Blair, Pentz, Alston, Pavlocak | 51-62



Positive Approaches Journal - Volume 2 Title

Volume 13 ► Issue 1 ► June 2024



Bridging Theory to Practice: Trauma Proficient Services for Youth with Autism and Developmental Disabilities

Kimberly Blair, Teri Pentz, Alonzo Alston, and Tara Pavlocak



Children with intellectual and developmental disabilities (IDD) are more likely to experience trauma than neurotypical children. 1 This higher prevalence is due to several risk factors including but not limited to: communication and language barriers, behaviors that can be mistakenly attributed to their disability rather than a traumatic experience, more frequently needing medical procedures or hospitalizations resulting in medical trauma, and the frequent need for multiple caregivers across multiple settings (increasing the risk of trauma from exploitation). 2 They are also more likely to experience bullying and rejection by peers in schools, communities, and on social media. 3 

Despite these individuals being more vulnerable and at higher risk, youth with IDD and their families may find it difficult to obtain trauma treatment. Mental health services and IDD services are typically provided through siloed systems of care, presenting a barrier to receiving trauma-informed care within either system. Additionally, providers in the mental health system are often hesitant to engage in trauma therapy with this population, often lacking the necessary expertise and possibly even being unaware that children with IDD can benefit from this type of care.3 Existing trauma therapies can be just as effective with children with IDD as it is with children without – by providing good quality, person-centered treatment in a way that appreciates their unique abilities, strengths, hopes, and goals. 

The National Child Traumatic Stress Network (NCTSN) provides a wealth of resources for clinicians, service providers, and caregivers on the impact of childhood trauma and available interventions for children and adolescents who have experienced trauma. For practitioners who need additional resources, information is available about how to adapt existing trauma treatments for children with IDD, as many of these evidence-based treatments can be effective with modifications to standard protocols. These recommendations include the types of adaptations appropriate for all children in various contexts. For example, adaptation may include adjusting the length, frequency, and pace of content in treatment sessions; significantly involving parents and other caregivers into treatment sessions; adjusting content to meet the needs of the child by breaking information into smaller chunks, simplifying information, or engaging in frequent repetition of key concepts; and using accommodations effective for the child in other contexts, such as frequent movement breaks, reinforcers, or rewards. 3 Despite the demonstrated need for access to trauma therapy, families with children who have IDD continue to struggle to find quality care. As described above, there are many reasons why finding trauma-proficient therapists to serve this population can be a challenge. 

For decades, young children and families have sought treatment from the Matilda Theiss behavioral health programs at UPMC Western Psychiatric Institute and Clinic (now UPMC Western Psychiatric Hospital). In 2012, the University of Pittsburgh Department of Psychiatry was awarded a federal grant from the Substance Abuse and Mental Health Services Administration (SAMHSA). With this grant, UPMC and the University of Pittsburgh became     part of the National Child Traumatic Stress Network (NCTSN) and implemented evidence-based treatment options through their outpatient program for children and families who have experienced trauma. Since the initial grant (2012-2016), two more rounds of funding were awarded, which allowed the programming to grow and evolve into what is now the Theiss Center for Child and Adolescent Trauma. Over the years, the program has attempted to provide high quality trauma therapy to all children who have experienced significant trauma and has engaged children with and without intellectual and developmental disabilities. 

A Case Example

The following is a case example illustrating how Theiss has successfully provided trauma treatment for a child with autism and comorbid mental health issues. 

Levi is a 17-year-old male referred by his residential program to the Theiss Center for Child and Adolescent Trauma at UPMC Western Behavioral Health for outpatient trauma therapy. Levi had a long history of trauma, including the death of his father from community violence and the death of his grandmother due to an overdose – all while he was still a toddler. Levi lived with his biological mother and her boyfriend until seven years of age, where he experienced severe neglect, physical abuse, and suspected sexual abuse. He was removed from this home at age seven and placed with his paternal grandmother. However, he was returned to his biological mother’s care several times before being permanently placed with his grandmother at age 11. While living with his grandmother, Levi exhibited extreme physical aggression, rage, and extensive property destruction, resulting in multiple hospital and residential placements throughout his adolescence.

