concept map 5

EMDR CASE STUDY
Session 1 (Phase 1): B is an 8-year-old male who resides at home with his mother, father, sister, and dog in a suburban town. B comes to the office with anxiety, phobia, loss of appetite, weight loss, and panic when he is in school. B is in the second grade. B verbalizes each morning to his mother that he “will die at school,” resists getting on the bus each morning, and many times needs parental supervision to acclimate to the school environment at the beginning of the school day. B is overly consumed with fears of dying due to allergies, bee stings, and natural disasters. His home environment is conflictual with his parents arguing and threats of divorce have been overheard by B. He resides in a town in which a school shooting took place when he was in preschool. His parents report that B is unaware of the school shooting for “he hasn’t asked or talked about it at home.” The APPN noted that B was 4 years old at the time of the school shooting and at the onset of marital discord. Research indicates that the impact of trauma on the brain makes an imprint during precise developmental milestones (Adler-Tapia & Settle, 2017). This informed the APPN that B’s cognitive development was in the preoperational phase where pretend play allows for accessing memories, thoughts, feelings, and belief systems. Thus, the approach for starting sand tray therapy with B was thought to be appropriate. According to Erikson’s theory of development, B was navigating industry versus inferiority, and in his case fear and anxiety were overriding his ability to engage in his school environment to gain knowledge and develop new skills (Erikson, 1950).B’s anxiety symptoms started 6 months ago and have now necessitated intervention because the school counselor reported that B cannot tolerate being in the classroom without being disruptive to the school environment. Before B’s first appointment, his APPN assessed the school environment by counselor report and Mom and Dad report. The counselor stated there is some marital discord, no friendship issues, and B has never asked about the school shooting nor has he watched any news media on the event because his parents are careful not to expose him to the news.Session 2 (with child and parents; Phases 2 and 3): B presented to the office fidgety; he was hypervigilant as evidenced by looking behind his shoulder frequently and making eye contact with his mom and dad for reassurance. B explored the office space, playing with Legos and looking through the APPN’s miniature collection. B was assisted to create a happy/fun/calm place in the sand tray. He created a recent trip to Florida with his family placing an airplane in the sand tray as well as trees and seashells. B and this APPN spent some time talking about the positive emotions of the calm place and getting to know all the things that B likes to do. He mentioned that he used to like soccer and baseball, but that he gets nervous on the field now. B was encouraged to create a container out of Legos that became a 4 × 4 box with no doors or windows and tightly closed in a pyramid fashion at the top, leaving no openings. B was instructed to think of all his mixed-up thoughts and put them in the container as the APPN opened the top of the pyramid structure. B leaned his head over and made a rushing water sound and emptied his mixed-up thoughts into the container. B was then asked if he liked a certain smell from an essential oil collection. B selected cinnamon, and as he focused on his fun/happy/calm place, he was taught the butterfly hug (an EMDR self-soothing technique) as he inhaled the smell of cinnamon. B took deep breaths while holding his cupped hands in front of his face like he was drinking an invisible bowl of soup. He inhaled the bowl of soup and then blew the soup, cooling it off slowly, focusing on belly breathing. B was then given a stack of sticky notes and a zip lock bag to take home, and he and his parents were instructed to write down the things that happen through the week that make him have mixed-up thoughts. B asked if he could take a little treasure chest home with him to put his worries in so he could bring them back to the office next week. The session then ended as he skipped out of the room.Session 3: (Phases 3 to 7): B returned to the next session exclaiming how excited he was to bring his mixed-up feelings back to the office. B gave the APPN his smaller treasure box and he put them in his pyramid container. The APPN then continued the assessment phase. B was asked to share what home was like on one side of the sand tray and on the other side what school was like. B created the home environment by placing a play cell phone (mom) in the middle of the sand, a boy figure (self) with two guard robot men next to the boy, a little girl (sister) playing in a corner of the sand with My Little Pony figures, and a man figure (dad) in a separate corner up on a hill by himself laying down sleeping. All figures in the home environment were separated in different corners of the sand. When B was asked to share what school was like with the APPN, B placed a little boy (self) in the middle of the sand with snakes all around him, three little snakes (his teacher, the principal, and his school therapist), and one large snake (not designated by B as any particular person) draped across the sand