their child because they know the behavior is due to the trauma. The issue here is by not disciplining your child you reinforce the problematic behaviors. They may also not discipline because they don't know how to correctly do this and need education on how to address certain behaviors at different ages/ developmental stages. When educating parents on parenting skills what is the guiding principle? Not one skill will work for everyone so we provide them with a tool kit, this includes:

• praise
• selective attention
• timeout
• use of behavior charts Anything can be used that can be practiced in a session, parents have to know how to use them well before they try to implement them. Parenting skills toolkit Praise: usually parents think they praise their kids more than they actually do. They tend to criticize for bad behaviors more than they praise for good. Its even more common in families with more family conflict. Don't assume parents know how to praise properly. Instruct to: praise specific forms of behavior, label the praise (instead of "Nice work!" be more specific "You did so good with ____!"), provide praise ASAP after desireable behavior occurs, be consistent, avoid complicating praise with negative add-ons ("You did a great job getting your hw done before dinner" don't add on, "Why can't you do that more often?"), use enthusiastic tone when praising.
• Note: this is the main skill and should be the focus, don't try other skills until this is being used Active ignoring: this is best used in combination with praise. Priase for the good but when bad but non- dangerous behavior happens don't react to it. By combining this with praise for good behavior it shapes healthy behavior. when ignoring you should: don't respond during and immediately after the behavior, avoid verbal or emotional reactions, eye contact, facial expression, or any other form of communication, never ignore unsafe behavior that could cause injury, use praise when they accept redirection or a negative response ("Thank you for understanding that now is not a good time for ice cream. You're a good listener!").
• Example behaviors to ignore: Defiant or angry statements directed at parent, nasty faces, eye rolling, or smirking at parent, mocking, taunting, or mimicking parent.

Use Timeout: the purpose of timeout is to interrupt the child's undesirable behavior and punish for the unwanted behavior by depriving the child of attention. Timeout has to be in a quiet, understimulating room, and should only last for a few minutes. The timeout procedure has to be as predictable for the child as possible (they understand what kinds of behaviors result in timeout, where they stay during timeout, and how long the timeout will last). Parents have to carry out timeouts according to rules (If timeout is 3 minutes and they behave well for 2 minutes and ask to be let out, don't change the rules due to good behavior. Has to stay 3 minutes, unless the child starts to respond to timeouts quickly then the rules for timeout may be changed for future timeouts). There is not recommended time for how long a timeout should last, but once timeout starts all behavior is ignored from the child unless its unsafe behavior or it allows them to escape from timeout. Only use timeout for kids under 11-12 y/o. Behavior charts: select only 1 behavior at a time for change, discuss with them how to earn a star, sticker, or symbol on the chart for positive behaviors, involve the child in decisions about what the reward will be, add up stars/stickers/ symbols and give rewards daily for younger children or at least weekly for older children, give stars and rewards consistently. How to role play with parents Start with having the parent play the role of the child and you play the role of the parent. Once you discuss how it went and they have an idea of what to do, switch roles. Once they demonstrate they know what to do, observe the parent practicing these skills during brief structured parent child interaction time. How do you follow up on parenting skills and why do you follow up? If they apply the skill incorrectly they will abandon the skill before it has had time to work. When they do this they lose fail in your ability to help them and provide direction. This is why you have to teach correctly and have them demonstrate. When they return for follow up appointments it is important to review one skill for a few minutes (ask about how its going and then role play again, do this throughout TF-CBT even during sessions where you work on other components). What cultures have which types of parenting typically? Hispanics: active

• has respect for authority in this culture, may make them reluctant to report if its not working out. Address this by saying beforehand "While I'm an expert on trauma tx, you're the expert on your child." Emphasize change takes time, we'll walk through each step together. Invite them to share honest views of how its going by asking open ended questions or ask for examples of what did and didn't work. AA: active Asians: passive
• has respect for authority in this culture, may make them reluctant to report if its not working out. Address this by saying beforehand "While I'm an expert on trauma tx, you're the expert on your child." Emphasize

change takes time, we'll walk through each step together. Invite them to share honest views of how its going by asking open ended questions or ask for examples of what did and didn't work. Active = punishment vs rewards Passive = not as involved and expressive Note: assess parenting styles with open eneded questions first and then apply parenting skills as they fit to their parenting style. Don't try to alter their style (unless its unsafe for the child). If their culture involves other family members or religious leaders in the upbring of the child then include them in parenting skills training. How do you address parents who believe kids should do what they say just due to their authority as the parent? Fram the behaivor management interventions as helping to increase the child's respect for their parents (AEB child's improved behavior). These parents may view ignoring or timeouts too mild. Remind them these are what work in the long run. Their view of punishment isn't what the kid views as punishment, timeout is punishment. Refer to the chair as the "punishment chair" or "Silla de castigo" (spanish). Remind them that physical punishment is shown to be ineffective by research and may be actually illegal (depending on the state). Physical punishment has a much higher risk of negative outcomes. Try to point out carefully that what they've been doing isn't working and so trying something new out is necessary just to see what happens. What can you do if families have limited resources (space for timeout, finances for behavior chart, or time to implement)?

