Structured Sensory Therapy (SITCAP-ARC) for
Traumatized Adjudicated Adolescents in Residential Treatment
Melvyn C. Raider
Wayne State University
William Steele
This study assessed the effectiveness of a structured group therapy (SITCAP-ARC) for traumatized, adjudicated adolescents in residential treatment. Youth were randomly assigned to a trauma intervention (SITCAP-ARC) or to a waitlist/comparison group. Study participants demonstrated statistically significant reductions in trauma symptoms, depression, rule breaking behaviors, aggressive behaviors and other mental health problems.
In 2001 the National Clearinghouse on Child Abuse and Neglect documented that almost one million children were identified by state child protective service agencies to be victims of child abuse and neglect. (National Clearinghouse on Child Abuse and Neglect Information NCANDS, 2001, p.2). For many of these maltreated children and adolescents the trauma that maltreatment produces has a significant impact on their emotional, behavioral and cognitive functioning. (Massachusetts Citizens for Children, 2001). As a result of the emotional, behavioral and cognitive deficits influenced by trauma, many children and adolescents developed dysfunctional coping mechanisms that may take the form of oppositional, defiant and aggressive behavior (Jacobs, J. 2005). Van Dalen (2001) suggests that many untreated traumatized children and adolescents demonstrate drug and alcoholic dependency as well as repeated delinquent behavior leading to adult criminal behavior.
Cognitive/behavioral therapies have been in widespread use to treat children and adolescents who have been traumatized. In fact, cognitive/behavioral therapy has been recommended as the “best practice” approach by the Society for Traumatic stress (Ovaert,L.B., Cashel, M.L., & Sewell, K.W., 2003) and American Academy of Child and Adolescent Psychiatry (AACAP, 1998). However, because of the cognitive distortions and deficits produced by traumatic events it may be more difficult and potentially less effective to treat children and adolescents using only cognitive/behavioral therapy. It may be hypothesized that the effectiveness of cognitive/behavioral therapy may be enhanced with the inclusion of sensory based activities.
What may be needed to supplement cognitive/behavioral therapy is sensory based therapeutic activities to assist with the processing of the implicit memories of trauma and to restore more effective emotional functioning. Once more effective emotional functioning is restored; cognitive behavioral therapeutic activities can more easily develop clearer thinking and positive coping strategies. The SITCAP-ARC structured trauma treatment approach, which is the focus of this article, utilizes a series of drawing tasks and treatment specific questions that target the major sensations which are experienced in a traumatic event (e.g., terror, fear, worry, powerlessness). The premise of SITCAP-ARC is that traumatic memories are experienced at a sensory level and must be reactivated in a safe environment in order to be moderated and tolerated with a sense of power and feeling of safety.
There has been limited research on post-traumatic stress disorder (PTSD) treatment in residential settings Ovaert, L.B., Cashel, M.L., & Sewell, K.W. (2003) conducted a controlled study to assess the efficacy of structured cognitive behavioral group therapy for PTSD in incarcerated male juveniles. Self reported PTSD symptoms were significantly reduced (p = .01). However, measures of symptoms of anxiety, anger and depression did not demonstrate statistically significant reductions
The purpose of this article is to report on a controlled research study to demonstrate the efficacy of a structured group therapy for adjudicated youth in residential treatment (Structured Sensory Intervention for Traumatized Children, Adolescents and Parents – Adjudicated and at Risk Youth SITCAP-ARC). The facility that participated in the study was the Multi-County Juvenile Attention Center, Ohio in collaboration with Northeast Ohio Behavioral Health, North Canton and Cuyahoga Falls, Ohio.
