DTD Clinical Practice Guidelines (DTD-CPG) Toolkit

This clinical practice guide provides an overview of best practices and evidence-based and promising treatment models for children, youth, and young adults who are experiencing DTD and complex PTSD.

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CSEC Practitioner Guide – Psychotherapy for Commercially Sexually Exploited Children

A Guide for Community-Based Behavioral Health Practitioners and Agencies

The guide describes the core components of treatment to promote recovery from the impact of ongoing trauma with youth and young adults who are experiencing exploitation in the context of social injustice and systemic oppression. As awareness of child sex trafficking grows and systematic screening for signs of exploitation improves, the need for information about how to serve youth who are sexually exploited is all the more urgent.

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Treatment Models

TARGET

TARGET originally was developed in order to make the two fundamental therapeutic mechanisms that are universal across multiple approaches to psychotherapy for PTSD and DTD transparent and practically accessible for clients and therapists: trauma processing and emotion regulation.

TARGET’s psychoeducation therefore was designed to enable clients (and therapists) to understand and mentalize (i.e., visualize the internal workings of) the networks within the brain that are responsible for stress reactivity and emotion dysregulation in PTSD and DTD. Clients are provided with pictures and a technically-accurate but non-technical description of how stress reactions involve an interaction of the stress/salience network (represented by the amygdala), the self-referential memory encoding/retrieval network (represented by the hippocampus), and the executive function network (represented by the prefrontal cortex). Additional pictures show how these neural interactions are altered in PTSD and DTD.

TARGET distills a complex array of skills/functions into a seven-step sequence for emotion regulation that is summarized by the acronym, FREEDOM. This sequence involves: (1) choosing an adaptive Focal point (referred to as an orienting thought), (2) Recognizing triggers that set off the alarm, followed by reappraisal in four domains, including (3) Emotion awareness, (4) Evaluation (i.e., thoughts, beliefs), (5) Defining goals, and (6) Option identification (i.e., plans, behaviors). The seventh and final step is Making a contribution, which involves taking responsibility for using the first six skills in the sequence in order to make decisions and take actions that increase the safety of the individual and others, and that honor the individual’ core values and life goals.

TARGET is implemented and has been demonstrated to be effective in research and field trial studies with elementary school age children and their parents, adolescents, young adults, and adults in mental health, residential treatment, juvenile justice, child welfare (foster/adoption), college, criminal justice, and military veteran populations. TARGET has brief (4-session), time limited (10-14 sessions), and extended (26+ sessions) individual, group, and family therapy versions.

Trauma Systems Therapy (TST)

Trauma Systems Therapy (TST) is a comprehensive, phase-based treatment program for children and adolescents who have experienced traumatic events and/or who live in environments with ongoing stress and/or traumatic reminders. TST is designed to address the complicated needs of a trauma system, which is defined as the combination of a traumatized child/adolescent who, when exposed to trauma reminders, has difficulty regulating his/her emotions and behavior and his/her caregiver/system of care which is not able to adequately protect the youth or help him/her to manage this dysregulation. The most common setting in which TST is implemented is for youth involved with the child welfare system who may be in birth homes, foster care, residential treatment centers, or community-based prevention programs. TST is also provided in juvenile justice settings, school-based programs, and programs for unaccompanied alien minors.

The TST Training Center is located at the Child Study Center at Hassenfeld Children’s Hospital at NYU Langone Medical Center. The NYU Center for Child Welfare Practice Innovation, also at the NYU Child Study Center, is a Category II Center funded by the SAMHSA’s National Child Traumatic Stress Network, focusing on implementing trauma informed practices based on TST in child welfare programs nationally.

TST aims to stabilize the child’s environment while simultaneously enhancing his/her ability to regulate emotions and behaviors. TST begins assembling a multidisciplinary team which assesses each child and his/her environment. Based on this assessment, the child is determined to be in one of three treatment phases. A TST priority problem is established, and the TST treatment team addresses this priority problem from multiple perspectives. Different interventions and therapies are indicated within each phase, designed to both help the youth to better regulate survival states, and to help caregivers and providers to become better able to meet the child’s needs. Detailed guides are provided to help guide the interventions for each phase.

TST is both a clinical model of care for traumatized children and an organizational model that specifies how an organization should configure and manage its services to implement and support a TST program such that the program is able to generate impact and to be sustained and to achieve scale within the organization (including partnerships between organizations).

Integrative Treatment of Complex Trauma for Children (ITCT-C) and Integrative Treatment of Complex Trauma for Adolescents (ITCT-A)

Integrative Treatment of Complex Trauma (ITCT) was developed to address complex trauma in culturally diverse, economically disadvantaged children, adolescents, and young adults. There are two versions, one designed for the assessment and treatment of traumatized children (ITCT-C; Lanktree & Briere, 2018, 2017) and one for the assessment and treatment of traumatized adolescents and young adults (ITCT-A; Briere & Lanktree, 2012, 2013). ITCT is a structured, multi-component, assessment-driven approach involving multiple modalities (individual, group, and family therapy) individualized for each client. ITCT also involves extensive collaboration and advocacy services on behalf of the child or adolescent and their family, with other systems in the community, to address socioeconomic disadvantage and improve access to crucial services. ITCT focuses on social and cultural issues with the use of culturally appropriate assessment and treatment resources. Interventions are adapted to the sociocultural context and specific needs of the client and their family according to periodic assessments throughout treatment. ITCT has been associated with significant complex trauma-related symptom reduction in children and adolescents in clinic and school-based contexts (Lanktree, et al., 2012).