• brianstorm ideas for non-purchased rewards with parent for good behavior with family (extra time with friends, bring friend home to play, being excused from chore, participate in extracurricular activities)
• if theres multiple children in the house brainstorm with parent trusted friend who can watch other child(ren) while they spend time-in with the child (while they're in timeout) or you can just have the child face away from the family as a timeout. How to discuss behavior management strategy implementation with children based on developmental stage Early childhood: keep strategies simple and straightforward. focus on 1-2 behaviors at a time rather than tackling all problem beheaviors. Don't involve multi-step directions (Put toys away, put pjs on, then brush your teeth) just give 1 step direction (Put your PJs on) then after that give another direction. Be sure to give praise after each completion of the direction. Identify as many opportunities with the parent as possible for playful interactions with their children. Middle childhood: more active role in designing behavior management plans. Give children a choice in type of reward they can earn. They can even decorate a personalized reward chart. If in school,

coordinate with teachers and guidance counselors on behavior management plans to improve behavior across all settings. Adolescence: Trauma distrupts family routines/rhythms which usually takes a hit anyways during adolescence. Help them find time for family activities inside and outside the home (focus on free activities). Help parents and teens to compromise on house rules, responsibilities, and consequences. Taking time to listen to a teens preference goes a long way and can result in a win-win situation. Teach how to communicate with each other by using I-statements, reflective listening, and paraphrasing. Strengthen caregivers validation skills, ensure they can differentiate validating emotional reactions from endorsing behavior or choices. Validation is affirming the teen as a person and that they are having their feelings and the parent is listening and concerned and will try to help them. Do this before you try to problem solve, often validation allows the teens to solve their own problems better and increase their self- confidence. Help the parent provide opportunities for the teen to be more independent without dropping the reins completely (monitoring their teen vs hovering constantly), encourage parents to stick to their guns especially when theres push back in regards to using consequences consistently. High risk behaviors have to be handled with clear consistency regardless of age. Whats the Zap Trap? When parents criticize while giving praise "Great job-was that so hard?" What usually happens the first time active ignoring is used? Behavior worsens for the first few times it is used (if throwing blocks, may throw harder and closer to the parent, or temper tantrums may get even more severe). When the child sees the parent is unfazed and they can't get the attention they are trying to get the child will eventually learn that behavior doesn't get them attention and will stop doing the undesirable behavior. This takes a huge amount of patience from the parent and the parent also needs praise from us. This is why we do role plays because parents need prepped for the amount of patience required. What happens if a parent isn't consistent?

• for consequences they stop taking the parent seriously and lose authority
• for rewards if not given when child achieves the goal the child loses trust in behavior chart and rewards won't work in the future How do you handle parents that say "I've tried it all and nothing works"? Parents will be cynical toward "so-called expert" parenting strategies and will be difficult to deal with. Ask them to explain what they've tried and how they implemented it. Usually there is a problematic application of technique (not following through, failure to stick it out through burst of bad behavior, or talking/lecturing during timeout). If you find these don't have a gotcha moment ("well no wonder it didn't work"), collaborate and suggests enhancements to what they've tried. Reset their expectations as well, nothing works perfectly and theres no one solution and they may have moments of weakness, this takes a huge amount of patience.

Relaxation Strategies management for tension when feeling anxious/ distressed: controlled breathing and progressive muscle relaxation less conspicuous activities: listening to music, mindfulness, guided imagery, meditation Controlled breathing: especially for this skill be sure to explain why you do this (breathing slowly helps control their level of tension).

• Procedure: sit with feet of floor and arms at side. Place on hand on your bellow below the rib cage (may also use a toy if laying on the ground with smaller kids) and the other on your chest. Breathe deeply so that the hand on your chest stays still but the hand on your belly rises and falls (praise them for their attempts at this). Once they've done it a few times instruct them to slow their breathing by slowing the exhalations (may need to count). Once they are exhaling slowly have them choose a word to say silently while exhaling (such as calm or relax) and only think about breathing and saying this word. As other thoughts come into mind they should try to picture them floating away. Have them demonstrate this procedure. Muscle relaxation: explain when peoples muscles aren't relaxed, we may feel tense, sore, or nervous. By relaxing them we feel calmer and more in control.
• Procedure: have relaxing environment with comfortable body position (usually lying down or reclined in a chair) with eyes closed. For younger kids do a full body relaxation and demonstrate a full body PMR before they repeat after you. For older children just demonstrate each muscle group and have them repeat after you each group. When doing this you first tense up each muscle group and then relax that muscle group and focus on the relaxation ("See how much better that feels"). Everyday activities as relaxation: listening to music, reading books, or watching TV Focus-based approaches to relaxation: mindfulness/meditation are especially helpful for older kids. Works by focusing attention on the present moment, non-judgmentally accepting thoughts, feelings, and sensations. Yoga and prayer may also be helpful to refocus on the present moment. Guided imagery gets them to focus on an image or place where they are safe, calm, and relaxed. You can also do 3 senses, ask them to close their eyes and ask them what they hear (Focus on the ticks of the clock, on the sound of my voice, on the sound of the air), then focus on what they see (ask to look at the table, look at how smooth the wood is, focus on the lines of the wood, then look at something else in the room and just look at it), then focus on 3 things you can feel (how your legs feel, on the curve behind your knee, on how the shirt feels on your arm, on how the floor feels under your feet). This is great to do during school before taking a test or during taking a test. Remember you can use sight, hearing, feeling, taste, or smell.