tray. B was introduced to a BLS handheld tapping (buzzing) device and orientated to how it worked. B was excited to use the buzzies with one in each sock and stated they “feel good buzzing in my feet.” B was asked to label the emotion in both sides of the sand tray. B stated “lonely” in his home environment, and “nervous” in the school environment. B was then asked what he believed about himself when he feels nervous; for example, “if he was wearing a T shirt that said something about himself when he felt nervous, what would it say?” B stated that, “It would say I am not safe.” B was then asked how he would like to think about himself. He stated: “I am safe,” which he rated as a 2/7 VOC. B was then asked to rate how much that bothered him from 0 to 10. B stated that he felt it big with his arms wide open as a 10 and that the feeling lived in his belly. B verbalized who each object stood for on each side of the sand tray without being asked. He then placed the buzzies in his sneakers as he focused his attention on his school environment with the buzzing left, then right (BLS). In between each set, B was asked to take a deep breath and let go of the feeling as well as rate the thought of feeling unsafe from 0 to 10. After 10 to 12 sets of BLS, B rated his level of unsafe to be a 0 and proceeded to remove the snakes from the school side of the sand tray, leaving only the boy by himself in the sand tray. B then moved onto playing with a truck in the office. B’s focus was then redirected to his happy/fun/calm place with three to four slow sets of BLS. At the end of the session, the APPN removed the top Lego of the container to allow for B to let the negative thoughts, images, and feelings in the container. He walked outside to the hammock and his mom was asked to swing him in the hammock slowly as he closed his eyes and imagined his happy/fun/calm place. He left again with his treasure chest and holding his mom’s hand.Session 4: (Phases 3 to 7): Continuation of reprocessing: B arrived at the next session with the treasure chest as he emptied it into the bigger Lego container in the office, all by himself this time. B and the APPN discussed the week and how things were at school. B informed his APPN that he is afraid when he is on the playground at school. B stated that he again “was unsafe” and it was a big 10 feeling in his belly. The APPN asked B to use the sand tray to show the playground. B placed a boy in the middle of the sand tray with 10 to 12 army figures all around the boy with guns facing him. He then placed the big snake (the same one he used during the last session) in the middle of the sand tray. He asked for the buzzies to put in his sneakers again. The APPN handed the buzzies to him, letting him know that he can use the stop word like they had talked about in the last session if he wanted to stop. B continued to play in the sand tray, this time moving the figures around, taking a two-headed dragon and blowing all the army men out of the sand tray and throwing the snake out of the sand tray. He continued by replacing the army men with a few other boy-like figures in the sand. He then stated, “I’m done.” The APPN asked him how big the unsafe was now. He stated, “It’s all gone now.” The session ended with a body scan and B swinging in the hammock, asking his mom to swing with him in the hammock. They swung for 15 minutes together.Subsequent sessions (Phases 3 to 8): These continued through the reprocessing of the “unsafe” NC at school for two more sessions. Within 1 month, B was able to tolerate being in the classroom without event and started riding the bus to school with his peers. His parents were counseled on having a talk with him about the school shooting. Upon disclosure, he stated to the parents that he had known for months and was waiting for them to tell him about it. This conversation and sand tray EMDR therapy allowed B’s anxiety symptoms to decrease, which helped him to re-socialize and play soccer and baseball again. These family conversations allowed B to reintegrate into a developmentally competent industrious school-aged boy, learning new skills and becoming social again, regaining Erikson’s development stage of industry. B spent his summer at a local summer camp with no panic episodes.RESOURCES FOR WORKING WITH CHILDREN
Technology advances are augmenting our practice and education. Telepsychiatry is an ever-expanding practice opportunity for APPNs and has dramatically increased access to mental healthcare for families who don’t have accessible services in their communities. Therapists are practicing via the Internet in real time sessions with patients. See Chapter 4, on tele mental health. Virtual reality via goggles can provide exposure therapy in the office with virtual reality simulations, and adolescents can practice problem-solving skills with virtual school or peer situations. Therapeutic games can provide mastery experiences that are very engaging for children and adolescents. Applications or apps provide a way for children to record and measure healthy behaviors and/or chart moods. See Table 21.6.Therapists are receiving training with avatars, virtual patients who respond to the therapist’s questions and comments and provide a safe learning environment for acquiring new psychotherapy skills.TABLE 21.6APPS FOR CHILDRENApplication NameDescriptionUsability/CostMoodKit

