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
Slide2Goals
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.
Slide3Objectives
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.
Slide4Overview
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
Slide5Why are there 7 presenters?
This is a team effort.
Collaboration is what it takes to make the program work.
Slide6History
Slide7The 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).
Slide8The 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.
Slide9New 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.
Slide10Non-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.
Slide11Initial 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.
Slide12The 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.
Slide14Key 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.
Slide15Description of the Yale Sexual Abuse Clinic and the South Central CAC
Slide16YCSAC 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
Slide17Description of Bridging Referral and Engagement Strategies
Slide18It 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.
Slide19Ideally, 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.”
Slide20It’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.
Slide21Sometimes it’s a concrete obstacle.
Transportation.
Parking.
Child care.
Work schedules.
Slide22Description of the Mental Health Intervention
Slide23The 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
Slide24CFTSI: 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.
Slide25Goals 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.
Slide26CFTSI: 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.
Slide27CFTSI: 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.
Slide28Randomized 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
Slide29Slide30Slide31Satisfaction 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).
Slide32CFTSI
in the Child Advocacy Center Setting
Slide33Change in PTSD Symptoms Following CFTSI (N=134)
Slide34Engagement
Begins at the forensic interview.
Starts with the non-offending caregiver.
Flexibility.
Collaboration.
Overcoming barriers.
Slide35Format 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).
Slide36Mechanisms 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.
Slide37Improving 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.
Slide38Developmental 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
Slide39Care 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.
Slide40Description of Community Involvement in Bridging
Slide41The 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.
Slide42Bridging 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.
Slide43Bridging Care Coordination
Slide44Doing 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.
Slide45Bridging Data Collection Strategies
Slide46Bridging 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.
Slide47Bridging 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.
Slide48Bridging 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.
Slide49Bridging 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.
Slide50Bridging Data
Slide512011 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.
Slide53Bridging Funding Strategies
Slide54Only 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).
Slide55Bridging 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.
Slide56Funding 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.
Slide57Future Directions
Slide58Longitudinal 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?
Slide59Some 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?
Slide60Bridging 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.
Slide61Key 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.
Slide62Questions?Discussion? Suggestions?
a
ndrea.asnes@yale.edu
The Bridging Program:
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