Note: before trying to apply any of these they need to practice them first outside the office when they aren't stressed yet so that they can prove they know what to do if they get stressed. Educate them when they might use relaxation techniques (when trauma sxs arise). Have them practice this strategy once per day and give a form where they record when/where they practiced and what barriers they may have. Cultural differences in responses to stress Asian: Physical complaints (HA, Stomach aches, nausea, nondescript aches and pains)

• note due to relious norms in this culture lean towards using mindfulness especially Tai chi if chinese. AA: Physical complaints (HA, Stomach aches, nausea, nondescript aches and pains) Hispanic: Physical complaints (HA, Stomach aches, nausea, nondescript aches and pains) Note: make direct link explaining that by relaxing the body and individual can reduce unpleasant physical sxs. If religious focus on religious music and prayer as relaxation technique. Age appropriate Progressive muscle relaxation (PMR) induction Early childhood: use full body fun activities like imaging as uncooked spaghetti and then cooked spaghetti to feel tension vs relaxation. When doing breathing just be simple and say "focus on breathing slow and steady". Middle childhood: some may be willing to do PMR but others may need imaginal scenarios to enhance relaxation. In this age range they like the challenge of diaphragmatic breathing (chest still and stomach rises). Taylor to whatever your pt enjoys. Adolescence: can do PMR and controlled breathing skills but may not like them. They may prefer their own favorite relaxation strategies (music etc.) and that is perfectly okay if they actually work and they don't just distract them (its not calming them if they're listening to violent aggressive music, more just distracting and riling them up). Note: overall go with whatever is most effective and they can do well (if they aren't able to do belly breathing correctly just have them focus on slowing exhalation and saying relaxing word, don't get caught up with doing it right). Pros and Cons of using a recording for relaxation Con: need a recording in order to relax Pro: the induction procedure is the same each time When not to lie on the floor for relaxation procedure

If the trauma is sexual abuse, this may trigger memories. Just have them slouch in a chair if this is the case. Being in a comfortable position is really the important thing and then having the therapist praise them for their effort. How to teach parents the relaxation exercises Its best to actually have the child take them through how to do it in a session. This allows the parent to then help them go through this when needed. When should feelings identification occur? in the first few sessions with the therapist in order to establish trust and rapport and get the pt comfortable with sharing everyday feelings with the therapist. Also helps us assess their ability to identify and express themselves emotionally verbally. What is affect modulation? teaching the child basic skills to express and regulate emotions, especially those emotions associated with trauma sxs. Includes linking relaxation skills to negative, trauma related affective experiences as well as healthy vs harmful expression of emotions like anger. Process of feelings identification (Affective expression and regulation)

1. explain rationale for feelings identification (explain benefits of identifying emotions correctly and being able to talk about those feelings comfortably with someone they trust)
2. Identify as many feelings as possible (helps to understand how my they are able to identify). Can do this with drawings with colors representing different feelings, for older children give them 60 seconds to write down as many feelings as possible. Then ask them their understanding of each emotion (ask about physiological sensations/bodily reactions like "nervous is when I have butterflies in my stomach"), may use a feelings charades game (write down the feelings on pieces of paper and each takes turn acting each emotion out while other tries to guess it). Whatever is used just make sure you discuss the feeling so they see someone talking about the feeling comfortably. Note: feelings identification helps with gradual exposure so we should focus on feelings that happen all the time and ones that happen when they're thinking about the trauma this works by naming and understanding the related emotion.
3. teach how to rate the intensity level of an emotion (help them differentiate what different degrees of intensity feels like, use scales for older children and emotional thermometers for younger kids)
4. Teach child how to express feelings appropriately (identify examples when the child experienced different emotions especially strong emotions and do a role play to demonstrate ways to express feelings appropriately in real life situations like using I-statement instead of ignoring someone when angry).