TRAUMA INTERVENTION PROGRAM
The Trauma Intervention Program for Adjudicated and At-Risk Youth (SITCAP-ARC) is a modification of Structured Sensory Intervention for Traumatized Children, Adolescents and Parents (SITCAP), (Jacobs, J. & Steele, W., 2003). The SITCAP-ARC model is a comprehensive treatment approach designed to diminish the terror that exposed individuals experience and facilitate feelings of safety. Trauma reactions are normalized the distinction between trauma and grief is emphasized. This structured protocol provides a session-by-session, situation specific (e.g., school vs. agency) guide to intervention. It is appropriate for individuals who have experienced violent or non-violent trauma and is age-specific (preschoolers, 6-12 year olds, adolescents, adults). Focusing on themes such as ‘hurt and ‘worry’ that accompany both violent and non-violent types of trauma enhances the generalizability of the model. The parent component encourages a supportive caretaker response and addresses past and present traumas in the parent’s life (Steele and Raider, 2001). SITCAP-ARC designed specifically for adjudicated youth integrates cognitive strategies with “sensory”, “implicit” strategies. SITCAP-ARC is designed to achieve the successful cognitive re-ordering of traumatic experiences in ways that move adjudicated adolescents from victim to survivor thinking and in ways that allow them to become more resilient to future traumas. With increased cognitive functioning resulting from sensory based processing, the adolescent has a greater chance of benefiting from intervention that addresses the maladaptive coping behaviors characteristic of adolescents who have experienced long-term trauma reactions.
The program consists of 10-11 sessions depending upon the progress made with each session. Seven of the sessions are group sessions with each group comprised of six participants. In addition, there is one individual debriefing session, one individual processing session and one parent/adolescent session. Each group session is scheduled for one hour and fifteen minutes.
The goals of SITCAP-ARC are:
- Stabilization (return to previous level of functioning or prevention of further dysfunction).
- Identification of PTSD reactions
- The opportunity to revisit the trauma in the supportive, reassuring presence of an adult (professional) who understands the value of providing this opportunity;
- An opportunity to find relief from trauma-induced terror, worry, hurt, anger, revenge, accountability, powerlessness, and the need for safety;
- An opportunity to re-establish a positive “connectedness” to the adult world;
- Normalization of current and future reactions;
- Support of the heroic efforts to become a survivor rather than a victim of their experience;
- When appropriate, assistance for parents in resolving those reactions triggered by their child’s traumitization;
- Replacement of the traumatic sensory experience with positive sensory experiences;
- Identification of additional needs and recognition of the role parents can take to help meet those needs;
- The provisioning of parents with ways to respond to their traumatized child’s reactions.
METHOD
The research was conducted at the Multi-County Attention Center in Ohio. The therapist was Margaret De Lillo-Storey, a staff member of Northeast Ohio Behavioral Health Center. Ms. Storey was trained in SITCAP-ARC and certified by the Trauma and Loss Institute which was the developer of the treatment model. To assure that each therapy session was conducted in compliance with the SITCAP-ARC Model, Ms. Storey completed a Fidelity of Treatment Checklist (FTC). Analysis of the checklists indicated 98.5 percent Fidelity with the manualized treatment model. The Multi-County Attention Center clinical staff identified youth with documented multiple trauma exposure were recruited to participate in the research study. Two thirds of research participants were between 16 and 17 years of age. Eleven were male and nine were female. Most were white (85 percent). There was one Hispanic participant. The most frequently reported problems which contributed to placement in residential facility were behavior problems at home, criminal behavior, alcohol/substance abuse, behavior problems at school, and attachment problems. The most frequently documented trauma exposures were psychological maltreatment, physical maltreatment, sexual maltreatment, domestic violence, neglect, traumatic loss or separation. Three quarters of research participants experienced multiple trauma. Fifty-five percent of the research participants have been assessed to have post-traumatic stress disorder, twenty percent traumatic or complicated grief. Youth and parents/guardians participated in an educational session in order to provide complete information about the SITCAP-ARC trauma treatment program. Participation was voluntary requiring approval of both youth and parent/guardians. Both youth and their parents/guardians signed informed consent forms approved by Wayne State University Human Investigation Committee.
