tbri thesis

TBRI: A SUCCESSFUL TREATMENT FOR FOSTER YOUTH 1

Trust-Based Relational Intervention: A Successful Treatment for Foster Youth with Behavioral

and Emotional Disorders

Elizabeth Torres

Chapman University

Psychology 498-01 MW

17 December 2015

Running head: TBRI: A SUCCESSFUL TREATMENT FOR FOSTER YOUTH


Hypothesis

If youth in the foster care system participate in Trust-Based Relational Intervention (TBRI), then

they will be more likely to overcome behavioral and emotional disorders than foster youth who

only receive pharmacologic treatment.


Operational Definitions

Alpha-adrenergic agonists: Clonidine hydrochloride, guanfacine hydrochloride (Fontanella,

Hiance, Phillips, Bridge, & Campo, 2014).

Antipsychotic drugs: Typical (chlorpromazine, hydrochloride, fluphenazine hydrochloride,

mesoridazine) and atypical (risperidone, olanzapine, quetiapine) (Fontanella et al., 2014).

At-risk youth: Youth who have experienced any type of trauma including the following:

physical, sexual, or emotional abuse; neglect; or witnessing domestic violence (Parris et al.,

2015).

Behavior problems: This includes both internalizing behaviors, such as depression, and

externalizing behavior, such as aggression (Juffer & vanIjzendoorn, 2005). Children who are

rested (Purvis, Cross, & Sunshine, 2007), well nourished (Purvis, Cross, G. Kellermann, M.

Kellermann, Huisman, & Pennings, 2006) and feel safe and predictable will start to practice new

behavioral skills.

Biochemical therapy: “Correction of innate or acquired chemical imbalances using amino acids,

vitamins, minerals, and other biochemicals naturally present in the body” (Walsh, Glab, &

Haakenson, 2004, p. 836).

Foster care system: Children taken from abusive or neglectful families are placed in the foster

care system, also known as the Child Welfare System (CWS). The intent is temporary housing

until they are adopted or return home (Lloyd & Barth, 2011).

Mood-stabilizers: Mood-stabilizers include anticonvulsants (carbamazepine, valproic acid,

gabapentin, lamotrigine, and oxcarbazepine) and lithium (dosReis et al., 2011).


Negative emotions: Negative emotions include anger, sadness, disgust, and fear. These

emotions can manifest more strongly in foster children if basic needs – like nutrition, safety, and

attachment – are not met (Purvis, Cross, & Pennings, 2009).

Pharmacologic treatment: Treatment of a disease or disorder by means of any type of

medication, primarily antipsychotic and psychotropic drugs (Donnelly, 2003).

Psychotropic drugs: There are six major categories of psychotropic drugs: (1) antidepressants

and monoamine oxidase inhibitors; (2) antipsychotics; (3) mood stabilizers including

anticonvulsants and lithium; (4) anxiolytics including benzodiazapines and nonbenzodiazapines;

(5) stimulants and other ADHD medications; and (6) alphaadrenergic agonists (Fontanella et al.,

2014).

Stimulants: Methylphenidate, amphetamine, and pemoline (Fontanella et al., 2014).

Trust-Based Relational Intervention: The Trust-Based Relational Intervention (TBRI) is a

program that began in the early 2000s by Karyn Purvis, PhD from the TCU Institute of Child

Development. The intervention targets behaviorally at-risk adopted children. There are three

main principles of this program: Empowering Principles, Connecting Principles, and Correcting

Principles. “Empowering” encompasses Ecology (i.e. predictability and transitions) and

Physiology (i.e. safe touch, nutrition, physical activity). “Connecting” includes Awareness (i.e.

recognizing behavior, eye contact, voice and inflection, etc.) and Engagement (active listening,

playful engagement, etc.). Lastly, “Correcting” addresses Proactive Strategies (emotional

regulation, choices for growth, etc.) and Redirective Strategies (choices for discipline, task

completion, consequences, etc.). This program can be integrated into homes, family camps,

summer camps, orphanages, and schools (Purvis et al., 2009).


Unhealthy child development: There are three factors that lead to unhealthy child development.

The first is maternal deprivation, which occurs when either a child is separated at birth from their

mother or the child does not receive proper care. The second – environmental deprivation –

occurs when postnatal environments do not provide enough sensory stimulation. Lastly, global

deprivation occurs when the environment does not meet basic needs such as proper nutrition,

physical and social stimulation, and good relationships (Purvis, Cross, Federici, Johnson, &

McKenzie, 2007).


TBRI: A Successful Treatment for Foster Youth with Behavioral and Emotional Disorders

In 2006, over 3.5 million children were reported as abused and neglected in the United

States. Out of that number, 905,000 were confirmed victims (US Department of Health and

Human Services, Administration for Children and Families, Children’s Bureau, 2008). About

20% of the victims are put into the foster care (child welfare) system where they are then placed

in either a family or a group home. Oftentimes, the trauma these children experience causes them

to struggle with one or more of many emotional, mental, and behavioral disorders. These are just

some of the disorders foster youth deal with: alcohol abuse, conduct disorder, generalized

anxiety disorder, intermittent explosive disorder, major depressive disorder, major depressive

episode, panic disorder, post-traumatic stress disorder (PTSD), separation anxiety disorder, and

social phobia (Pecora, White, Jackson, & Tamera, 2009). Usually, the recommended treatment is

a combination of pharmacological and psychosocial treatment. Unfortunately, the children who

are medicated tend to only take the medication and do not see a therapist or engage in any sort of

social treatment. Furthermore, the people prescribing medications to foster youth are not trained

psychologists, but are pediatricians, primary care doctors, and nurse practitioners. These doctors

also allow their young patients to get refills without checkups. In addition to this, many of the

youth take multiple psychotropic drugs concurrently. What makes the overmedication of foster

youth most disconcerting is there is little empirical research behind the pharmaceuticals they are

receiving, not to mention the many negative side effects. Some of the side effects are weight

gain, Type-2 diabetes, and dyslipidemia (Pecora et. al, 2009).