FOCUS (Families OverComing Under Stress)

Adapted from the developers’ EBPs shown through randomized control trials to improve parenting, family functioning and youth and parent outcomes over longitudinal follow-up, common core intervention elements were defined through expert consensus on shared contributing structures, processes and core elements (Beardslee et al., 2003, 2007; Rotheram-Borus, et al., 2004; Layne et al., 2008; for review see Saltzman, 2016 and Lester et al., 2016). The core elements were defined as (a) evidence-based assessment and real-time personalized guidance, b) context specific education (e.g., trauma-and resilience-informed education, positive parenting, developmental guidance); c) individual and family-level skill development (emotional regulation, problem solving, communication, goal setting, managing separation/trauma reminders), d) development/sharing of individual and family level narrative communication timelines). These elements were customized, piloted and manualized using a community participatory methodology with military providers, families and leaders that informed intervention tailoring and implementation design (Saltzman et al., 2009; Beardslee et al., 2013).

Delivered within the DOD as a “suite of services” based on EBP core elements, FOCUS services are delivered as a tiered continuum of prevention consistent with a population health model (NRC and Institute of Medicine (2009), from universal to indicated prevention using multiple platforms to support flexible engagement, screening and intervention delivery (educational workshops, web-based/mobile tools, skills groups, consultations, and in-person and in-home tele multi-session family interventions) (Beardslee et al., 2011, Beardslee et al., 2013).

FOCUS services have been implemented for active duty families from 2008-2018 at 24 installations with consistently high levels of engagement and participation across the continuum of tiered services, as well as of adherence by families within the multi-session models. Evaluations of the multi-session family intervention and its adaptations have demonstrated significant and sustained individual and family level outcomes up to one year of follow-up in adults (reduced depression, anxiety and PTSD symptoms), children (decreased internalizing and externalizing symptoms, improved prosocial behaviors, reduced anxiety, improved coping), and improved family/couple adjustment (Lester et al., 2016, Saltzman et al., 2016, OSD FOCUS Report 2018).

An adaptation for early childhood delivered as an in-home telehealth platform has recently been completed a randomized trial, demonstrating improvements in reported parenting stress, parent-child relationship, observed parenting and reduced parental PSTD symptoms compared to a web-based parenting curriculum (Mogil et al., in submission). Lessons from the large-scale implementation have been translated to reach military-connected couples and families in a range of settings, including school systems, international military, community mental health, and veteran serving organizations (Ijadi-Maghsoodi et al., 2017, Garcia et al., 2015, NATO report, RAND WBV Report), providing an example of the relevance of this approach across multiple systems. 

TGCTA (Trauma and Grief Components Therapy for Adolescents)

TGCTA is an evidence-based, manualized intervention that addresses the complex needs of older children and adolescents contending with trauma, bereavement, or traumatic bereavement. TGCTA’s modularized, flexible design allows clinicians to customize their intervention according to the specific needs, strengths, and life circumstances of specific youth and the time available. TGCTA combines state-of-the-art assessment and treatment of trauma exposure, bereavement, and the interplay between posttraumatic stress and grief reactions that can arise following traumatic bereavement. TGCTA has been widely implemented and studied both nationally and internationally. The manual and accompanying support materials offer detailed session-by-session guidance for conducting the program in either a group based, individual, or combined modality (i.e., combined = group-based + individual pullout sessions to address highly personal/distressing material). Psychoeducational and skills-building components from Modules 1 and 4 have also been implemented successfully in classroom settings. TGCTA’s four treatment modules permit therapists to flexibly tailor (make minor adjustments to) or adapt (make major adjustments to) their intervention plan to accommodate their client’s specific needs, strengths, life circumstances, and informed preferences. Depending on which modules are implemented, the total number of sessions ranges from 8 to 24. The program has been extensively implemented and evaluated in both individual and group-based modalities. An optional family-focused intervention component is available.

Trainings were provided to a number of juvenile justice residential and correctional facilities serving adolescents. This included Hanna Boys Center in Sonoma, CA and North Dakota Youth Correctional Center. Trainings were also provided to community mental health centers, hospitals and hospices that serve traumatized and bereaved youth. These included Lurie Children’s Hospital in Chicago, Inyo County Behavioral Health in California, and Santa Cruz Hospice in California.

Plans have been made to launch TGCTA across the Georgia Department of Juvenile Justice. Initial trainings will support a pilot implementation at short-term detention center and a long-term residential center and then be expanded in phases across the 29 facilities comprising the state JJ network. To increase outreach and accessibility to TGCTA training and services, a website was designed and launched (tgcta.com) during the year.