The group of research participants completed three instruments. The instruments were the Trauma Symptom Checklist (TSCC) (Briere, 1996), the Youth Self Report (YSR) (Achenbach T.M. and Rescoria, L.A., 2001), and the Child and Adolescent Questionnaire (CAQ) developed by the authors (Steele, W. and Raider, M., 2001). In addition, the youth therapist, utilizing the Youth’s clinical case record completed clinical data form which gathered information on demographics, trauma exposure, and severity of symptoms, services utilization and limited information about domestic environment.
Research participants were randomly assigned to two groups. The first group began immediate group treatment utilizing the SITCAP-ARC program. The second group was the comparison/control group which remained on the waitlist for treatment and received the SITCAP-ARC program identical to the treatment group when the treatment group had completed treatment (approximately ten weeks). Youth assigned to the comparison/control waitlist group were contacted bi-weekly by the group therapist, Ms. De Lillo-Storey in order to monitor any changes, escalations, and/or life event which required immediate intervention. Upon completion of the SITCAP-ARC program, the treatment group completed the CAQ, TSCC and the YSR. The waitlist group completed these instruments as well at that time. After the waitlist group completed the SITCAP-ARC program, they completed the CAQ, TSCC and YSR.
MEASURES
The Trauma Symptom Checklist for Children (TSCC-A) is a standardized self report measure of post-traumatic and related symptoms for children 8 – 16 years of age. The instrument can be used with children as young as 7 and adolescent as old as 17 (Briere, J., 1996). The instrument was developed to assess symptoms of children who have experienced traumatic events, not to assess the DSM-IV construct of PTSD specifically (National Child Traumatic Stress Network, 2007). The version of the instrument utilized in this study evaluates children’s responses in five symptom domains: anxiety, depression, anger, post-traumatic stress, dissociation. Dissociation has two subscales overt dissociation and fantasy. The five scales all demonstrate high internal consistency reliability (a = .82 – 87) and moderate convergent validity .51-.63.
The Youth Self Report (YSR) is a standardized self report measure that assesses problem behaviors in two summary domains: internalizing and externalizing (Achenbach, T.M. and Rescoria, L.A., 2001). These summary domains are comprised of eight symptom scales: anxious/depressed, withdrawal/depressed, somatic complaints, social problems, thought problems, attention problems, rule breaking behavior, and aggressive behavior. The YSR is designed to assess problem behaviors of children and adolescents 11 – 18 years of age. The YSR is a parallel instrument to the Child Behavior Checklist (CBCL). The YSR is one of the most widely used instruments in research which measures child and adolescent problem behaviors. Test/retest reliability is high (a = .87), internal consistency is very high (a = .95). Construct validity when used in conjunction with the CBCL is high (a = .85 - .89).
The Child and Adolescent Questionnaire (CAQ) (Steele, W. and Raider, M., 2001) is a self report measure of post-traumatic stress symptoms as specified in the DSM-IV (APA, 1994). The CAQ was developed by Steele and Raider and is a modification of the Child PTSD Reaction Index (Frederick, D.J., Pynoos, R., and Nader, K. (1992). The CAQ consists of 35 Likert-type questions comprising three scales. Scale I is the re-experiencing of the traumatic event, Scale II is avoidance of stimuli associated with the traumatic event, and Scale III is symptoms of increased arousal due to the traumatic event. C.A.Q. has demonstrated high internal consistency (Cronbach’s alpha = .82-87) satisfactory convergent validity was demonstrated by correlating the C.A.Q. scales with the trauma symptom (r=.40-.67) checklist scales.
RESULTS
TRAUMA SYMPTOM CHECKLIST FOR CHILDREN (TSCC)
Table I and Table II reflects paired t-tests for the seven scales of the TSCC. Table I reflects results of changes in scales from pre-test to post-test for the Control Group. The Control Group did not demonstrate statistically significant changes (p = < .05).
