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Have a Challenging Child? Evidence-Based Therapy May Help You Cope

by Stacey Burling, STAFF WRITER

Amy Herschell and Kristen Schaffner,  experts at taming particularly difficult children, described the kind of kid who gets referred to the treatment model they espouse, one that harnesses the power of parental attention:

He’s 5 and in danger of being thrown out of day care.  He’s mean to other kids in his class and his siblings.  He refuses to do what adults tell him to do.  He throws things or spits or bites or swears.  He has tantrums.  His problems are so consuming, his  parents’ jobs are at risk.  No one wants to be his babysitter. No one wants to be his friend.

It’s the kind of behavior that puts a kid on a bad path that some never get off. Herschell and Schaffner say a program that coaches parents to reward good behavior and ignore bad, to discipline consistently and effectively, can quickly transform even that hypothetical child into one whose behavior is better than average.

The duo, who both work at the University of Pittsburgh and West Virginia University, along with Sarah Taber-Thomas, clinical assistant professor at the University of Buffalo, spent three days in Philadelphia this month teaching therapists and managers at Community Behavioral Health about Parent-Child Interaction Therapy (PCIT). Though the program was developed in the 1970s, it has only recently begun spreading from universities to community treatment centers.   The approach has been shown to improve children’s behavior both at home and at school and to reduce parental depression and stress. Studies found that the results persisted for years.

CBH offered the training to seven agencies that provide services to its Medicaid clients (there were also a few trainees from Chester County) as part of its effort to expand access to treatments that are proven to work, said Ronnie Rubin, director of CBH’s Evidence-Based Practices and Innovation Center.  While translational medicine — the effort to move cutting-edge science more quickly from bench to bedside — has been trendy in the medical world for several years, Rubin said it has been slower to take off in mental health care.

Herschell said there has been widespread interest in PCIT in Pennsylvania. About 100 agencies have some workers who have  had training. Philadelphia, she said, has given an unusual amount of support at the county level.

PCIT consists of two parts delivered over 10 to 20 sessions  that last an hour or so.  In the first, a therapist helps a parent create a stronger, warmer bond with the child.

They focus on discipline in the second.  Most of the work is between the parent and child. They play — the child decides how — while a therapist watches behind a one-way mirror, coaching the parent, who wears a “bug” in the ear.

The goal is to praise the child for behaving well.  Maybe he sat still for a while or drew something creative.  If he has a tantrum, Mom can focus on drawing her own picture until he’s ready to interact nicely again.  The coach may suggest what to say and do with the child but also praises the parent. “Great labeled praise,” the coach might say, or “I like the way you’re following his lead.”  The coach, Schaffner said, is “working on shaping the parent behavior just like they’re trying to shape the child behavior.”

That voice in the ear is a key difference between PCIT and other efforts to help parents manage difficult children.

“Coaching is where the magic happens,” Schaffner said. “It’s amazing how powerful it is.”

Herschell said that children in PCIT programs typically start out doing what their parents ask only about 30 percent of the time.  Average kids have compliance rates of 60 to 70 percent.  By the time the program ends, PCIT graduates are doing what they’re asked 80 to 90 percent of the time, she said.

Some of this sounds like advice you’d get in any parenting program,  but the experts said children who need PCIT really are more challenging than other kids.

Rubin said that in PCIT, parents are taught the sorts of things therapists learn in advanced classes. “It’s like good parenting on steroids,” she said.

Some children truly are harder to parent, and a mismatch between parenting style and the child’s temperament can bring out the worst in both of them.

“Negative behaviors pull for negative attention,” Taber-Thomas said.  “Over time, that spirals.”

Parents sometimes have trouble seeing the good in a child who misbehaves a lot, Rubin said. The program helps parents reconnect with all the good things their child is doing and to appreciate them.  That helps the child relax and feel closer to the parent.

“We’re making the parent’s attention more powerful and more strategic,” Herschell said.

The beauty of PCIT, the trainers said, is that it “empowers” parents to change their children’s lives and, as a consequence, their own.

“The difference is those therapeutic skills are being given to the parents as an agent of change,” Rubin said.