Fortunately, there are other treatment options that exclude the use of medications

altogether. One such example is Trust-Based Relational Intervention (TBRI), which focuses on

improving important life habits purely through family training and interpersonal therapy. The


three main principles of this program are Empowering, Connecting, and Correcting. The first

focuses on the health of the individual child by helping with predictability, transitions, safe

touch, and nutrition. The second takes a step further by addressing communication through eye

contact, voice and inflection, recognizing behavior, and active listening. The last principle

focuses on higher thinking and interacting through emotional regulation, choices for growth, task

completion, choices for discipline, and consequences. TBRI helps each child relearn healthy

attachment and positive ways of interacting with themselves and others. I hypothesize that the

foster youth who use programs like TBRI as their only form of treatment will be more likely to

overcome their disorders than youth receiving only pharmacologic treatment.

There is both confirming and disconfirming evidence about my hypothesis. The

disconfirming evidence comes primarily from older studies since providing children with strong

medications is more of a pre-turn-of-the-century concept. Regardless of the time that these

studies were conducted, there is strong research that shows the immediate benefits of medicating

children who seemed unable to escape the pervasiveness of the trauma they experienced in the

past (Donnelly, 2003; Seedat et al., 2002). Indeed, their emotional and behavioral struggles were

able to cause so much dysfunction in their daily lives that their caregivers were willing to give

them strong – yet under-researched – medications in order to get the kids under control.

Caregivers tended to desire a quick-fix solution, which is what prescriptions are known for. A

thing to note about the articles that oppose my hypothesis is that the researchers acknowledged

the small amount of research upon which they based their claims. In fact, between 1980 and

2002, there were no randomized, double-blind, placebo-controlled clinical trials done to test the

efficacy of pharmacologic treatment of children and adolescents with PTSD (Donnelly, 2003).

Unfortunately, the late 90s/early 2000s was the time period that most of the evidence supporting


medicinal treatment of traumatized youth came from. Fortunately, the focus of treatment has

changed in the past decade since many researchers are becoming aware of the pitfalls the old

studies overlooked.

Many new sources have data that indicate foster youth are clearly overmedicated

(Brenner, Southerland, Burns, Wagner, & Farmer, 2013; Barlas, 2008; dosReis, Yoon, Rubin,

Riddle, Noll, & Rothbard, 2011). Foster children are given drugs at double or triple the rate of

kids not in foster care (Korry, 2015). About 59% of foster youth take at least one psychotropic

medication, but many take more than that. Indeed, hundreds take as many as five psychotropic

medications at a time (Brenner et. al, 2014; Korry, 2015). What makes the situation even more

alarming is the fact that thousands of children are receiving doses that exceed Food and Drug

Administration (FDA) guidelines. The FDA is right to disapprove of these strong drugs because

the negative side effects of these prescriptions cannot be ignored. Therefore, as an alternative to

pharmaceuticals, TBRI is a successful treatment option that both treats children without any use

of medications and is supported by lots of research (Purvis, McKenzie, Razuri, Buckwalter,

2014; Purvis, Razuri, Howard, Call, DeLuna, Hall, & Cross, 2015). TBRI provides a hands-on

setting where children can overcome their social and behavioral setbacks instead of masking the

problems through drugs. Nevertheless, the undeniable popularity and effectiveness of

psychotropic drugs are what cause the controversy.

This issue needs to be addressed in order to ensure the well-being of youth both currently

in the foster system and alumni. The fact that so many are currently being prescribed strong

medications without proper research is unacceptable and must be fixed immediately. The more

recent evidence suggesting negative side effects of prescriptions makes the predicament all the

more imperative to review. The difficulties that foster youth face do not have to be a permanent


fixture in their lives. If their caregivers are willing to take the time, the quality of the

relationships of the family can be improved and the child can have a more satisfying life. The

roots of foster youth’s poor behavior can only be solved through a process of undoing and

relearning with trustworthy adults who can restore a healthy attachment and a sense of security.

Even though the process may be lengthy, it is the means through which each foster child can

overcome the past and live a fulfilling life.


Purvis, K.B., Cross, D.R., Dansereau, D.F., & Parris, S.R. (2013) Trust-Based Relational

Intervention (TBRI): A Systemic Approach to Complex Developmental Trauma. Child &

Youth Services, 34:4, 360-386, doi: 10.1080/0145935X.2013.859906

This article is a review of the research behind the Trust-Based Relational Intervention. It

asserts that TBRI is the best treatment for foster children who have experienced severe trauma

and provides examples of how TBRI can be applied in different settings. There were no

hypotheses to be tested.