Table II reflects results of changes in the seven scales. The TSCC from pre-test to post-test for the Treatment Group (1st Treatment Group and Waitlist Crossover). The Treatment Group demonstrated statistically significant reduction for symptoms in the anxiety, anger, dissociation, dissociation overt scales (p = <.05). A very impressive reduction in symptoms in the post-traumatic stress scale was achieved (p = < .01).
(See Table I and II)
CHILD AND ADOLESCENT QUESTIONNAIRE (CAQ)
Table III and Table IV reflect paired t-tests for the three trauma scales in the CAQ. Table III reflects results of pre-test and post-test comparisons for the Control Group. Changes from pre-test to post-test for all scales did not achieve statistical significance (p = < .05).
Table IV reflects results of the pre-test to post-test comparisons for the Treatment Group. The Treatment Group demonstrated very substantial reductions in trauma symptoms for all three scales. The re-experiencing and avoidance scales demonstrated highly statistically significant reductions in symptoms (p = <.01).
(See Table III and IV)
YOUTH SELF REPORT (YSR)
Table V and Table VI reflects paired t-tests for changes in syndrome scales on the YSR. Table V reflects results of the pre-test to post-test comparisons for the Control Group. The Control Group did not demonstrate any statistically significant changes in symptoms in syndrome scales.
Table VI reflects results of pre-test and post-test comparisons for the Treatment Group which includes the original Treatment Group as well as the waitlist group. (N = 19). As specified in the crossover protocol, the waitlist group received treatment after the original Treatment Group completed the SITCAP interventions.
The anxious/depressed, withdrawn/depressed, thought problems, behavior, internalizing behavior, externalizing behavior and total problems scales reflected reductions in symptoms and achieved statistical significance (p = .05), The rule breaking and aggressive behavior scales demonstrated impressive reductions in symptoms and achieved statistical significance at the p = <.01 level.
The somatic complaints and social problems scales reflected a reduction in symptoms but did not achieve statistical significance. The very impressive reductions in the rule breaking and aggressive behavior scales are of particular importance for residential treatment settings.
(See Table V and VI)
DROPOUTS
There were five study participants who dropped out of the research study in the early sessions of the group therapy. Dropouts were similar in demographics to those who completed the program. Pre-test scores on the CAQ and the TSCC were lower on average than the pre-test scores of those who completed the program. It may be hypothesized that dropouts may have been experiencing fewer trauma symptoms than those who completed the SITCAP-ARC program.
DISCUSSION
The first hypothesis that the treatment group would demonstrate statistically significant reductions in trauma symptoms at the conclusion of treatment was supported. (The comparison/control group did not demonstrate statistically significant reductions in trauma at that time.) The Trauma Symptom Checklist for Children demonstrated statistically significant reductions in anxiety, anger, post-traumatic stress, and dissociation. The CAQ demonstrated statistically significant reductions in the re-experiencing, avoidance and arousal scales.
These results are consistent with the findings of Ovaert, et. al (2003) which the authors assert was the first controlled study to evaluate the efficacy of a structured cognitive behavioral therapy program for traumatized incarcerated youth. The researchers used a measure of post-traumatic stress PTSD-RI (Frederick, 1982) which is somewhat similar to the CAQ. They did not use the Trauma Symptom Checklist for Children.
The second hypothesis that the treatment group would demonstrate statistically significant reductions in mental health symptoms was supported (The Waitlist/Control Group did not demonstrate statistically significant reductions in mental health symptoms at that time). The Youth Self Report (YSR) demonstrated statistically significant reductions in total problems: depression, anxiety as well as withdrawn, thought problems, attention problems, rule breaking behavior, aggressive behavior, internalizing behavior, externalizing behavior. Very significant reductions were demonstrated for rule breaking behavior, aggressive behavior and externalizing behavior. Aggressive behavior and rule breaking behaviors are highly associated with at-risk adjudicated youth and are behavioral manifestations of the arousal response to trauma victimization (Ford et al, 2006). The reduction of arousal symptoms reported by the TSCC and CAQ are also supported by the YSR’s reported reduction of these behavioral manifestations of arousal.