5. Relaxation is focused on reducing physical arousal and has limited ways to be done, regulating truama emotions can be done in many ways. Examples are distraction, exercise, social activity, self talk, doing something fun, or using previously learned relaxation skills. This helps manage feelings of anger, sadness, fear, or anxiety. Help them become good at more than 1 skill in case they can't do their favorite in all situations (running but in math class).
6. Discuss chosen regulation tools listwith parent in conjoint session Note: Hw isn't given but if child can't identify aspect of an emotion (like facial expression of embarrassment) have child monitor or parent monitor and report what they noticed next session. Cultural norms around emotional expression Some families aren't comfortable in discussing emotions Hispanic: view conversations as too adult for children Asian: place importance on appearing calm American indian: may relate well to creating physical items to represent emotions (beading, masks etc.) Others: consider emotional expression a sign of weakness (boys shouldn't cry or feel sad) To assess this ask the following questions:

• Tell me more about how people in your family share their feelings with each other?
• Growing up, how did your parents/caregivers express their emotions?
• Growing up, were there any common sayings about when or how you should shre your feelings? Like children should be seen, not heard? How do you think that impacted the way you expressed your emotions? Note: If any of these occur frame the skills in terms of a common goal of helping the child recover from the trauma. Also for bilingual children consider what language the trauma happened in (did it happen in country of origin before learning english?) use this language. If possible, identify through both languages and discuss with both the child and parent, if you aren't bilingual ask the child to teach you the feeling words in their language and frame this as genuine interest in learning more about the child's heritage as a opposed to deficit in the childs english vocabulary. Can also use spanish story books (read through them together) to identify emotions. If they're religious use religion to support positive self talk. Can also use childs favorite shows to identify emotions. With boys make sure to say that showing emotions demonstrates true strength not weakness. Age related Emotion identification notes

Young children: help them learn bigger words to describe the emotion (more than just good or bad, may know embarrassed but not embarrassment) School aged: Modulation activities involving activitiy is best. May like doing emotional expression in different situations (home vs school) or if older may like to do a mask activity (create artistic masks to describe emotions they show, they keep to themselves [put inside of mask], parents show, or others show) this may help them share feelings better with parents as well. Adolescents: expected to master wide range of emotion identifcation (more complex emotions). Have them describe them in terms of emotional dimensions (feelings I like ot have vs feelings I don't like to have, feelings I know how to deal with vs feelings that are hard to manage, feelings I show vs feelings I hide). Self-conscious emotions (shame and guilt) are more important for teenagers recovering from truama. What to do if they have difficulty discussing emotions (no self-awareness or have to much self- consciousness)? May not be able to talk about own emotions so give them distance by talking about feelings of other children or even imaginary characters from books or stories (you can read/tell stories and have child identify how the character felt or how they can express feelings in an appropriate manner). What to do for children that talk about their emotions as very matter of fact and are detached from them? Help them identify how he/she currently experiences emotions and what strategies they're using to avoid engaging in emotions. Once you have rapport attempt to elicit emotions in session to help them experience and discuss emotions in the moment. Thoughts vs feelings Be sure when asked to describe feelings they don't just describe thoughts. Describe the difference. If asked how they would feel they shouldn't respond saying I would want to leave. What to say to parents when they say "My child doesn't seem at all upset by what happened or they seem angry all the time and then tell me nothing is wrong"? Help them understand this is normal response to trauma. Some children never learned to identify or express their emotions appropriately. Encourage them to reinforce the affect identification and expression skills taught by:

• label emotions for the child: have them role play, use games or drawings to do this. Let the parent know difficulties the child has in session to work on this at home (label anger if they are fighting with sibling)
• Reinforce the child: priase the child for appropriate emotion management and encourage the parent to seek out instances where child will be able to express how they feel appropriately.
• Parents have emotions too: if parent struggles to express emotions teach them appropriate emotion expression/identification in a session too (How do you feel when your daughter gets a bad grade? etc.)

They are a model for their kids. Also help them become aware of how they respond to emotions (reward, magnify, punish, avoid, or override their children's expressions of sadness, anger, or shame). Which emotions are hardest for them to accept or tolerate from their child, which emotions are easiest for them? Other parents are overly emotional about their childs trauma and can't stop crying. Give them a chance to express their feelings in a session and process through their own trauma. Inform them their distress is understable but it can have a negative impact on their child, they need to see their parent can handle talking about the trauma, if they don't see this they will protect their parents by completely shutting down about the abuse. For these parents usually talking about trauma and using relaxation and coping skills is sufficient. If not, then refer them for tx as well. Steps of cognitive coping