The article begins by addressing the need for trauma treatment in the foster care system

and continues for the remainder of the paper by explaining the intervention in detail. A study

conducted at Harvard University in 2005 found that children in the U.S. foster care system live

with the trauma they have experienced in the form of post-traumatic stress disorder (PTSD) at a

rate that is more than two times the rate of war veterans (Pecora, White, Jackson, & Wiggins,

2009). Early trauma impacts the rest of a child’s development and tends to cause alterations in

their brain chemistry as well as the development of unhealthy attachment styles, dysfunctional

coping behaviors, and other problem behaviors. Usually, foster children are treated through the

traditional medical model, including medication and frequent visits to a therapist’s office. This,

however, is not the most effective method because the best treatment takes place in the place

where the problems begin – the home. There are three main factors that are necessary in order to

treat complex trauma: (a) development of safety, (b) promotion of healing relationships, and (c)

teaching of self-management and coping skills (van der Kolk & Courtis, 2005). These three

pillars reflect the three TBRI principles, which are (a) Empowerment (attention to physical

needs), (b) Connection (attention to attachment needs), and (c) Correction (attention to


behavioral needs). These three principles address the internal and external needs of the child,

both of which are necessary for the best possible healing.

This article relates to my hypothesis because it clearly points to TBRI as the best

treatment of traumatized foster children. All of its principles revolve around interpersonal and

inner healing techniques that do not require any medication. In fact, the authors emphasize that

certain physical changes like increased physical exercise, improved sleep, and hydration can

decrease the need for medications for other illnesses like asthma and ADHD. Even though there

is no specific mention of a measured comparison between TBRI and psychotropic/antipsychotic

drugs, the article does show very strong evidence in favor of TBRI. Although TBRI may not be

the easiest or the quickest treatment, it appears that it will result in the longest-lasting change.

+4


Seedat, S., Stein, D. J., Ziervogel, C., Middleton, T., Kaminer, D., Emsley, R. A., & Rossouw,

W. (2002). Comparison of response to a selective serotonin reuptake inhibitor in children,

adolescents and adults with posttraumatic stress disorder. Journal Of Child And

Adolescent Psychopharmacology, 12(1), 37-46. doi:10.1089/10445460252943551

The purpose of this article was to examine differences in two groups’ responses to

citalopram – an SSRI that is very selective for serotonin reuptake inhibition. The hypothesis

tested for a decrease in PTSD symptoms in the participants.

The sample for this study was 24 children and adolescents (ages 10-18, 16 girls and 8

boys) and 14 adults (ages 19+, with seven men and seven women) with a diagnosis of

moderately severe PTSD (assessed by a Clinical Global Impression Severity [CGI-S] score of ≥

4). The participants were also measured by the either the Clinician-Administered PTSD Scale

(CAPS) or the Clinical-Administered PTSD Scale-Children and Adults (CAPS-CA). Any

subjects who also met the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition

(DSM-IV) criteria for psychotic disorder, bipolar disorder, organic disorder, or substance

abuse/dependency within the previous six months were not allowed to participate. Participants

weren’t excluded if they had a comorbid mood or anxiety disorder, so long as PTSD was the

primary diagnosis. The participants had two weeks to discontinue their current mediations

(benzodiazepines or antidepressants). Participants were not allowed to attend psychotherapy

during the course of the study. The two main measures were: (1) a change in the mean from

baseline PTSD symptoms defined by CAPS or CAPS-CA and (2) changes in CGI scores.

Paired t tests revealed significant changes between baseline and endpoint for both CAPS

and CGI-S scores. Among the child/adolescent group, there was a mean reduction by 54% in


CAPS-CA total scores (t = 9.88, p < 0.001). Among the adult group, there was a mean reduction

by 39% in CAPS total scores (t = 6.4, p < 0.001). Children/adolescents actually improved more

than adults.

This article relates to my hypothesis because it supports the use of pharmacological

treatment in children with PTSD while I propose that no medication be a part of their treatment.

Although these were not children in the foster care system necessarily, foster children tend to be

diagnosed with PTSD a majority of the time. Therefore, the children in this study are a sufficient

comparison due to their similarity to foster children. It especially contradicts my hypothesis

because the researchers made sure to mention that no additional psychotherapy was allowed

during the course of this experiment. This means that the positive results were only based on

what citalopram was responsible for. Overall, this article provides a secure argument for the

safety and efficacy of SSRIs (e.g. citalopram) in pediatric populations and the general use of

medication as a treatment.

-3


Purvis, K., Cross, D., Federici, R., Johnson, D., & McKenzie, L. (2007). The Hope Connection: a

therapeutic summer day camp for adopted and at-risk children with special socio-

emotional needs. Adoption & Fostering, 31(4), 38-48 11p.

The purpose of this article was to meet socio-emotional needs of adopted and at-risk

children deprived of healthy development through a therapeutic summer camp program called

The Hope Connection. The researchers expected the camp to help treat the children’s attachment,

pro-social behavior, and sensory processing problems, since these are three areas of

psychological development that are affected due to the lack of healthy child development.

The camp consisted of 19 children (ages 4-13) living in the United States who had

histories of early deprivation and/or maltreatment. Out of the total sample size, 16 were adopted

from orphanages in Eastern Europe. The children were split up into two groups based on age,

with 5.7 being the mean age of the younger group and 10.7 for the older group. The summer

camp program lasted for two weeks and was broken up into two sessions, the first session for

younger kids and the second for older kids. The days lasted from 8:30am to 3:30 pm. Each child

was paired with a “buddy,” an undergraduate student who was trained to use therapeutic

techniques, bond with their younger buddy, and model appropriate behavior. All the activities

chosen for camp were designed to be (a) attachment rich, (b) sensory rich and (c) behaviorally

structured. Assessments of children’s progress included parent report and child report measures.