Since the time of referral, Levi has resided within a specialized residential program for children and adolescents with complex needs. Staff members from this program contacted Theiss after attending a virtual training on child trauma, not only referring Levi for therapy, but also seeking additional training and consultation to support him in the residential setting given his extensive trauma history.   

Prior to his initial evaluation for services, Levi received a variety of diagnoses including Autism Spectrum Disorder, Intellectual Disability, Disruptive Mood Dysregulation Disorder, Post Traumatic Stress Disorder, Intermittent Explosive Disorder, and Reactive Attachment Disorder. He continued to exhibit rage, physical aggression, and property destruction within this residential placement. This behavior necessitated the need for two staff to accompany him for most of the day. These staff members felt it was unsafe to transport Levi into the community due to aggression and elopement concerns. Staff communicated that Levi wanted to talk about his painful early experiences and that he was requesting the support of a therapist. Therefore, after extensive safety planning, Levi began treatment in-person at the outpatient clinic. 

When he began trauma treatment, the initial focus was establishing rapport and providing Levi with a safe space to talk. The therapist focused on ways that Levi could communicate his wants, needs, and feelings without resorting to aggression. The therapist also provided Levi with feeling words and helped him identify nonverbal signals that he could utilize to label what he was feeling. They also worked on identifying Levi’s triggers and helping him connect these feelings with his past trauma experiences. During the early days of Levi’s treatment, both the therapist and the trauma consultant have maintained contact with the residential staff who support him, helping them to establish a “safe space” in his home. They helped Levi learn how to let staff know when he is becoming dysregulated and how to utilize the space, ultimately preventing him from having to resort to aggression. These strategies were very effective, particularly early in treatment when Levi was still having difficulty putting his emotions and pain into words. The therapist further supported the residential staff by helping them understand all the ways that Levi was trying to communicate with them. Later in treatment, the therapist began working with Levi to talk about his future dreams and how he could move toward these goals, while working with residential staff and Levi to focus on more than just behaviors and consequences – including processing early trauma and understanding how his early experiences have impacted Levi emotionally.

Throughout treatment, the therapist also adjusted the more typical treatment strategies as needed, taking into consideration the following:

Levi’s chronological and developmental age

Challenges with verbal expression

Need for extensive repetition before mastery and use of skills

- History of trauma

Need for concrete strategies and ideas

- Building Levi’s tolerance for therapy and “holding” difficult emotions

His current relationship with his mother and his grandmother

Initially, one of the residential staff attended all of Levi’s therapy sessions to help him feel comfortable. Gradually, as Levi and his therapist developed rapport and Levi was feeling safe, the residential staff member was more frequently able to step back and allow the therapist and Levi to meet alone.

A year since initial referral, Levi continues to participate in trauma therapy at Theiss. His incidents of aggression have greatly declined, and he is beginning to move toward increased time in the community with reduced levels of support. Levi’s ultimate goal is to transition out of residential placement into his own home with minimal support. As everyone recognizes that success is not a “straight line” process, the therapist and residential staff continue to maintain open communication and adjust treatment strategies as needed and at Levi’s own pace, in order to support his progress. Levi’s success has been largely due to the collaborative work between the trauma therapist and the care providers, all becoming much more skilled in applying our knowledge of early trauma to Levi’s day-to-day needs.