1. Review difference between thoughts and feelings: easiest to generate social scenarios relevant to the child and prompt identification of thoughts and feelings to provide corrective info and feedback.
2. Outline cognitive triangle: on a piece of paper draw a triangle with words thoughts, feelings, and behaviors (or actions) arranged at the corners. Older children draw the traingle themselves and write the words. Point out that all 3 are connected by the traingle because in real life they are all related as well.
3. Use examples to explain how thoughts affect behavior: use examples they can imagine themselves in (own real life experiences) and describe an unhelpful cognition that might seem normal ("They are making fun of me" when they walk up to a group of friends and they start laughing) have several scenarios in mind and include some that have accurate but unhelpful thoughts ("I'm no good at something"). For each example be sure to describe each aspect of the triangle and how they're connected.
4. Generate scenarios and have child identify thoughts, feelings, and likely behaviors: ask child for example situation where they were upset or avoided. Have them identify thoughts, feelings, and behaviors but not yet suggest helpful thoughts, just identify. Each scenario can be diagrammed on a separate piece of paper or triangles.
5. Help child identify which thoughts may be inaccurate or unhelpful and help generate more accurate or helpful ones: once they identified thoughts discuss whether those thoughts are accurate and helpful. If not ask what other thoughts might be possible in the situation and what feelings they might have had if they thought about it that way. If they struggle to form better thoughts then pose questions with hints to help them or make suggestions but don't just tell them. questions to ask are:

• is the thought true? How do you know?
• Is the thought helpful or unhelpful? How do you know?
• What kind of emotion and behavior does the thought lead to?

• Does thinking this help you feel good about yourself?
• Does thinking this help your relationships?
• Does think this help you in daily life?
• Does thinking this help you accomplish your goals?

6. Discuss how to apply this skill to real life (be explicit in how they can apply it to their lives and trauma related sxs)
7. Cognitive coping skills beyond the triangle: the triangle is helpful but also use positive self talk (to manage stressful situations or trauma cues). This helps identify positive or motivating messages and they say these expressions to themselves during these times such as "I can cope with this" etc. Do you give practice forms to fill out to children (ABC thought tracking sheets)? If they are younger than 13 then usually no. If older then yes, initially just have them only record what actually happened. Once they get the hang of it in session then you can increase complexity and have them think of alternative thoughts, feelings, and behaviors. Cognitive coping related to each age group Early Childhood: cognitive triangle isn't useful for younger than 6 or 7. 3 y/o cannot link thought-feeling- behavior chains, but 4-5 y/o aren't much better. They can understand cause and effect though. Have to usually use story books to encourage positive thinking/self-statements ("I am brave", "I'm not good at soccer but I'm really good at catching a ball"). They can also understand that what they say to themselves is connected to how they feel. Middle Childhood: can understand cognitive triangle but struggle to make alternative thoughts. Make reference to fictional characters (like super heroes) and how they might think to spur different kinds of thoughts. Can also help to get to better thoughts to logically question their thinking. Do this by identifying the problematic thought and a healthier alternative thought ahead of time, this will allow you to think of questions to ask to help them try out more helpful alternative thoughts. Adolescence: by teens they are able to thinking about how they know what they know, this makes conversations about accuracy of specific thoughts more difficult to change. The thoughts may be accurate but point out how they are unhelpful, help them make just as accurate but more helpful thoughts. Note: with any child if they just can't understand the cognitive triangle, then just simply state that thoughts and feelings are intertwined and move on to the next topic. How should caregivers monitor hw for their child? Prompt the teenager to complete at a given time each day, ask about it in the morning, or check on it some other pre-determined time. But don't actually look at it because that can violate their privacy. Don't

need to actually discuss it either. And remember to praise and reward when they complete and utilize hw skills. When do you start to challenge the childs trauma related thoughts? The caregiver's trauma related feelings/thoughts? After the trauma narrative for the child. During cognitive coping for the parent (parents have to alter inaccurate or unhelpful thoughts related to the trauma as well such as "I should have known/kept my child safe", "My child will never be happy again", "Our family is destroyed" etc. if they communicate these subtly then the child may also develop these negative thoughts. Help them do this with encouragement and positive statements "I admire your strength", "You are doing a great job of keeping a positive attitude and modeling this for your child") What is the goal of having the child create a trauma narrative? They try to cope in unhealthy ways or by avoidance of triggers. There are healthier ways to manage their fear and distress. A narrative helps minimize intrusive upsetting trauma related imagery, helps reduce avoidance of cues, situations, and feelings associated with trauma exposure, and indentifying helpful and unhelpful cognitions about traumatic events. The ultimate goal is to break apart unpleasant associations between thoughts, reminders or discussions of trauma from overwhelming negative emotions like fear, horror, or helplessness. The trauma turns into just an experience within their larger life story by talking or writing about the truama to gain a sense of control and mastery over their trauma and any possible future traumas. When does the trauma narrative happen? After rapport is developed and the child has achieved basic emotion regulation and coping strategies to help deal with the distress of talking about their trauma so that doing so won't be overly distressing. Steps of the trauma narrative processing

