The Bridging Program:

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The Bridging Program: - Description

A . Promising Mental Health Engagement Program for Sexually Abused Children and Their Non-offending Caregivers. . Andrea G. Asnes, MD, MSW. , Yale School of Medicine Department of Pediatrics, Yale Child Sexual Abuse Clinic, The South Central . ID: 229587 Download Presentation

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The Bridging Program:




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Presentations text content in The Bridging Program:

Slide1

The Bridging Program: A Promising Mental Health Engagement Program for Sexually Abused Children and Their Non-offending Caregivers

Andrea G. Asnes, MD, MSW

, Yale School of Medicine Department of Pediatrics, Yale Child Sexual Abuse Clinic, The South Central

CAC

Maria Gallagher, MSW

, Northeast Regional

CAC

Hilary Hahn,

EdM

, MPH

, Yale School of Medicine Child Study

Ctr.

Kristen

Kowats

,

LCSW

, Yale School of Medicine Child Study

Ctr.

Theresa

Montelli

, LCSW

, Yale-New Haven Hospital, Yale Child Sexual Abuse Clinic, The South Central

CAC

Peggy Pisano

, Milford/Ansonia Multidisciplinary Team Coordinator and Rape Crisis Center of Milford, Inc., The South

Central CAC

Paula Schaeffer, MA

Yale School of Medicine Department of Pediatrics, Yale Child Sexual Abuse Clinic, The South Central

CAC

Slide2

Goals

WE

will tell you the story of our Program and share with you all the things we learned along the way.

YOU

will learn from our mistakes and our good ideas.

WE

will explain why it takes all seven of us to lead this one workshop.

Slide3

Objectives

Learners will:

R

eview

the barriers to successful engagement in needed mental health services that confront the caregivers of sexually abused children.

U

nderstand

the multiple aspects of a successful service engagement program for sexually abused children and their non-offending caregivers.

E

xplore

creative funding strategies that allow for optimal engagement of sexually abused children in needed mental health services.

Slide4

Overview

History of the Bridging Program

Brief

description of the Yale Child Sexual Abuse Clinic and the

South Central CAC

Description of Bridging referral and engagement

strategies

Description

of

the mental

health services provided in

Bridging

Description

of community involvement in Bridging

Description

of Bridging care

coordination

Data

collection strategies for

Bridging

Overview

of Bridging

data

Overview

of Bridging funding

strategies

Discussion of future directions

Slide5

Why are there 7 presenters?

This is a team effort.

Collaboration is what it takes to make the program work.

Slide6

History

Slide7

The Problem

Child sexual abuse can lead to multiple downstream negative health outcomes.

One mechanism for poor outcomes is via the development of posttraumatic disorders such as post traumatic stress disorder (PTSD).

Despite the availability of evidence-based treatment, children and families engage in treatment at suboptimal rates (35% of those seen at CACs and referred received services).

Slide8

The Opportunity

Family support is a primary protective factor against posttraumatic symptoms in children exposed to trauma such as sexual abuse.

The forensic sexual abuse evaluation offers a prime opportunity for a targeted engagement effort to link children and families to needed mental health treatment.

Slide9

New Haven, CT 2005

Well established child sexual abuse clinic serving five MDTs.

Quality community mental health partners with waiting lists and arduous intake processes.

A population of non-offending caregivers who were making it to treatment at suboptimal rates.

Slide10

Non-offending Caregivers

Key element to linking sexually abused children to treatment.

O

ften in full-blown crisis at the time of forensic evaluation when referrals to treatment are made.

Frequently live in chronically stressed circumstances that may interfere with engagement in treatment.

Slide11

Initial Response to the Problem

We conceived a program that would be a “bridge” between forensic evaluation and eventual mental health treatment.

A holding program to combat waiting lists.

We ended up creating something different.

Slide12

The Collaboration

Yale Child Sexual Abuse Clinic +

Yale Child Study Center/

Childhood Violent Trauma Center

+

The Salomon Family Foundation =

The Yale Bridging Program

Slide13

Request

Make the non-offending caregivers the focus.

Ask how they are before you ask about the child.

Be lovingly aggressive in engaging the family: think infectious disease.

Give lots of chances to make a successful engagement, not just a couple.

Slide14

Key Lessons We Learned Fast

Families need more than mental health treatment: resources and linking between involved services (like schools, child protective services, police, court system).

We can help the other services involved, such as CPS, by providing expert case management services that offer a roadmap to CPS investigators/treatment workers.