Parent report instruments consisted of pre- and post-test versions of the Child Behavior Checklist

(CBCL), Beech Brook Attachment Disorder Checklist (Beech Brook), and Randolph Attachment

Disorder Questionnaire (RADQ). Child report was assessed by evaluating their pre- and post-

camp drawings of their families through analyzing the overall mood of the picture.


The CBCL tests displayed that mostly all internalizing and externalizing behaviors

decreased after the camp. There was a main effect for the anxious/depressed the aggressive

behavior subscales. Beech Brook and RADQ indicated a significant increase in positive

attachment behaviors (F(1,12) = 9.35, p = .010), and a complementary decrease in negative

attachment behaviors (F(1,12) = 8.01, p = .015). Child reports displayed similar outcomes.

This article supports my hypothesis because the methods used in this study clearly

advocate for a non-medicated treatment style that utilizes the same basic outline as the Trust-

Based Relational Intervention (TBRI). The three areas of psychological development that they

focused on (attachment, pro-social behavior, and sensory processing) are almost identical to the

three principles of TBRI (connection, correction, and empowerment). In the introduction, the

authors made a point to mention that at-risk children usually receive drug treatments that “can be

ineffective and even detrimental” and assert that their summer camp method is overall more

effective and better for these children. Lastly, Dr. Karyn Purvis – one of the creators of TBRI –

was very active in this report on the Hope Connection.

+3


Fontanella, C., Hiance, D. h., Phillips, G., Bridge, J., & Campo, J. (2014). Trends in

Psychotropic Medication Use for Medicaid-Enrolled Preschool Children. Journal Of

Child & Family Studies, 23(4), 617-631.

The purpose of this article was to examine recent and specific trends in the use of

psychotropic medication for very young children from 2002-2008. The secondary purpose was to

examine the context in which medications are prescribed.

The researchers conducted a longitudinal analysis of preschool children who had been

prescribed psychotropic medication and were enrolled in Ohio’s Medicaid program from 2002-

2008. Medicaid originally had 751,637 children with these specifications in 2002 but the number

increased to 954,976 in 2008. There were three categories through which a child could qualify

for Medicaid: (1) children whose family income was at or below 200% of the federal poverty

level (CFC); (2) children with a disabling condition whose family income was at or below 64%

of the poverty level (ABD); and (3) children in foster care, the adoption system, or institutional

placements – such as facilities for the mentally retarded. Children who had at least one

prescription claim for a psychotropic medication were used (n = 23,019). The researchers then

examined certain demographic predictor variables such as age, gender, race/ethnicity, Medicaid

eligibility category (CFC, ABD, or foster care), and area of residence. They also analyzed

clinical predictor variables such as primary diagnosis, number of psychiatric disorders, number

of medications, and comorbidity of disorders.

The results showed that the rate of psychotropic medication use only slightly increased

from 1.7 to 1.9% between 2002 and 2008. On the other hand, the use of stimulants, alpha-agonist

medications, and antipsychotics more than doubled from .2% to .5%. Shockingly, 63.4% of the


children received their mental health diagnoses from a non-specialty provider like nurse

practitioners, primary care doctors, and pediatricians. They also found that the kids who were

most likely to receive psychotropic medications were older, white, male, disabled, and in foster

care.

This article supports my hypothesis because despite the focus on medications, these

authors stress the importance of psychosocial treatment. Through their findings, they found that

psychosocial services are very underused, even though they technically should be a part of a

child’s treatment. Indeed, most preschool children who are advised to use both medication and

psychosocial services as their treatment only receive the former. Furthermore, most preschoolers

do not receive another mental health assessment before getting a refill of their prescription. The

researchers recognize the shortage of child mental health specialists and call for an increased

involvement of trained psychologists in the mental diagnoses of children instead of primarily

relying on pediatricians or primary care doctors. The results of this article clearly show that there

is an overuse of psychotropic medications among preschoolers and point to a greater reliance on

interpersonal and psychosocial therapy.

+3


Walsh, W. J., Glab, L. B., & Haakenson, M. L. (2004). Reduced violent behavior following

biochemical therapy. Physiology & Behavior, 82835-839.

doi:10.1016/j.physbeh.2004.06.023

The purpose of this study was to test the effectiveness of biochemical therapy on people

with a wide array of behavior disorders. The goal was to help the participants minimize their

violent behavior, including physical assaults and destroying property.

There were 207 participants in the study (149 males and 58 females) whose ages ranged

from 3 to 55, with a median age of 11.5. They were included in the study because they had been

diagnosed for at least 4 months with either attention-deficit disorder, conduct disorder,

oppositional-defiant disorder, or another behavior disorder. Upon admittance to the study, each

participant went through a chemical analysis to reveal chemical imbalances in their body so that

proper medication could be prescribed. A certain combination of amino acids, vitamins, and

minerals were developed for each subject based on this analysis. Many of the common chemical

imbalances found among the sample included the following: (a) low levels of amino acids,

vitamins, minerals, or glucose; (b) high levels of lead, cadmium, or other toxic metals; (c)

elevated or depressed blood histamine; and (d) elevated serum copper or depressed plasma zinc.

All the participants who were already taking other medications or receiving other therapies were

asked to continue throughout the duration of the study. Each participant attended a follow-up

visit 4 to 8 months after the initiation of the treatment to see the effectiveness of the supplements

on violent behavior.

The results showed that statistical significance was discovered for both reduced

frequency of assaults (t=7.94; p<0.001) and reduced destructive incidents (t=8.77, p<0.001).


Among the assaultive patients, 58% were able to eliminate the behavior altogether. Similarly,

53% of the destructive patients completely eliminated the behavior.