1. Consult with the child the best format for narrative (usually the book format because its a familiar structure for them and an easy way to track their progress through chapters of unhelpful thoughts and beliefs in narrative form. This can be mostly text or mostly pictures and captions or other forms [non-book] a poem, song, puppet show etc. they just have to have their own description of the trauma and incorporate their thoughts and feelings about it)
2. Create a table of contents: make a framework for organization of contents (for a book its chapters, a poem its stanzas, a play its scenes etc. but has to have 3-4 chunks for a section for including info about the child [their likes, dislikes, family etc}, a section about the trauma and their reactions, a section about what happened when the trauma was disclosed, and a section looking forward to the next part of their life [lessons learned or advice they'd give others]).
3. Use the table of contents to make progress (child gets to choose which sections to work on each session, usually they start with the easier stuff like info about them. But save the future section for last.)

4. Elicit content: ask (need to do this in a way that allows them to tell their stories on their own [use open ended questions like "Tell me about what happened when... Where were you on the day of the accident? How did you hear your mother died?" etc if you get a one word response, ask for more info by saying "I wasn't there so try to make me able to get a clear picture of what happened, what happened next?")
5. Listen (keep an ear out for gaps in the narrative but don't interrupt or be emotionally reactive. Take notes on issues that concern you [inaccurate or unhelpful thoughts, expressions of self-blame, or other things requiring cognitive processing])
6. Repeat (after they're done, repeat back to them what they told you. This is helpful for those who try to rush through the narrative because it slows them down or speeds up those who dwell on less relevant details to avoid the hard details. Or you can repeat and then ask to fill in a gap, but don't engage in cognitive processing at this time.)
7. Write down (childs account should be recorded in writing, for younger kids you are scribe. But if able, have them write. This increases gradual exposure. If not using book form you need to keep records of important details to make sure they're incorporated. Repeat the Ask-Listen-Repeat-Write down process until you've accomplished enough for the session until each section is completed)
8. Be sure to include thoughts and feelings (done during initial development of the narrative or part of the review of sections of narrative)
9. Monitor and manage emotional arousal (before starting explain scale for distress you use so you can measure how upset the child is throughout if its very high [7-10] stop and use some anxiety management skills [PRAC] once reduced continue on)
10. Elicit worst moment, memory, or part of traumatic event (at some point ask to describe the worst moment, memory, or part of the trauma with as much detail as possible)
11. End the narrative by looking forward (thoughts/beliefs are self-fulfilling so they have to create a positive ending to the narrative. Also helps them see the trauma is only one part of their lives and it doesn't define them. Do this by asking them how they are different now from when the trauma happened and when therapy began, what have they learned? How have they grown? What advice would they give others?)
12. Praise the child's effort (at the end of each session and reward them [stickers or activity])

Note: the narrative is created only in sessions and not at home or anywhere else (don't want distress without therapist there). This also gives comfort of privacy as this going outside the office is higher risk for someone reading it. This goes for all ages and all formats of narratives. Important things to consider culturally for trauma narrative Asians, AA, Hispanics are typically very private of outward appearances and may be reluctant to air their dirty laundry. To assess this ask "Growing up, weer there any sayings your parents sued to tell you about how to handle 'family business' or personal matters?"

• if culutre does a lot of storytelling then use folklores or fables to show the importance of talking about something hard for the greater good
• for american indians use totems, songs, or dances to express narrative Some religions may impact their willingness to give narrative or for parents to hear one and they may attribute trauma to spiritual causes (perpetrator was possessed by devil) to assess this "Does your family ever talk about god or a higher power?" For some the narrative may be described as "giving your tesitmony" with an emphasis on overcoming adversity. You want to have the trauma narrative given through the language the trauma happened in because it will allow for more detail. Trauma narrative differences based on childs age Early childhood: will have less detail and may only be able to focus for 5-10 minutes of work in a session. Make deals with kids to trade time on narrative for more enjoyable activities after the narrative (never before). Middle childhood: Maybe more detail so assess whether its ability or willingness to share. Do this by asking for a non-traumatic story. Adolescence: detail should be good with thoughts and feelings. But they often want to put own flair into narrative (make poem or song) which is okay if it is consistent and has enough detail to identify trauma cues and unhelpful or inaccurate thoughts. What do you do for children with multiple traumatic events? Process the very first or most recent first. The go to occassions associated with special occasions like birthdays, vacations, holidays, or seasons of the year. All of the details will be difficult to get into the narrative so choose the details that you believe are causing the most sxs and distress. Do this by asking them to talk about the most difficult things to talk about. Remember the point is to talk about these things until the memories no longer cause significant fear, anxiety, or avoidance. recommended to have 2- 3

