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
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.
Objectives
• Learners will:
– Review the barriers to successful engagement in
needed mental health services that confront the
caregivers of sexually abused children.
– Understand the multiple aspects of a successful
service engagement program for sexually abused
children and their non-offending caregivers.
– Explore creative funding strategies that allow for
optimal engagement of sexually abused children
in needed mental health services.
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
Why are there 7 presenters?
• This is a team effort.
• Collaboration is what it takes to make the
program work.
History
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).
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.
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.
Non-offending Caregivers
• Key element to linking sexually abused
children to treatment.
• Often 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.
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.
The Collaboration
Yale Child Sexual Abuse Clinic +
Yale Child Study Center/Childhood Violent
Trauma Center +
The Salomon Family Foundation =
The Yale Bridging Program
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.
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.
Description of the Yale Sexual Abuse
Clinic and the South Central CAC
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
Description of Bridging Referral
and Engagement Strategies
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.
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.”
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.
Sometimes it’s a concrete obstacle.
•
•
•
•
Transportation.
Parking.
Child care.
Work schedules.
Description of the Mental Health
Intervention
The Child and Family
Traumatic Stress Intervention:
Early Intervention
and Secondary Prevention
for At-Risk Children and Youth
Developers:
Steve Berkowitz, MD
University of Pennsylvania
Steven Marans, MSW, Ph.D.
Yale University School of Medicine
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.
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.
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.
CFTSI: Filling a Gap
in 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.
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
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).
CFTSI
in the Child Advocacy Center Setting
Change in PTSD Symptoms
Following CFTSI (N=134)
25
PTSD Symptom Severity
21.68
20
17.57
15
10.87
9.58
10
5
0
Pre-Tx Parent
Post-Tx Parent
Pre-Tx Child
Post-Tx Child
Engagement
•
•
•
•
•
Begins at the forensic interview.
Starts with the non-offending caregiver.
Flexibility.
Collaboration.
Overcoming barriers.
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).
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.
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.
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
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.
Description of Community
Involvement in Bridging
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.
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.
Bridging Care Coordination
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.
Bridging Data Collection
Strategies
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.
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.
Bridging Metrics
• Documentation of collaboration efforts
between clinicians and other individuals and
agencies within the community.
• To document this effort we track the:
– number of attempted contacts with other
individuals and agencies within the community.
– number of successful contacts with other
individuals and agencies within the community.
Bridging Metrics
• Engagement/completion/referral outcome data:
–
–
–
–
–
–
–
–
never 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.
completed treatment or intervention.
required additional referral at the close of
treatment/intervention.
Bridging Data
2011 Data
94 Total Referrals
86 (91%) Initiated Treatment/Services
75 (80%) Completed Treatment/Services
55
20
Received Treatment/Services
Received Phone Consultation
11 Failed to Complete Treatment/Services
8 (9%)
No Show/Refused
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.
Bridging Funding Strategies
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).
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.
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.
Future Directions
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?
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?
Bridging Program Components
1. Immediate referral to services.
2. Intensive engagement efforts.
3. Evidence-based, caregiver-inclusive, trauma
focused assessment and short-term treatment.
4. Optimized community collaboration evidenced
by strong linkages to multidisciplinary teams and
victim and family advocacy.
5. Expert care coordination.
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.
Questions?
Discussion? Suggestions?
andrea.asnes@yale.edu