This article refutes my hypothesis because it clearly advocates for the increased

utilization of biochemical treatments for people with behavior disorders. Although it does not

directly mention foster kids, most of the children in the foster care system have many of the same

behavior disorders as the participants in this study. This study also can be applied to my

hypothesis because a majority of the people in the study were children. In fact, the results found

that this treatment was most effective for children under age 14. Furthermore, the researchers

claim in the introduction that chemical imbalances in the body may cause just as much harm (if

not more) to the mind as certain environmental influences like poverty and abuse, suggesting that

psychosocial therapy are not the best treatment option. Data like this certainly provides a strong

support for the quick-fix option of medications/supplements.

-3


Donnelly, C. L. (2003). Pharmacologic treatment approaches for children and adolescents with

posttraumatic stress disorder. Child And Adolescent Psychiatric Clinics Of North

America, 12(2), 251-269. doi:10.1016/S1056-4993(02)00102-5

The purpose of this article was to review pharmacologic treatment of posttraumatic stress

disorder (PTSD) in children and adolescents. The researcher asserted that despite a lack of

thorough and empirical research examining the affects of medication on children with PTSD,

there is enough research to indicate that medical treatment plays an important role in recovery.

The article provided a thorough discussion of PTSD, including its symptoms, the

neurobiology involved, comorbidity, and useful medications. The author began by discussing the

complexity of PTSD. When one accounts for all the possible symptoms that meet the criteria for

diagnosis of PTSD, there are about 1750 possible combinations (American Psychiatric

Association, 2013). This makes it very difficult to medicate appropriately. Thus, psychologists

need to be very careful to tailor medical treatment based on each child. Usually, the treatment of

one symptom (i.e. sleep deprivation) can lead to the treatment of other related symptoms. When

trauma occurs in early life, the central nervous system, physical development, and the

neuroendocrine and immunologic systems are affected. There may also be dysregulation in the

hypothalamic-pituitary axis and cortisol secretion. Overall, neurobiological deficiencies lead to

three symptom clusters of PTSD: re-experiencing, avoidance, and hyperarousal. The focus of

pharmacologic treatment is hyperarousal. By calming this, other symptoms that would otherwise

be hidden (like depression) are unmasked. Many children do not respond to psychotherapeutic

interventions such as Cognitive Behavioral Therapy, making the need for medication even

greater. Some medications the author suggested were adrenergic, dopaminergic, serotonergic,


gamma-aminobuyric acid, and opioid agents. All of these at least address hyperarousal

symptoms but many also help re-experiencing and avoidance symptoms. Out of them all, the

author claimed that SSRIs and tricyclic antidepressants were the best first choice. In summary,

Donnelly concluded that medication could be a rational and safe manner to treat PTSD in

childhood.

This article refutes my anti-medication hypothesis very strongly due to its exhaustive list

of studies showing the efficacy and usefulness of medications in childhood PTSD. Even though

the paper did not directly relate to foster children, it can be applied to my paper because rates of

PTSD are found to be significantly higher among kids and adolescents in the foster care system

than normal youths (Pecora, White, Jackson, & Wiggins, 2009). The author cited lots of research

that showed the positive effects that medications have on children and adolescents, putting the

argument in favor of pharmacologic treatment. For example, one study found improvement in

anxiety, concentration, mood, and behavioral outbursts in every child in the sample after the

introduction of adrenergic agents (Perry, 1994). In a similar study, 13 out of 18 subjects

experienced remission of their PTSD symptoms due to dopaminergic agents (Horrigan &

Barnhill, 1996). Studies like this provide a strong argument for a quick fix, reliable treatment

through medication.

-4


Purvis, K. B., McKenzie, L. B., Becker Razuri, E., Cross, D. R., & Buckwalter, K. (2014). A

Trust-Based Intervention for Complex Developmental Trauma: A Case Study from a

Residential Treatment Center. Child & Adolescent Social Work Journal, (4), 355.

This article is a case study about 16-year-old Rachel who found herself in the foster

system at age 12 after a long history of abuse and neglect. She did not respond to traditional

residential treatment plans and was deemed by different residences one of the most difficult

children they ever had to deal with. The Trust-Based Regional Intervention (TBRI) was applied

to her situation to help her learn healthy attachment.

Rachel’s intervention was a combination of the traditional TBRI method and a treatment

individualized for her specific situation. At the point of intervention, her life consisted of

physical, sexual, and emotional abuse from her time in Bulgaria. She was treated as a gypsy and

neared death by starvation many times. She lived with an American family for six months before

being admitted to a residential treatment center (RTC) due to numerous threats and attempts to

harm herself or others in her family. Rachel’s specific treatment was carried out in three phases.

Phase 1 was focused only on teaching her healthy relationship skills. This included physically

close proximity to either the main researcher, her adoptive mother, or one of the RTC staff

members at all times, mimicking the beginning of a relationship between mother and infant. By

keeping within 36 inches, the caregivers were able to assure Rachel that she would be attended to

immediately. If physical constraint was necessary, it was done by trained RTC staff other than

the ones assigned to her – not her primary caregivers. Phase 2 took a step further by challenging

her to achieve small goals to self-regulate. Phase 3 was a transition to the RTC’s traditional

treatment program, while continuing to use TBRI principles. She remained in Phase 1 and 2 for

two months each.


Over the course of the 10 months preceding the intervention, Rachel had about 6.3

restraints and 6 seclusions per month. In the 6 months after TBRI, the numbers dropped to 2.5

restraints and 2.2 seclusions per month. Her neurochemical levels also increased dramatically

over the course of the treatment. For example, one year after she began TBRI, her serotonin

levels rose over 500%.