examples of each trauma type because this is enough for each cue for each trauma type and the associated feelings to be brought up. How do you prepare the child and parent for the narrative? Let them know what type of response is predicted. And then repeat the rationale for doing it. Give a ton of praise throughout. Link their decreased sxs with their accomplishments in tx. Remind of stress management skills in each session. Let them know you will go at the childs pace and you will check in with the parent weekly to assess coping at home and monitor lingering effects from the sessions. The child will initial seem more distressed (nightmares, sleep problems, acting out etc.) but this will dissipate and this is critical actually to deal with the trauma. Warn them of this. Remind them not to question their child about the trauma outside of the therapy sessions. Only after the narrative is complete does the child share the narrative with their parent in a session after this then discussions about it are encouraged. Sometimes you may determine its not beneficial for the parent to ever hear the narrative. Before sharing the narrative with the parent always first assess what they already know and their reactions to it so you know if they are ready to hear the narrative in a conjoint session. They have to be able to be supportive. In a parent session have the parent read through the narrative and talk about it to become comfortable with it and increase their ability to be supportive. How will you know if the child is ready to terminate tx? They will be able to openly discuss and go through their trauma narrative while exhibiting healthy emotional responses. Note: not all the sxs have to be completely gone for the tx to have had a positive impact. Sometimes if a child wants to complete therapy after significant progess it is important to support that desire. Sometimes the child is good but the parent still isn't and at this point tx focus switches onto the parent and their reactions. How to respond to the comment that "my child will never be happy again" or any other absolutes point out that between the trauma and starting tx the child had moments of normal mood and happiness even when having significant sxs. Once they ackowledge, explain that it happened already before tx and it will happen more often as they go through and finish tx. It may initially be more distressing and they may currently be distressed if in therapy currently but this will improve. Never is a long time and the child has already made progress. Instill hope for the future. Present some of the childs work to the parent, they are often encouraged to see they have been able to alter their own cognitions. Give examples of the cognitions the child came up with. Then help them with their own cognitive triangle. What is In Vivo Mastery and whats the goal? Some kids fear or avoid specific people, places, or thinkgs that are trauma cues. For some kids these go away after they complete the trauma narrative but sometimes these still persist. The goal is to get rid of these symptoms. In vivo is latin for "in the living" so these exercises are direct, in person confrontation of what is feared but that isn't actually dangerous.

Steps of In Vivo Mastery

1. Determine whether in vivo techniques are necessary, not all kids have lingering trauma cue sxs. Assess by speaking to child and adult about fear or avoidance sxs. Give psychoeducation on in vivo strategies if sxs return, if not present just go to the next module.
2. Provide a rationale: childs current avoidance of non-dangerous cues is related to trauma and confronting this in a safe controlled manner can eliminate the fear.
3. Gather info about feared situations: ask both caregiver and child
4. Construct a hierarchy: list the elements of a feared situation and assign a score (1-100) for each item of how distressing it is, include sounds, smells, things, sights etc.
5. Choose starting point and implement a plan: discuss what item should be addressed first, starting with the highest item may be too difficult until some confidence is developed but starting too low may not be challenging enough. Pick one that is challenging and achievable.
6. Make a plan for the in vivo activity: when, where, who will be present, how long will it last? youth should remain in feared situation until distresses decreases to minimal level (below 30/100) or until they can't stay any longer. Never force them to stay but encourage them by saying "try to stay for another 30 seconds" and remind them to use relaxation and coping skills.
7. Repeat and progress: progress has to be recorded and proceed to more difficult items. When intermediate levels make items higher on the list seem easier if completed first. Continue until fear and avoidance behaviors are resolved. Usually takes just a few weeks. Examples: some in vivo can be done in office (show images, bring objects etc.) but more is outside the office. Just make sure their confidence stays high throughout, if they can't do one go to an easier one for a while and go back. In vivo process based on age Early childhood: similar to overcoming normal childhood fears (monsters in closet), use these examples if possible. Parens are importance resources for info with this and to model behavior in exercises. Turn exposures into games ("who can stay longest?") or blending with fun activities (having story time in feared room). Middle childhood: parents are again important facilitators, but children themselves have to be taught to identify and implement coping strategies especially relaxation and positive self talk. Parents need to

encourage child ("can you do 10 more seconds?"). Adolescence: Harder with this age, teens more capable of independly doing activities but may be reluctant if left to do it on their own. Parents help implement the process even if not present during practice exercises. Teens tend to make judgements about safety of social situations, plan ahead of time to avoid this issue. What to do when kids refuse to do in vivo exercises?