Trauma-Proficient IDD Services

Professional development opportunities about trauma and the impact of those traumatic experiences on the mental health of children and adolescents are becoming increasingly accessible. Few professionals working with children today would reject the notion that trauma can have a profound impact on development and behavioral health outcomes. However, there is significant variation in how being trauma-informed impacts the day-to-day work of teachers, therapists, caseworkers, etc. It is therefore important to move beyond trauma-informed care, to trauma-proficient care. This demands a different type of training, one that moves from providing information to caregivers to the application of knowledge about trauma to everyday practice

The Theiss Center for Child and Adolescent Trauma not only supports the implementation of evidence-based treatment within UPMC’s child and adolescent trauma specialty outpatient clinic, but it also provides a mechanism through which child and adolescent clinicians may become trauma proficient, not just trauma informed. This mission is supported through training UPMC clinicians and graduate students in evidence-based treatments for trauma, as well as by offering professional development opportunities that provide practical, practice-oriented information, and a mechanism through which to assist programs in becoming trauma proficient in the work they do with traumatized children and families. 

The Theiss Training Center was established to develop and deliver professional development programs that better equip professionals to provide services to children and adolescents with trauma histories across the UPMC Western Behavioral Health Network and beyond. The inaugural offering of the Theiss Training Center is a child trauma curriculum that provides a framework for use by clinicians and programs across target populations, clinical specialties, and levels of care. This curriculum begins with foundational general concepts in trauma and child development and moves toward integration into practice, focusing upon training tailored to individual clinic/population needs. Ideally, participants are encouraged to progress in sequence through the components to achieve the best training outcomes. Overall, the curriculum helps participants understand how early traumatic events can impact the emotional and behavioral functioning of children with a variety of clinical presentations and treatment needs. More specifically, the Theiss child trauma curriculum includes the following components.

Trauma Foundations: Understanding how early traumatic experiences impact child and adolescent development, identity, and behavior is critical to providing quality mental health care. A Child Trauma Lecture provides foundational concepts related to trauma, including the impact of child trauma on brain development, personality, relationships, and behavior. This didactic focuses on general clinical practice with children, delivers a detailed discussion about the impact of early attachments on mental health, and explores the influence of intergenerational trauma on child and family functioning. This component integrates information from a variety of sources including Infant Mental Health principles, early attachment models, Child Parent Psychotherapy foundational concepts (an evidence-based trauma treatment modality focusing on young children), current research regarding the impact of early trauma experiences on developmental processes, and the training developer’s extensive treatment experience.

Trauma Demonstration: Training that provides a seamless transition from theory to practice is vital for clinicians to truly develop the skills to become trauma-proficient in clinical work. After providing the foundational knowledge on trauma and developmental theory, training shifts to demonstrating how trauma histories can impact a child’s current behavior and how to incorporate these concepts into treatment planning. This component is called the Child Trauma Laboratory.   Drawing heavily from psychosocial theories of development, the trainer uses fictitious case examples of children with different behavioral health presentations to demonstrate how to move from a conceptual understanding of the developmental impact of trauma to individualized treatment planning and intervention. In addition, this component also includes a review of the impact of secondary traumatic stress on clinician functioning and client outcomes. 

Trauma Application: The third component provides more in-depth instruction though the direct application of trauma concepts to specific clinics and their populations (Child Trauma Practice), including providers who serve children with IDD. This component is typically provided at the training participants’ clinic or program and incorporates information from their specific clients. Participants are asked to bring detailed social histories for real clinical cases, excluding any identifiable information. Within the context of psychosocial and attachment theories, the trainer then helps the participant plot the child’s early traumatic events on a timeline, analyze the potential impact of these traumatic events, discuss how these trauma experiences are influencing the child’s current functioning, and most importantly, discuss recommendations regarding how all this valuable information can now inform current treatment. 

- Consultation: To reinforce the development of trauma proficiency in clinical practice, ongoing consultation is available for individual clinics to support the incorporation of trauma-focused concepts into treatment. Consultation support can be scheduled regularly, or as needed, depending on clinic preference. It is anticipated that consultation may be more frequent immediately following the Child Trauma Practice training and then tapered down over time as the concepts take hold in clinical standards of care. As in Levi’s case, the ability of the trauma therapist to collaborate with caregivers, and the ability for caregivers to obtain training and ongoing specific consultation on how to support Levi across environments, allowed for dramatic improvements in behavioral health functioning.