The PCIT trainers will be back early next year to teach workers about the discipline phase, but Rubin hopes agencies will begin offering the program immediately to 2.5- to 7-year-olds and their parents.  People who are interested in participating in the program or referring patients to it can call 888-545-2600.   A brochure on PCIT can be found here.  And a link to a map of Philadelphia PCIT providers and their contact information is here.

Kids and Trauma: When Does It Require Treatment?

A child watches her father kill her mother. A tween has a medical emergency and nearly dies. A teen is sexually assaulted.

When children experience a serious trauma, most will show a visible change in behavior and emotions but will recover within a few months. A significant minority, however, go on to develop Post-Traumatic Stress Disorder— a severe and often chronic anxiety disorder whose symptoms include nightmares, intense fearfulness, preoccupation with avoiding memories of the trauma, and decreased interest in formerly enjoyed activities.

Is there any hope for them? It appears so. Psychological interventions – particularly cognitive-behavioral therapies (CBT) – are effective in treating PTSD in children, concludes recent research from Clinical Psychology Review. A round of psychotherapy for PTSD may even alleviate the additional depression that frequently co-occurs with PTSD in children.

One review estimated at 16 percent – about one in six children will develop PTSD from experiencing trauma. Rates appear to be lowest for boys exposed to non-interpersonal traumas such as life-threatening accidents or natural disasters (8 percent) and highest for girls who are exposed to interpersonal traumas such as assault or sexual abuse (33 percent).

This latest study is an important one because it is a well-designed meta-analysis in which the authors carefully selected 39 already-published studies of treatments for childhood PTSD and combined the results using sophisticated mathematical techniques.

CBT was defined by the authors as psychotherapy that focuses on the memory of the trauma and/or its meaning. Examples include TF-CBT (Trauma-Focused CBT) and Prolonged Exposure. CBT for PTSD might also include helping clients to approach the memories and triggers they have been avoiding, such as by telling the story of the trauma, drawing pictures of it, or visiting safe places that remind them of the trauma like the site of their car accident or the hospital at which they were treated.

You might be having a “well, duh” moment, assuming that any therapist who treats PTSD would necessarily have the client speak directly about the original trauma.

You would be incorrect. Other research with adults has shown that therapists are often reluctant to encourage patients to approach memories and other trauma-related triggers for fear that this might be too upsetting, make the PTSD permanently worse, or somehow erode the trusting relationship between therapist and client.

But, as the current study and many others have shown, in the hands of a trained therapist, focusing the treatment on the remembering and processing of the trauma can help a lot, even with children and teens.

My own experience as a clinician providing CBT to traumatized children is in line with the published research: Helping the child gradually to tell me about the trauma in detail helps them, even when a child is reluctant at first. Over a course of therapy, the memories become less scary and the child more willing to talk about them. Parents, too, are helped, and report exhilaration at watching their child emerge from the aching fog of PTSD.

Two major hurdles for parents are finding a trustworthy source of information about what psychotherapies have scientific backing and then locating a therapist who has been trained in these evidence-based interventions. One online resource I highly recommend for both is Effective Child Therapy, a website maintained by the Society of Clinical Child and Adolescent Psychology of the American Psychological Association. The National Center for PTSD has lots more about the disorder in both children and adults. The Philadelphia Department of Behavioral Health and Intellectual disAbility Services website has information on accessing evidence-based treatments for PTSD locally.

EPIC Seminar Series: Making Your EBP Stick for the Long Haul!

The 2016 EPIC Seminar Series is focused on the theme of implementing evidence-based practices (EBPs) in community behavioral health settings. These presentations are geared toward behavioral health administrators and clinicians who are interested in an exploration of the latest topics in the field of evidence-based practice and implementation science. Seminars will cover a range of issues that cut across EBPs, including organizational, cultural and practice change factors related to successful implementation of EBPs.

Torrey Creed, Ph.D. will join us to share concrete ideas about what it takes to keep your EBP or innovative practice going. Dr. Creed will share key insights into what sustainability is, why it doesn’t happen automatically, and how to make it more successful.