The Ovaert, et. al. study discussed earlier did not demonstrate reductions in symptoms of anxiety, anger and depression. Goenjian in a study of the outcome of psychotherapy among early adolescents after trauma (Goenjian, 1997) similarly did not report reductions in depression after trauma treatment.
The very impressive reduction in mental health problems, especially reductions in rule breaking and aggressive behaviors of SITCAP-ARC participants, suggests the hypothesis that sensory based therapeutic activities in combination with cognitive/behavioral therapy is more likely to reduce mental health symptoms among traumatized youth than cognitive/behavioral therapy alone. SITCAP-ARC uses sensory based activities which are then followed by cognitive reframing and processing. From a neurological standpoint ARC initiates interventions that addresses the implicit (sensory) memories of trauma and only thereafter address the explicit (cognitive) responses to traumatic exposure. For most youth trauma is initially an implicit experience (Steele & Raider, 2001; Steele, 2003; Van Dalen, 2001; Rothschild, 2000; Saigh, 1999; Perry, 1999; Michaesu and Baettig, 1996; van der Kolk, 1987), SITCAP-ARC leads to emotional regulation and clearer thinking which allow the youth to better understand how their traumatic experiences have activated their thoughts and emotions to avoid further victimization by engaging in those behaviors associated with delinquency.
Following implicit processing SITCAP-ARC may influence the reintegration of implicit memories with the cognitive reframing of the implicit trauma memories; a “rewriting” or “reordering” of the experiences in ways the child/adolescent can now best manage. It may be hypothesized that the significant gains reported by the TSCC, YSR, and CAQ are the result of the sensory/cognitive integration process of the SITCAP-ARC program.
Since completion of the SITCAP-ARC group therapy program, therapists and staff members have observed positive attitude and behavioral changes in the youth. They are not as negative, less aggressive, and less resistant. There have been no “repeat lock ups” reported for youth who participated in the program. The Superintendent felt so positively with regard to the outcomes of the SITCAP-ARC program as to suggest providing the program for all youth in residential placement. Prior to the use of SITCAP-ARC in this controlled research study the therapy was field tested in 2005. Eighty five at-risk adjudicated adolescents in Gainsville and Jasper, Georgia participated in the field test under the supervision of the Juvenile Court. Following SITCAP-ARC group therapy field test, in a descriptive satisfaction survey, 100 percent of the 85 participants reported a reduction in trauma symptoms as indicated by a comparison of pre-trauma and post-trauma PTSD scores on a scale of 1 to 10, 90 percent indicated they definitely felt better following intervention using “9” and “10” to rate that difference. One year following this field test, 85 percent of the youth had no additional “criminal” contact with the court.
The results of this study, although impressive, must be viewed as preliminary. The control group was small and the treatment group was of modest size. Further research in additional residential settings is necessary. However, it is clear that SITCAP-ARC has demonstrated value for assisting traumatized adjudicated youth in residential settings with both trauma symptoms and mental health symptoms. “Williams and Sccker, et. al. stated that delinquent youths who experienced dysregulated emotions and survival or victim based information processing will be be able to become responsible citizens if they are assisted in gaining the capacity to manage their emotions and think clearly (Ford, et al., 2006, p. 18).” The ARC program demonstrated significant gains in these two critical areas.