Slide15

Description of the Yale Sexual Abuse Clinic and the South Central CAC

Slide16

YCSAC and the SCCAC

Yale Child Sexual Abuse Clinic

Hospital based sexual abuse clinic

Approximately 375 evaluations per year

Participation in 5 Multidisciplinary Teams for Child Sexual Abuse

South Central Child Advocacy Center

Yale-New Haven Hospital, Yale School of Medicine, Clifford Beers Clinic, Rape Crisis of Milford, Department of Children and Families, State’s Attorneys

Slide17

Description of Bridging Referral and Engagement Strategies

Slide18

It starts right away.

Engagement begins with the first contact (usually with forensic interviewer/family advocate and/or MDT or CAC coordinator, but can be CPS or police, too).

The forensic evaluation is also about care and support to sexually abused children and their non-offending caregivers.

This care and support (often very powerful) is the first step.

Slide19

Ideally, it’s co-located, but it is always an immediate and “warm” handoff.

The best scenario is an in person introduction from a known person (like a family advocate) to the mental health provider at the time of forensic evaluation.

If not, a call within 1-3 days of the forensic is crucial.

Best if the known person has mentioned a name to the caregiver(s): “Kristen will call you.”

Slide20

It’s firm, patient and keeps on coming.

Sometimes it takes multiple phone calls, and sometimes the work must start on the phone (telephone engagement McKay).

Sometimes it takes some missed appointments to make it in and that’s okay (think infectious disease).

The “lots of fish in the sea” idea has to be carefully avoided.

Slide21

Sometimes it’s a concrete obstacle.

Transportation.

Parking.

Child care.

Work schedules.

Slide22

Description of the Mental Health Intervention

Slide23

The Child and FamilyTraumatic Stress Intervention:Early Interventionand Secondary Preventionfor At-Risk Children and Youth

Developers

:

Steve Berkowitz, MD

University of Pennsylvania

Steven

Marans

, MSW, Ph.D.

Yale University School of Medicine

Slide24

CFTSI: What Is It?

Brief (4-6 session) evidence-based early intervention model for children following a range of potentially traumatic events (PTE):

After exposure.

After disclosure of earlier sexual or physical abuse.

Based on a family strengthening approach:

Improves caregivers’ abilities to support children impacted by traumatic events.

Goal is to decrease post-traumatic stress reactions and onset of PTSD by increasing communication and family support.

Slide25

Goals of CFTSI

CFTSI aims to:

Reduce traumatic stress symptoms and prevent onset of PTSD.

Improve screening and initial assessment of children impacted by traumatic stress.

Assess child’s need for longer-term treatment.

Slide26

CFTSI: For Whom?

Children aged 7-18 years old.

Identified potential traumatic event(s), either recent or recently disclosed.

Child is experiencing traumatic stress reactions.

Non-offending caregiver (bio or foster) able to participate.

Slide27

CFTSI: Filling a Gapin Available Interventions

CFTSI

:

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

Slide28

Randomized Control Trial: Preliminary Results

CFTSI versus 4-session

psychoeducation

/supportive comparison intervention.

Sample size = 112 (evenly matched comparison and intervention groups).

Participants recruited from:

Forensic Sexual Abuse Program.

Pediatric Emergency Department.

New Haven Department of Police Service.

Funded by SAMHSA

Slide29

Slide30

Slide31

Satisfaction Trends

Youth and caregivers in the comparison group were significantly more likely to feel they needed more sessions beyond the intervention they received (p<.05).

Youth in the CFTSI group felt their experience was more helpful to their family than those in comparison group (p=.06).

Caregivers in CFTSI group felt the intervention helped their children at a higher rate (p=.08).

Slide32

CFTSI

in the Child Advocacy Center Setting

Slide33

Change in PTSD Symptoms Following CFTSI (N=134)

Slide34

Engagement

Begins at the forensic interview.

Starts with the non-offending caregiver.

Flexibility.

Collaboration.

Overcoming barriers.

Slide35

Format of CFTSI

4 – 6 Sessions:

Individual sessions for caregiver.

Individual sessions for child.

Joint sessions with caregiver and child.

Each session is 1 to 1 ½ hours in length.

CFTSI focuses discussion on the child’s traumatic reactions, not on the details of traumatic event(s).

Slide36

Mechanisms of CFTSI

CFTSI works by:

Improving support by increasing communication.

Providing skills to family to help cope with traumatic stress reactions.

Care coordination and addressing concrete external stressors.

Slide37

Improving Support by Improving Communication

Increases communication between caregiver and child about child’s traumatic stress reactions:

Uses clinical tools to help child communicate about reactions and feelings more effectively.

Increases caregiver’s awareness and understanding of child’s experience.

Provides skills and behavioral interventions to help children and families cope with trauma reactions.

Slide38

Developmental Focus

Providing a developmental perspective, CFTSI helps caregivers to better understand their children’s reactions:

Find the most useful ways of communicating with their children.

Find the best ways of being supportive without being intrusive.