About our Presenter:
Torrey A. Creed, PhD. is an Assistant Professor in Psychiatry at the University of Pennsylvania’s Aaron T. Beck Psychopathology Research Center. As the director of The Beck Community Initiative at Penn, she leads a large-scale implementation program to increase community access to evidence-based cognitive behavioral therapy (CBT). This program implements CBT in community services with diverse populations, presenting problems, and levels of care. Dr. Creed has traveled nationally and internationally to deliver tailored training in CBT. Her co-authored book, Cognitive Therapy for Adolescents in School Settings, is used as a guide for mental health services in Philadelphia and other public schools. Dr. Creed’s primary research interests are the adaptation, implementation, and sustainment of CBT for community mental health settings, and the role of recovery and resilience in behavioral health.

Frequently Asked Questions

Frequently Asked Questions

DBHIDS-Funded Practice Initiatives in Philadelphia

DBHIDS-Funded Practice Initiatives in Philadelphia

Evidence-Based Practices in Philadelphia

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Evidence-Based Practices in Philadelphia

Below is a listing of the behavioral health evidence-based practices (EBPs) in Philadelphia. For each of the following EBPs you will find a brief case example, an in-depth overview of the treatment, and contact information for providers who currently deliver each EBP. You can learn more about each practice by clicking on the practice title.

Please note: This website currently features EBPs that were implemented through DBHIDS-sponsored training initiatives or EBPs that require training or monitoring from treatment developers. This is not an exhaustive list of the evidence-based practices, programs, or innovations in the Philadelphia behavioral health provider network. This website will be periodically updated with additional EBPs in Philadelphia.

Find EBPs by Age Range

Birth – 5 years old

Child Parent Psychotherapy (CPP): 0-5 years

Child Parent Psychotherapy (CPP) helps caregivers of young children who have experienced trauma develop a strong, nurturing relationship with their child to restore the child’s sense of safety and to support positive development.

CPP Case Example: A young child is displaying a lot of acting out behaviors, such as fighting, defiance, hyperactivity, and disregulation. Both child and caregiver have histories that include trauma. Caregivers’ history from their own childhood experiences may be influencing the current relationship. In joint sessions the caregiver will learn new ways to interact and provide support to their child.

Get more in-depth information about the CPP treatment option.

Find providers in Philadelphia who offer the CPP treatment option.

2 – 8 years old

Parent Child Interaction Therapy (PCIT): 2-7 years

Parent Child Interaction Therapy (PCIT) is a treatment for young children and their caregivers that uses a coaching model to strengthen the parent-child relationship and build skills for behavior management.

PCIT Case Example: A young child doesn’t listen to instructions, is aggressive at home or at school and is having frequent, intense tantrums. The caregiver is feeling frustrated and overwhelmed as they struggle to manage behaviors. This family could benefit from both relationship building and additional behavior management skills.

Get more in-depth information about the PCIT treatment option.

Find providers in Philadelphia who offer the PCIT treatment option.

Parent Child Interaction Therapy (PCIT) Brochure

Parent Child Interaction Therapy (PCIT) Provider Map

5 – 18 years old

Child and Family Traumatic Stress Intervention (CFTSI): 7-18 years

Child and Family Traumatic Stress Intervention (CFTSI) is a brief intervention for children who have experienced a potentially traumatic event. This intervention is aimed at preventing post-traumatic stress disorder symptoms by strengthening the family’s ability to communicate and offer the child support.

CFTSI Case Example: A child or adolescent has recently been involved in a traumatic experience and is exhibiting symptoms such as sleep difficulty, intrusive thoughts, depressive withdrawal, anxiety, tantrums, and aggression. The child’s caregivers want to better understand their child’s response to the event and learn strategies to support the child through this difficult time.

Get more in-depth information about the CFTSI treatment option.

Find providers in Philadelphia who offer the CFTSI treatment option.

Cognitive Behavior Therapy (CBT): 5-18 years

Cognitive Behavior Therapy (CBT) is a solution-focused treatment that helps a person learn skills and solve problems by identifying unhelpful thinking patterns, changing inaccurate beliefs, engaging in new behaviors, and relating to others in more positive ways that support meeting their personal goals and recovery.