This article supports my hypothesis a great deal. It clearly advocated for TBRI over any

pharmacological treatment. Even though it did not explicitly degrade medications, there was no

pharmacological usage at all during the intervention. After reading the description of the

difficulties Rachel faced, she certainly would have been the perfect candidate for many

medications, yet transformation was found through only interpersonal relationships. The data

about the rise in her neurotransmitter levels showed that even chemical imbalances could be

treated naturally without the help of pharmaceuticals. Although TBRI is a lengthy and

complicated process, it is exceedingly more useful in teaching traumatized youth how to interact

with others and themselves. TBRI aims to strengthen the person and increase their quality of life

by giving them lifelong relational skills that can also increase their self worth. This is by far the

more beneficial route to healing.

+5


dosReis, S., Yoon, Y., Rubin, D., Riddle, M., Noll, E., & Rothbard, A. (2011). Antipsychotic

Treatment Among Youth in Foster Care. Pediatrics, 128(6), E1459-E1466.

The purpose of this article was to compare antipsychotic treatment among foster youth

with other youth eligible for psychological, physiological, and development impairment. They

specifically focused on youth receiving medications “concomitantly,” meaning multiple

prescriptions were being taken at once for a long period of time.

The sample was 16,969 youths younger than 20 years old who were enrolled in a Mid-

Atlantic state Medicaid program. Each participant in the sample had at least one claim with a

psychiatric diagnosis and at least one antipsychotic claim in 2003. “Antipsychotic treatment”

was operationally defined as any concomitant use of at least two antipsychotics for more than 30

days. There were three Medicaid program categories: foster youth (n=2310), disabled youth

(Supplemental Security Income; SSI; n=8787), and Temporary Assistance for Needy Families

(TANF; n=3631). The subcategories of the foster youth group were foster care/Supplemental

Security Income, foster care/TANF, and foster care/adoption. The medications that this study

targeted were stimulants, antidepressants, antipsychotics, and mood-stabilizers. The psychiatric

illnesses that were included were attention deficit hyperactivity disorder (ADHD), anxiety,

autism, bipolar, conduct disorder, depression, oppositional defiant disorder, psychoses,

schizophrenia, and substance abuse. In order to measure concomitant use, they examined two

variables on each pharmacy claim: (1) medication-dispensing date and (2) the days of medication

supplied. For usage to be concomitant, at least two antipsychotics needed to be taken on the same

day for greater than 30 days.

The results showed that concomitant usage and length of usage of antipsychotics were

overall greater in foster care in comparison with TANF and SSI. For example, the average


antipsychotic use for foster care ranged from 222 to 110 days and only 135 to 101 days in TANF

(p<.001). Overall, concomitant usage among all foster care groups was 34.7% in comparison to

19% in TANF (p<.001). This percentage is the same as the percentage for SSI, which is

remarkable because the youth in SSI are disabled.

This article supports my hypothesis because it provided lots of strong data against the

usage of antipsychotic medications. The authors pointed out the issue that concomitant

antipsychotic use among children is absolutely not empirically supported. This is consistent with

many of the other articles I have read up to this point. They also discussed the fact that many

medications like second-generation antipsychotics (SGAs) – one of the more popular

prescriptions – have lots of adverse side effects among children. Such side effects include weight

gain, Type-2 diabetes, and dyslipidemia. What is just as disconcerting is that these effects have

been reported to be 2.3 to 5.3 times greater among children and adolescents who receive multiple

antipsychotics at the same time. Still worse, more than half of the children in foster care do not

receive a medical evaluation (Correll, 2009). Clearly, antipsychotic diagnoses are being abused

and little evidence supports their distribution to children. This backs up my hypothesis, which

suggests a complete absence of pharmacologic treatment.

+4


Purvis, K., Razuri, E., Howard, A., Call, C., DeLuna, J., Hall, J., & Cross, D. (2015).

Decrease in Behavioral Problems and Trauma Symptoms Among At-Risk Adopted

Children Following Trauma-Informed Parent Training Intervention. Journal Of Child &

Adolescent Trauma, 8(3), 201-210. doi:10.1007/s40653-015-0055-y

This study was the first research project to use a randomized sample, pre-post design with

a control group to test the effectiveness of TBRI. It had already been used in intensive home

programs, residential treatment centers, and schools, but it had not been used in an experiment.

The researchers hypothesized that behavioral problems and trauma symptoms would decrease for

at-risk adopted children whose parents participated in a TBRI trauma-informed parent-training

program.

The study consisted of 96 adoptive parents who were interested in learning how to care

for their adopted children with traumatic histories. Eligible participants were parents of children

who had either been adopted domestically or internationally, were between the ages of 5 and 12,

and had lived with that family for at least one year. There were 48 participants in the treatment

group and 48 in the control group. The control group participants were matched to those in the

treatment group based on the child’s age, sex, adoption type (domestic vs. international) and age

at adoption. All participants took an online pretest before the intervention as well as online

posttest two weeks afterwards. They also completed the Strengths and Difficulties Questionnaire

(SDQ) and Trauma Symptoms Checklist for Young Children (TSCYC) pre- and post-

intervention. The treatment group attended a 4-day TBRI parent training (6 hours per day) that

taught them the TBRI program and how they could incorporate it into their homes. The control

group received no information on TBRI until after the experiment. All participants completed the

posttest as well as the SDQ and TSCYC two weeks after the intervention.