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TABLE I – TRAUMA SYMPTOM CHECKLIST FOR CHILDREN (TSCC)
Paired t-test N = 9
CONTROL GROUP (WAITLIST)
|
|
|
|
|
|
|
Mean |
Mean |
Mean |
|
Sig |
Scale |
Pre-Test |
Post-Test |
Difference |
t |
(12 tailed) |
|
|
|
|
|
|
Anxiety |
16.00 |
12.44 |
3.57 |
1.242 |
0.249 |
|
|
|
|
|
|
Depression |
14.89 |
12.11 |
2.78 |
1.927 |
0.090 |
|
|
|
|
|
|
Anger |
16.33 |
14.00 |
2.33 |
1.373 |
0.207 |
|
|
|
|
|
|
Post-Traumatic Stress |
20.78 |
15.78 |
5.00 |
1.917 |
0.092 |
|
|
|
|
|
|
Dissociation |
18.11 |
15.56 |
2.56 |
0.890 |
0.400 |
|
|
|
|
|
|
Dissociation Overt |
12.22 |
11.22 |
1.00 |
0.524 |
0.614 |
|
|
|
|
|
|
Dissociation Fantasy |
5.89 |
4.33 |
1.56 |
1.346 |
0.215 |
TABLE II – TRAUMA SYMPTOM CHECKLIST FOR CHILDREN (TSCC)
Paired t-test N = 20
TREATMENT GROUP (1ST TREATMENT AND WAITLIST CROSSOVER)
|
Mean |
Mean |
Mean |
|
Sig |
|
Scale |
Pre-Test |
Post-Test |
Difference |
t |
(2 tailed) |
|
|
|
|
|
|
|
|
Anxiety |
10.30 |
7.50 |
2.8 |
2.525 |
0.021 |
* |
|
|
|
|
|
|
|
Depression |
11.25 |
9.00 |
2.25 |
1.779 |
0.091 |
|
|
|
|
|
|
|
|
Anger |
13.60 |
. 10.05 |
3.55 |
2.406 |
. 0.026 |
* |
|
|
|
|
|
|
|
Post-Traumatic Stress |
13.85 |
10.30 |
3.55 |
2.891 |
0.009 |
** |
|
|
|
|
|
|
|
Dissociation |
13.00 |
9.35 |
3.65 |
2.265 |
. 0.035 |
* |
|
|
|
|
|
|
|
Dissociation Overt |
9.75 |
6.70 |
3.05 |
2.877 |
0.010 |
* |
|
|
|
|
|
|
|
Dissociation Fantasy |
3.25 |
2.65 |
0.600 |
0.993 |
0.333 |
|
|
|
|
|
|
|
|
* p = < .05
** o = < .01
|
TABLE III – CHILD AND ADOLESCENT QUESTIONNAIRE (CAQ)
Paired t-test N = 9
CONTROL GROUP
|
Mean |
Mean |
Mean |
|
Sig |
Scale |
Pre-Test |
Post-Test |
Difference |
t |
(2 tailed) |
|
|
|
|
|
|
Re-experiencing
Traumatic Event |
38.11 |
34.89 |
3.22 |
0.619 |
0.553 |
|
|
|
|
|
|
Avoidance of Stimuli
of Traumatic Event |
39.22 |
39.22 |
0.00 |
0.000 |
1.000 |
Symptoms of Arousal
Due to Traumatic Event |
33.67 |
30.56 |
3.11 |
0.695 |
0.506 |
TABLE IV – CHILD AND ADOLESCENT QUESTIONNAIRE (CAQ)
Paired t-test N = 20
TREATMENT GROUP (1ST TREATMENT GROUP AND CROSSOVER WAITLIST)
|
|
|
|
|
|
|
|
Mean |
Mean |
Mean |
|
Sig |
|
Scale |
Pre-Test |
Post-Test |
Difference |
t |
(2 tailed) |
|
|
|
|
|
|
|
|
Re-experiencing
Traumatic Event |
31.75 |
21.25 |
10.500 |
5.214 |
0.000 |
** |
|
|
|
|
|
|
|
Avoidance of Stimuli
of Traumatic Event |
36.90 |
22.05 |
14.850 |
5.732 |
0.000 |
** |
|
|
|
|
|
|
|
Symptoms of Arousal
Due to Traumatic Event |
28.95 |
20.5 |
8.450 |
. 4.413 |
0.000 |
** |
|
|
|
|
|
|
|
** p = < .01 |
|