 


References

1.     Brendli C, Broda MD, Brown R. Children with intellectual disability and victimization: A logistical regression analysis.  Child Maltreatment. 2021; Children With Intellectual Disability and Victimization Journal Article.

2.     Horton C, Evans N, Charkowski R, et al. Children with intellectual and developmental disabilities can experience traumatic stress: A fact sheet for parents and caregivers.  Los Angeles, CA, and Durham, NC: National Center for Child Traumatic Stress. 2021.

3.     Trauma and Intellectual/Developmental Disability Collaborative Group. The impact of trauma on youth with intellectual and developmental disabilities: A fact sheet for providers. Los Angeles, CA, and Durham, NC: National Center for Child Traumatic Stress. 2020.




Biography

Kimberly Blair, PhD: A licensed psychologist and an Associate Professor in the University of Pittsburgh Department of Psychiatry. As part of her role with the University of Pittsburgh, in 2005, Dr. Blair was appointed as the Director of the children’s early childhood behavioral health programs at the Matilda Theiss Early Childhood Center in Pittsburgh, the cornerstone of early childhood mental health services at UPMC Western Behavioral Health. In 2012, Dr. Blair established what is now the Pittsburgh-based Theiss Center for Child and Adolescent Trauma, part of the National Child Traumatic Stress Network and funded by grants from Substance Abuse and Mental Health Services Administration (SAMHSA). Dr. Blair is currently serving as the program director for the Child & Adolescent Trauma Services Outpatient Clinic. The current NCTSN Complex Child & Adolescent Trauma Project is working to expand trauma treatment access to children ages 2 through 17, as well as provide trauma training and consultation across UPMC Western Behavioral Health programs and beyond.

Teri Pentz, MS, LPC: Has over 25 years of experience working with children and their families, both in Early Intervention and in Infant and Early Childhood mental health.  She has a master’s degree in Counseling Psychology, is a board certified Licensed Professional counselor, and has earned Infant Mental Health endorsement (IMH-E®) through Michigan AIMH and Pennsylvania AIMH at the Clinical Mentor level.  She has been a direct service provider, Service Coordinator, and supervisor for Early Intervention and Behavioral Health services within several agencies and counties and has participated in intervention services for children of all ages across her various positions. Currently, Teri works at the Theiss Center for Child and Adolescent Trauma as a supervisor, therapist, and trainer, specializing in Child-Parent Psychotherapy and working with young children who have experienced trauma including issues with attachment, as well as children of adoption.

Alonzo L. Alston, MS, LPC: Earned his Master of Science Degree from Slippery Rock University in Community Counseling and acquired his License in Professional Counseling (LPC). For the past three years Alonzo has been employed as an outpatient therapist at Theiss Center for Child and Adolescent Trauma at UPMC. Alonzo has over twenty-five years of experience working with children and adolescent trauma clients in various treatment settings. He began his career completing individual and group therapy services for children and families in residential settings, going on to work with homeless children and families completing mental health assessments, offering treatment linkages, and completing therapeutic services, and then returning to work with adolescents with conduct issues in residential settings before joining the outpatient trauma clinic at UPMC Western Behavioral Health.

Tara Pavlocak, MSW: A Research Program Administrator with UPMC and is currently responsible for day-to-day management of the Theiss Complex Child and Adolescent Trauma Project. She has a Master of Social Work degree from the University of Pittsburgh with a specialization in Community Organizing/Social Administration and is a Dean’s Scholar Award winner. Tara has 20 years of community and non-profit experience with an emphasis on federal/state and foundation grant proposal writing and grant project implementation and management. Tara has had a vital role in the growth and continued funding of the SAMHSA-funded, NCTSN Category III Theiss Center for Child and Adolescent Trauma since its inception in 2012 and has served as its manager since 2013.


Contact Information

Kimberly Blair: blairka@upmc.edu

Tara Pavlocak: pavlocakta@upmc.edu

Teri Pentz: pentzt@upmc.edu

Alonzo Alston: alstonal@upmc.edu