The results revealed significant interaction effects for time (pre and post) and treatment

group in four of the five SDQ subscales (p<.01). The caregiver reports on four of the nine

TSCYC scales also showed significant interaction effects for time and group. Overall, TSCYC

scales showed a significant decrease in total difficulties for the treatment group (Mpre =18.90,

SD=6.83; Mpost =16.90, SD=6.64) but not for the control group (Mpre=17.69, SD=5.46;

Mpost=18.08; SD=5.87).

This article strongly supports my hypothesis because it demonstrated the effectiveness of

TBRI, which operates without any medicinal influence. Besides the stark differences between the

treatment group and the control group, the results also confirmed that TBRI could take effect

quite quickly. Indeed, changes in SDQ and TSCYC scores began to decrease after only two

weeks. TBRI is extremely helpful because it targets families in addition to individual foster

children. This allows change to take place within the family environment, which tends to be the

root cause to many behavioral problems and traumatic symptoms. Even if the foster child’s new

family does not cause any additional trauma, it can still be a negative environment if the family

does not know how to respond to the child’s traumatic outbursts when they do occur. Therefore,

TBRI is a far more effective – and less expensive – treatment for foster children than any kind of

pharmacologic treatment.

+5


Parris, S., Dozier, M., Purvis, K., Whitney, C., Grisham, A., & Cross, D. (2015). Implementing

Trust-Based Relational Intervention in a Charter School at a Residential Facility for At-

Risk Youth. Contemporary School Psychology (Springer Science & Business Media

B.V.), 19(3), 157. doi:10.1007/s40688-014-0033-7

This study examined the implementation of TBRI in a charter school at a residential

facility for at-risk youth. They hypothesized that TBRI would result in improvements in

behavior.

The researchers selected a charter school in Texas where youth had been placed due to a

variety of reasons including abuse/neglect, family violence, parent-child conflict, difficulties at

school, and behavioral issues. Involved in the study were 138 students (n=138), grades 7-12.

The intervention began in August 2011 when TBRI trainers worked with the administrators to

incorporate TBRI principles into the school system. Prior to the following school year, TBRI was

implemented more strongly by means of seminars and training days for the school staff. Data

were collected through interviews with school staff and administrators about their personal

observations and experiences, and through school incident reports. Focus groups were also held

throughout the study with the researchers and school staff. The groups were held one month

before the second year of TBRI implementation, three months after implementation, and one

month after the year was completed. The different techniques that were utilized followed the

three TBRI principles (empowering, connecting, and correcting). Firstly, the effective

empowering principles were hydration at all times, multiple snack times, fidgets (e.g., silly putty,

stress balls) and the removal of conflict triggers (e.g., always eating indoors). Secondly,

connecting principles like relationship building, healthy touch, and affirmations were also found


to be helpful. Lastly, different types of discipline like “compromises” and “redo’s” were popular

correcting principles.

During the first focus group before the second year of TBRI, participants noticed that the

students had begun to discuss problematic issues with the staff, used less profanity, were less

likely to complain, and fought less. Upon completion of the second year of TBRI, data showed

significant decreases in negative behavior: 68% in referrals for physical aggression, 88% in

referrals for verbal aggression, and 95% in referrals for disruptive behavior.

This article supports my hypothesis because the results clearly displayed a large

improvement in the children’s behavior due to the success of TBRI and its principles. As

previously stated, TBRI does not utilize any medications whatsoever. Thus, this significant

improvement took place entirely through psychosocial therapy. The results of this article are very

important to my hypothesis because they displayed the efficacy of TBRI. TBRI is something that

not only works in a select few individual foster youth, but can have impact over a hundred at-risk

youth. Furthermore, this study provided strong evidence that TBRI can be applicable both in

family life and outside it – that is, in a school environment. This is also extremely important

because normally, children are prescribed medication to help them behave in class, but now it is

clear that medications are not vital for good school behavior. Lastly, this experiment suggested

that TBRI is a treatment that never ceases to improve behavior. As long as the child is a recipient

of TBRI principles, they will continue to get better.

+5


Brenner, S. s., Southerland, D., Burns, B., Wagner, H., & Farmer, E. (2014). Use of Psychotropic

Medications Among Youth in Treatment Foster Care. Journal Of Child & Family

Studies, 23(4), 666-674.

The purpose of this article was to describe the use of psychotropic medications among

youth in treatment foster care (TFC), which is a community-based intervention for youth with

emotional, behavioral, and mental health problems. They aimed to find the prevalence of

psychotropic medication use and polypharmacy among foster care youth.

Data was collected from youth in TFC in a southeastern state between 2003 and 2008.

Fourteen TFC agencies were chosen at random for the purposes of this study. The participants

were 247 youth (ages 2-21; M=13.0, SD=3.8) and their foster care parents. Of the TFC youth,

32% were white, 58% were African American, and 25% were other races. The data for this study

came from interviews with all treatment parents. They were asked to report if their TFC youth

had taken any type of medicine for emotional or behavioral issues in the past two months and

whether or not they were still taking them. The two indicators of “questionable polypharmacy”

were two or more medications within the same class, and/or three or more psychotropic

medications. They also completed the Strengths and Difficulties Questionnaire (SDQ) to

evaluate the severity of psychopathology among the children. Psychotropic medications were

broken up into five categories: (1) antidepressants; (2) ADHD/stimulants; (3) antipsychotics; (4)

non-antipsychotic mood stabilizers/antimanic agents; and (5) anxiolytics (antianxiety

medication). The types of analyses used included logistic regression, Chi squares, and t tests.