Approach for Young Children

Slide39

Care Coordination and Addressing External Stressors

Care Coordination:

Multi-disciplinary Team.

Additional provider’s in the child’s life.

Addressing External Stressors:

Goal:

To decrease concrete needs that interfere with caregiver’s ability to attend to and support child.

To link family to services that may provide support to adults and other family members.

Slide40

Description of Community Involvement in Bridging

Slide41

The CAC and the MDT

Bridging must be at the table:

Individual case assistance.

General expert advice around trauma-exposed children.

Sustained buy-in from all community partners (it’s a person, not a program).

Opportunities to intervene and help are identified around the MDT table.

Slide42

Bridging and Victim Advocacy

They are not the same thing.

Victims’ advocates have special knowledge about navigating the legal system that is crucial to share with families.

Communication between the Bridging clinician and an assigned victims’ advocate is key.

Simultaneous service delivery in concert is the goal.

Slide43

Bridging Care Coordination

Slide44

Doing what needs to be done.

Collaborating with Child Protective Services.

Collaborating with Developmental Services.

Collaborating with schools.

Addressing material resource needs.

Interfacing with adult service providers.

Sometimes helping siblings and other family members.

Slide45

Bridging Data Collection Strategies

Slide46

Bridging Data Strategies

Engagement:

Collaboration with other individuals and agencies who provide services to children and non-offending caregivers.

Rates

of

engagement in the Bridging program.

Completion of treatment/intervention.

Referrals/expert assessment.

Slide47

Bridging Metrics

Documentation of time and effort dedicated to engagement:

this can

be more

time-consuming

than the actual appointments.

To

document this effort we track the:

number

of attempted contacts to

non-offending caregivers.

number

of successful contacts to non

-offending

caregivers.

Slide48

Bridging Metrics

Documentation of collaboration efforts between clinicians

and

other individuals and agencies

within the

community.

To

document this effort we

track the

:

n

umber

of attempted contacts

with

other individuals and agencies within the

community.

n

umber

of successful contacts with other individuals and agencies within the community.

Slide49

Bridging Metrics

Engagement/completion/referral outcome data:

n

ever

responded to phone

calls.

never made an appointment.

refused treatment.

did

not show for

appointment.

began

treatment but did not

complete treatment.

only

needed

telephone assistance.

c

ompleted treatment or intervention.

r

equired additional referral at the close of treatment/intervention.

Slide50

Bridging Data

Slide51

2011 Data

94 Total

Referrals

86

(91%)

Initiated Treatment/Services

75 (80%) Completed Treatment/Services

55

Received Treatment/Services

20 Received Phone Consultation

11 Failed to Complete Treatment/Services

8

(9%

)

No Show/Refused

Slide52

2011 Data

Of those 55 families who received treatment/services:

27

(49%)

received

a referral for additional

treatment.

28 (51%) did not require additional treatment after Bridging.

Slide53

Bridging Funding Strategies

Slide54

Only a portion of what Bridging is can be billed to third party payers.

What can be billed should be billed.

The additional cost for clinician time can be covered:

By CPS (as it is in CT).

By grant funding (especially to meet shortfalls in funding as occurs when a family is not CPS involved).

Slide55

Bridging can be cost saving

Short term treatment but also expert assessment.

This means that we know what children and families need after Bridging:

Some are done.

Some need trauma focused treatment.

Some need other treatment.

Knowing what’s next is cost saving.

Slide56

Funding should be designed to reflect collaboration.

Consider a strategy that ensures all important constituents are involved in planning and execution of program activities.

Co-writing grants lends strength to applications.

Shared data can be more powerful to funders as well.

Slide57

Future Directions

Slide58

Longitudinal Care

Children seen in Bridging as victims have returned to our CAC as alleged perpetrators.

We know that child sexual abuse is a chronic morbidity that can have lifelong consequences.

How do we follow children and families after Bridging?

Slide59

Some possibilities…

Scheduled check-ins with families:

Yearly?

At key developmental milestones, like puberty?

In coordination with pediatric primary care providers:

Shall we be focusing more on this resource?

Slide60

Bridging Program Components

I

mmediate

referral to

services.

I

ntensive

engagement

efforts.

Evidence-based, caregiver-inclusive, trauma focused assessment and short-term treatment.

O

ptimized

community collaboration evidenced by strong linkages to multidisciplinary teams and victim and family

advocacy.

E

xpert

care coordination.

Slide61

Key take home points

Think infectious disease.

Build a model that reflects a commitment to collaboration.

Be ready to highlight the long term savings that can result from up

front

costs.

Advocate for the value of the work that occurs outside the therapy room.

Slide62

Questions?Discussion? Suggestions?

a

ndrea.asnes@yale.edu


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