1. remind of rational for why doing it
2. encourage minimal attempts (a few seconds) to start
3. move down the hierarchy to less threatening situation then once successful at those, move up and remind they were scared of the easier ones as well but was able to do it.
4. reward minimal efforts What is the point for the conjoint parent-child sessions?
5. enhance childs comfort int alking about the trauma with parents
6. have parent listen supportively to narrative
7. to work through any other pertinent issues the family wants to address Keys: prepare both prior and practice with both the child and parents to fulfill these goals Steps of the conjoint sessions
8. Prepare: make sure both the parent and child are ready to share trauma narrative. Assess parents willingness to be supportive, parents ability to express support, parents ability to manage personal distress, and willingness of child to engage in conjoint sessions.
9. Assess parent readiness: parents are often distressed at start of tx, this will decrease as they learn coping strategies and process their own beliefs. They have to be able to settle down and be supportive. To assess this discuss their anxieties, rehearse responses, and share the narrative. If they can tolerate the narrative without disruptive emotions they're ready.
10. Assess child readiness: children are usually comfortable discussing the narrative with you before they're ready to share with the parent. To assess readiness discuss their concerns about conjoint session.
11. Explain the rational for structure of conjoint sessions: gives parent change to show their comfort with the trauma, they can model good coping, child gets to share and have pride further alleviating feelings of shame, communication about trauma improves, misunderstandings can be cleared up, sharing the narrative sets them up for having discussions after therapy is over.

Note: during conjoint session the framework is 15 min with child, 15 min with parent, then 30 min together.

5. Get started together: simply make a few brief comments about how hard the child has worked to develop the narrative and explain what will happen ("Jenny will read her narrative, we'll ask for mom's reactions, then we'll talk about any questions that either of you have")
6. Sharing: child reads narrative uninterrupted except for encouraging comments. Reminders about coping strategies might help. Once sharing is over, parent is prompted to respond (these have been discussed in your individual sessions so they could practice appropriate responses).
7. Discussion and questions: ask parent what it was like to hear the narrative and the child what it was like to share it.
8. Ending session: end on a positive note. 1 good way is to encourage the exchange of praise. Start by having them expressing something positive they did last week ("Thank you for doing a great job cleaning the dishes last night" or "I'm so proud to be your mom"). Note: sharing the narrative is an ongoing event. Theres no set number of conjoint sessions to have, but start with the narrative and have open dialogue until you feel all feelings have been discussed. Outside of session, remind them not to discuss the narrative. Cultural factors for conjoint sessions AA, hispanic and asian cultures have a hard time discussing sexual abuse because they see this as undermining the innocence of the child. Religious families minimize the impact of the abuse in order to preserve the family name or have gendered views about what constitutes seductive behavior. Cultural values may believe only the mother should discuss sexual issues with their daughters. Note: with any of these, the parent has to have made progress on these issues before the narrative can be shared. They don't have to abandon their views but they have to be supportive in the conjoint sessions. If they cannot overcome this, then make alternative plan for conjoint session where child never shares narrative. Age related concerns for conjoint sessions Early childhood: parents need to address childs questions developmentally appropriately (simple language, withhold graphic details, give examples in concrete terms).

Middle childhood: make sure parent knows that the childs needs are the most prominent concern in these sessions and they will run the session. Adolescence: practice gradual exposure by adding 5-10 min during earlier sessions of conjointness. During this time parent is to reflect on progress, give praise, and reflect on positive emotions (pride in childs engagement). This will make sharing easier later. If needed, let the child know you can go back to processing their trauma themselves if they get too uncomfortable and feel shame. Parents have to be prepared for the topics of the sessions (drug/alcohol use, sexual partners). What is the point of enhancing safety and future development? In vivo addresses fears of things that are completely safe. Here we want to make sure kids prepare themselves for legitimate future danger. Steps of enhancing safety and future development

1. Timing is important: wait until end to do this because talking about ways to avoid trauma before they have processed the trauma they may think its their fault for not being safe enough. This may cause them to not share important details when developing the trauma narrative.
2. Acknowledge/praise responses to previous trauma: repeatedly praising reduces the lieklihood that they will feel they weren't safe enough to prevent the trauma. Identify healthy things they did related to the trauma (telling someone what happened, protecting a sibling or friend etc.) and praise them for that.
3. Involve caregivers in these sessions: discuss safety plans, psychoeducation etc.
4. Communicate feelings clearly and openly: review info from psychoeducation to ensure they will be able to communicate future traumas (feelings from trauma, doctors names for private parts, who might engage in abusive behavior) discussing this empowers them to talk about trauma.
5. Practice effective responses to threatening situations: some kids who go through trauma pay less attention to cues signaling danger. Others may be sensitized to danger and see a threat when its actually not there. Rehearse in session how they might respond to dangerous situations.
6. Identify people/places that are safe: create a list of people and places the child can go if feel threatened. Include self-protective strategies, trusted adults, safe places, and encouragement to call 911. Practice these things in session. Instruct parents to inform others of safety plan (neighbors etc).
7. Emphasize body ownership: esp for sexual abuse, teach what OK and not OK touches are. Teach doctors names for body parts. Then in role plays they practice using these words to disclose to parents