*Through the Beck Community Initiative, providers have been trained in transdiagnostic Cognitive Behavior Therapy (CBT) for a broad range of presenting concerns, or in a model of CBT for adults with schizophrenia and serious mental illness (Recovery Oriented Cognitive Therapy – CT-R).

CBT Case Example: An adult or child’s feelings of depression and anxiety are getting in the way of their engagement in activities. They want to develop new skills and strategies for managing their thoughts, feelings, and behaviors so they can achieve their goals.

Get more in-depth information about the CBT treatment option.

Find providers in Philadelphia who offer the CBT treatment option.

Dialectical Behavioral Therapy (DBT): 11-18 years

Dialectical Behavior Therapy (DBT) helps individuals who have struggled with suicidal thoughts, self-harm, and emotion disregulation to develop coping strategies and skills for committing to “a life worth living.”

DBT Case Example: An adult was recently admitted to the hospital because of suicidal feelings. He/she has significant challenges regulating emotions, managing interpersonal relationships and has a history of self-harm behaviors such as cutting and/or suicidal thoughts. He/she could benefit from learning new ways of coping with personal and relationship challenges, as well as coaching to use those skills during times of crisis.

Get more in-depth information about the DBT treatment option.

Find providers in Philadelphia who offer the DBT treatment option.

Ecosystemic Structural Family Therapy (ESFT): 5-18 years

Ecosystemic Structural Family Therapy (ESFT) helps families build new patterns of interacting in order to reduce conflict and improve behavior and relationships among family members.

ESFT Case Example: A child is defiant toward his caregivers, frequently engaging in verbally and physically aggressive behavior. His caregivers are frustrated and feel they don’t know how to get their child’s behavior under control. There is a lot of tension among family members. They want to find new ways of interacting and relating to one another so they can address these behaviors and begin to reconnect.

Get more in-depth information about the ESFT treatment option.

Find providers in Philadelphia who offer the ESFT treatment option.

Functional Family Therapy (FFT): 11-18 years

Functional Family Therapy (FFT) is a family-based intervention aimed at changing the patterns of how families members communicate, problem solve, and support one another.

FFT Case Example: A teenager is acting out, getting in trouble at home, school, and with the juvenile justice system (e.g. truancy, violent acting out, delinquent and disruptive behavior). The family is in crisis and the teen is at risk for more serious problems down the road. They would benefit from intensive, family services in their home and community to address these challenges.

Get more in-depth information about the FFT treatment option.

Find providers in Philadelphia who offer the FFT treatment option.

Joint Planning Team (JPT): 10-17 years

Joint Planning Team (JPT) is a support and planning process that brings people from different parts of the family’s life together to help them identify resources and develop skills to sustain youth in the home.

JPT Case Example: A family is involved with multiple systems (e.g. school, behavioral health, juvenile justice, and/or child welfare) and needs help with complex service coordination. This family could use support in learning how to navigate the system, community supports, and treatments that will help them get back on track.

Get more in-depth information about the JPT treatment option.

Find providers in Philadelphia who offer the JPT treatment option.

Multisystemic Therapy for Problem Sexual Behaviors (MST-PSB): 11-17 years

Multisystemic Therapy for Problem Sexual Behaviors (MST-PSB) is a treatment for youth who have exhibited problematic sexual behavior. MST-PSB works with the whole family to address the behavior and develop skills and supports while keeping the youth in their community and maintaining the safety of others around them.

MST-PSB Case Example: A young person has engaged in problem sexual behavior. The family knows that the safety of the victim, community, and their child is a top priority and wants to engage in intensive treatment that addresses the behavior while allowing their child to remain safely at home.

Get more in-depth information about the MST-PSB treatment option.

Find providers in Philadelphia who offer the MST-PSB treatment option.

Trauma Focused Cognitive Behavioral Therapy (TF-CBT): 3-18 years

Trauma Focused Cognitive Behavioral Therapy (TF-CBT) helps children and their caregivers overcome the impact of traumatic events through psychoeducation, creating a safe space to process the event, and developing new coping strategies.

TF-CBT Case Example: A child or adolescent is exhibiting significant emotional or behavioral difficulties after a traumatic event. Her caregiver is struggling to manage these new challenging behaviors. The child and parent would benefit from gaining a better understanding of how trauma has impacted their family and learning new strategies for coping with this experience.