-Exportable mood charts with 7- and 30-day views

-Unlimited mood ratings and notes per day

1. -Over 200 mood improvement activities

-Includes a thought checker

-Good for teens

-Easy to use

-$4.99

Headspace: Mindfulness App

-Guided meditation

-Good for teens.

-Easy to use

-$12.99/month

Stop, Breathe, and Think Kids40+ missions to develop the superpowers of quiet, focus, and a more peaceful sleep.

-Easy to use

-Free

Breathe2Relax

-Stress reduction and stress management tool provides info on toxic stressors

-Engages diaphragmatic breathing

-Log level of stress

-Good for teens

-Easy to use

-Free

Optimism

-Mood charting app

-Captures triggers that induce stress

-Wellness planning

-Good for teens

-Easy to use

• -Free
• Calm Kids
• -Mindfulness/Meditation through story telling/music/sound
• -Daily tracker
• -Age categories: teaching children meditative practices (all ages)

-Easy to use

-$20.00

• Finger Driver
• -Left right (bilateral) games to allow for finger to drive a car on screen to initiate calming reflex. Ages 4+
• -Easy to use-

Free

CBT Tools for YouthAllows children ages 4+ to label feelings, find level of the emotion, locate feeling in body, recognize tools to use to decrease negative emotions, and perform a guided muscle relaxation exercise within app.

-Easy to use

-$2.99 a year

• Binaural Beats
• Ages 12+

Anxiety Stress/Relief app

-Easy to use-

• Free
• Other resources for advanced practice psychiatric nurses who specialize with children include:
• Journal of Child and Adolescent Psychiatric Nursing

American Psychiatric Nurses’ Association—Child and Adolescent Council

See Table 21.7 for resources for therapists and families

TABLE 21.7RESOURCES FOR THERAPISTS AND FAMILIESTherapist Resources:American Academy of Child and Adolescent Psychiatrywww.aacap.orgAmerican Academy of Pediatrics/Mental Health Initiativeswww.aap.org/mentalhealthEvidence-Based Child and Adolescent Psychosocial Interventionswww.aap.org/enus/Documents/CRPsychosocialInterventions.pdfState Statutes Child Abuse & Neglectwww.childwelfare.gov/topics/systemwide/laws-policies/stateBest Children’s Books About Mental Healthchildmind.org/article/best-childrens-books-about-mental-healthResources for Families:Facts for Familieswww.aacap.org/aacap/families_and_youth/facts_for_families/fff-guide/FFF-Guide-Home.aspxCenter for Disease Control and Prevention/Children’s Mental Healthwww.cdc.gov/childrensmentalhealth/index.htmlReach Institute: Evidence-based mental health information for familieswww.thereachinstitute.orgAttachment and Trauma Center of Nebraska: Free resources and free parent class for parents raising children with a history of traumawww.atcnebraska.com POST-MASTERS TRAINING FOR CBT & EMDR THERAPY
APPNs who love working with children and adolescents can have a challenging and rewarding career as a nurse psychotherapist. Graduates leave psychiatric mental health nurse practitioner (PMHNP) programs with beginning competencies in psychotherapy. Study, consultation, further training, and experience with different schools of psychotherapy and with different age groups allow students to “try on” the role of psychotherapist and see which therapeutic approach and which population resonates with them. As a licensed mental health provider, you will have many educational workshops available so you can develop expertise. Ongoing supervision with a master child therapist is essential for expert practice.CBT Training
Beck Institute for CBT Training – CBT for Children & Adolescents, now also online. In order to achieve certification as a trauma-focused cognitive behavioral theraoy (TF-CBT) therapist, one must be a licensed mental health practitioner; participate in a live TF-CBT 2-day training; participate in 12 consultation sessions by an approved TF-CBT consultant; complete three TF-CBT cases with measurable outcomes; and pass a TF-CBT knowledge-based exam. The criteria are available at tfcbt.org/TF-CBT-certification-criteria/ EMDR Therapy Training
Therapists start by participating in an Eye Movement Desensitization and Reprocessing International Organization (EMDRIA) approved basic training that is 50 hours, which includes 20 hours of didactic, 20 hours of practice and 10 hours of consultation. See Chapter 7. Some EMDRIA approved basic trainings focus on teaching therapists to work with developmentally grounded EMDR therapy focused on children (Adler-Tapia & Settle, 2017). There is also EMDR therapy advanced training to work with children available after basic training and certification in EMDR is completed. Additional training in EMDR therapy for working with children is available from:

Ana Gomez, LPC: Online and in person intensives on EMDR with children as well as sand tray therapy with EMDR www.anagomez.org

Robbie Adler-Tapia, PhD: Offers basic training and advanced training approved by the EMDRIA Institute with in-person training and remote clinical supervision https://www.drrobbie.org/trainings-workhops

• CONCLUDING COMMENTS
  Child/Adolescent specialists are on the forefront of some exciting trends in psychiatric/mental health practice. “There is accumulating evidence that some behavior problems can be prevented. Effective strategies include supporting parents’ mental health, reducing exposure to stresses, helping parents learn to both read and help modulate infant’s emotions, and helping parents learn ways to stimulate and have positive interactions with their infants and young children” (Adam & Foy, 2015, p. 203). Another prevention opportunity is the incorporation of psychoeducation into school health curriculums so that all children and teens receive instruction in mental health resources, coping strategies, and problem-solving knowledge and disemination about to build resilience. This is beginning to happen in response to school tragedies and the impact of ACEs on mental and physical health.Integration of behavioral health into primary care/pediatric settings provides new practice opportunities for APPNs. Screening of all children for depression is recommended by the United States Preventive Services Task Force (USPSTF) and American Academy of Pediatrics. APPNs also advocate for routine screening for anxiety, substance use risk, and adverse childhood experiences in all health settings for children and adolescents. Early intervention is key to improving the trajectory of psychiatric disorders that begin in childhood and adolescence. Also, teaching and providing brief evidence-based interventions such as MI for young people at risk of substance use and other risky behaviors is essential.In working with children and adolescents with common age-related adjustment struggles, those who have trauma and stressor-related disorders, and other psychiatric disorders that generally present in childhood, the nurse therapist can facilitate optimal growth and mastery. From what we know from neuroscience, change is always possible with children and teens, and the young person’s ongoing growth and development is on the side of learning and positive outcomes as they work with the APPN in therapy. With so much potential for positive change, child and adolescent psychiatric/mental health nursing is an exciting and rewarding practice specialty for APPNs.DISCUSSION QUESTIONS
  1.Discuss your experiences with using evidence-based therapies in child/adolescent treatment

  2.Compare/contrast the development of a therapeutic relationship with adolescents versus adults.3.Describe how the APPN can partner with parents in psychotherapy with adolescents/children.4.Review the “Evidence-Based Child and Adolescent Psychosocial Interventions” chart at www.aap.org/en-us/Documents/CRPsychosocialInterventions.pdfWhat surprised you? What did you assume was an evidence-based intervention that has little evidence to support it?5.Discuss the pros and cons of using therapy treatment manuals with children/adolescents.
  6.Discuss the role of the therapist with the child who has experienced significant trauma.7.How does the APPN conduct an initial interview with a child/adolescent differently than the initial psychiatric evaluation with an adult?8.Describe how the APPN can integrate psychotherapy and pharmacotherapy in an outpatient practice.

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