Get more in-depth information about the TF-CBT treatment option.

Find providers in Philadelphia who offer the TF-CBT treatment option.

Adult (18 years and older)

Assertive Community Treatment (ACT)

Assertive Community Treatment (ACT) teams provide case management, psychiatric services, employment and housing assistance, family support, substance abuse treatment, and other services and supports critical to an individual’s ability to live successfully in the community.

ACT Case Example: An adult is struggling with a serious mental illness, and is having difficulty functioning in areas such as work, relationships, housing, money management, physical health, and wellness. Coordinated, comprehensive services will help them manage these complex needs and engage in community activities and supports.

Get more in-depth information about the ACT treatment option.

Find providers in Philadelphia who offer the ACT treatment option.

Cognitive Behavior Therapy (CBT)

Cognitive Behavior Therapy (CBT) is a solution-focused treatment that helps a person learn skills and solve problems by identifying unhelpful thinking patterns, changing inaccurate beliefs, engaging in new behaviors, and relating to others in more positive ways that support meeting their personal goals and recovery.

*Through the Beck Community Initiative, providers have been trained in transdiagnostic Cognitive Behavior Therapy (CBT) for a broad range of presenting concerns, or in a model of CBT for adults with schizophrenia and serious mental illness (Recovery Oriented Cognitive Therapy – CT-R).

CBT Case Example: An adult’s feelings of depression and anxiety are getting in the way of their engagement in activities. They want to develop new skills and strategies for managing their thoughts, feelings, and behaviors so they can achieve their goals.

CBT for Schizophrenia and Serious Mental Illness (CT-R) Case Example: An individual experiences auditory hallucinations and, at times, is aggressive and disruptive in their treatment setting. The CT-R model uses strategies to engage the individual in meaningful, interactive activities that are connected to their recovery goals.

Get more in-depth information about the CBT treatment option.

Find providers in Philadelphia who offer the CBT treatment option.

Find providers in Philadelphia who offer CBT for schizophrenia and serious mental illness (CT-R) treatment option.

Dialectical Behavioral Therapy (DBT)

Dialectical Behavior Therapy (DBT) helps individuals who have struggled with suicidal thoughts, self-harm, and emotion disregulation to develop coping strategies and skills for committing to “a life worth living.”

DBT Case Example: An adult was recently admitted to the hospital because of suicidal feelings. He/she has significant challenges regulating emotions, managing interpersonal relationships and has a history of self-harm behaviors such as cutting and/or suicidal thoughts. He/she could benefit from learning new ways of coping with personal and relationship challenges, as well as coaching to use those skills during times of crisis.

Get more in-depth information about the DBT treatment option.

Find providers in Philadelphia who offer the DBT treatment option.

Prolonged Exposure (PE)

Prolonged Exposure (PE) aims to reduce post-traumatic stress disorder (PTSD) symptoms by helping individuals approach trauma-related thoughts, feelings, and situations that had previously been avoided.

PE Case Example: After experiencing a traumatic event, an adult is displaying PTSD symptoms such as reliving the event, avoiding situations that remind them of the event, remaining jittery or on alert, and changing the way they think about themselves or others. These symptoms are impacting their ability to engage in activities and relationships. They are looking for a treatment that will reduce these symptoms and help them move forward in life.

Get more in-depth information about the PE treatment option.

Find providers in Philadelphia who offer the PE treatment option.

For Providers:

This is not an exhaustive list of the evidence-based practices, programs, or innovations in the Philadelphia behavioral health network. If you know of any other EBPs that are currently available and that are not currently listed, please contact us with that information at EPIC_DBHIDS@phila.gov.

For Individuals Seeking Services:

This website is a resource for information about EBPs in Philadelphia. It does not include the full continuum of behavioral health services available and is not a substitute for a comprehensive evaluation to identify the most appropriate course of treatment for an individual or family. Learn more about the full continuum of behavioral health services available in the DBHIDS network.

For additional information about accessing services please contact CBH Member Services at 888-545-2600 or visit DBHIDS’s Resources Page.