The results displayed that about 59% of the sample youth took psychotropic medications

within the two months prior to the studies. Of this percentage, 61% took two or more

medications. The 59% that took medications had significantly higher SDQ scores (M= 17.2,


SD=6.2) compared to youth not taking medication (M= 14.1, SD= 7.4; t = -3.04, p<.01). There

were no differences in SDQ scores for youth on “any polypharmacy” versus “questionable

polypharmacy.”

This study supports my hypothesis in a couple important ways. Firstly, the statistics on

questionable polypharmacy brought some key issues to light. The fact that SDQ scores were

similar for both the “any polypharmacy” and “questionable polypharmacy” groups shows that

foster youth are unreasonably medicated. Children participating in “questionable polypharmacy”

act the same as other children yet receive amounts of medication that are unreasonable and even

hazardous. Furthermore, this same group of children was both less likely to have seen a

psychiatrist within the two months they were prescribed medications and less likely to be

receiving other services outside of the medications. Secondly, the researchers of this study also

compared rates of psychiatrist visits in TFC youth to youth in outpatient settings and found that

the latter group received psychotropic prescriptions from non-psychiatrists. This puts foster

youth in extreme danger. Overall, this article is compatible with my hypothesis because the

researchers called for a decrease in presence of psychotropic medications and an increase in

usage of other psychosocial services.

+3


Emslie, G. J., Heiligenstein, J. H., Wagner, K. D., Hoog, S. L., Ernest, D. E., Brown, E., & ...

Jacobson, J. G. (2002). Fluoxetine for acute treatment of depression in children and

adolescents: a placebo-controlled, randomized clinical trial. Journal Of The American

Academy Of Child And Adolescent Psychiatry, (10), 1205.

The purpose of this article was to measure the effects of fluoxetine – a selective serotonin

reuptake inhibitor (SSRI) – on children and adolescents with major depressive disorder (MDD).

The researchers hypothesized that fluoxetine would be a safe and effective treatment for these

youth.

The study took place over nine weeks and had a sample size of 219, which included 122

children (aged 8 to <13 years) and 97 adolescents (aged 13 to <18 years). All participants had a

diagnosis of nonpsychotic major depression disorder. The study began with an interview process

where participants and their caretakers met separately with a researcher once a week for three

weeks before treatment began. Next, participants were given a placebo for a week and if any

improvements occurred, they were eliminated from the study. The rest of the participants were

randomly assigned to either the placebo group or the treatment group. The placebo-treated (PT)

patients were told to take three tablets once daily for 9 weeks. The fluoxetine-treated (FT)

patients were given the same instructions. For the first week, the capsules distributed to FT

patients consisted of two placebo tablets and one 10mg fluoxetine tablet. For weeks 2 through 9,

they were given one placebo tablet and two 10mg fluoxetine tablets. This was done to test ensure

20mg of fluoxetine would be effective and well tolerated. All patients returned for efficacy and

adverse effects assessments at weeks 1, 2, 3, 5, 7, and 9. At each meeting, patients were assessed


by patient, parent, and clinician reports using the Children’s Depression Rating Scale-Revised

(CDRS-R) and the Clinician’s Global Impressions (CGI) Severity scales.

The results were in favor of the hypothesis. In regards to efficacy, FT patients had a

significantly higher mean change in CDRS-R score (p <.001). Significantly more FT patients

(41.3%) than PT patients (19.8%) met criteria for remission (p <.01). Half of all FT patients

(52.3%) were rated as very much improved (CGI score of 1 or 2) compared to one third of PT

patients (36.8%; p = .028). In regards to safety, there was no significant difference between FT

and PT patients reporting headaches as a side effect (p = .273).

This study refutes my hypothesis very strongly. Even though this particular article does

not apply directly to foster kids, it can be applied to my hypothesis because MDD is the most

common mental health disorder among foster youth (Pecora, White, Jackson, & Wiggins, 2009).

The results displayed the efficacy and safety of SSRIs in youth with MDD. Indeed, the data

showed that FT patients improved significantly more than the PT patients. Even though the main

reported side effect was headaches, the placebo group also experienced headaches. This might

even suggest that headaches are merely a side effect of MDD, not medication. This data makes a

strong case for SSRIs and their use in youth who have experienced trauma.

-3


Discussion

The youth in the foster care system have been taken from their families due to some level

of inadequate parenting (Lloyd & Barth, 2011). Most children who have experienced out-of-

home care have experienced trauma, and the symptoms of trauma – like emotional and

behavioral problems – can persist or get worse over time (Purvis et al., 2015). In response to

these problems, the usual solution is a combination of prescription medications – typically

psychotropic drugs – and psychosocial therapy (Brenner et al., 2013). Unfortunately, most of the

children who receive a prescription for psychotropic drugs do not follow through with the

psychosocial element and continue getting refills without approval from a psychiatrist or child

mental health specialist (Fonatella et al., 2014). This means that many foster youth are not

receiving the proper treatment they need to begin the healing process. They only get half of the

treatment. Clearly, there are not enough restrictions in place to ensure this does not happen

because the caregivers of foster youth are finding ways around doctoral supervision. The fact

that many youth are taking such strong medications without proper monitoring means they are in

danger. Being on a medication for too long has ramifications for the body, especially for

children’s bodies (dosReis et al., 2011). Furthermore, research is beginning to indicate negative

side effects that psychotropic drugs have on children. These side effects include weight gain,

Type-2 diabetes, and dyslipidemia (dosReis et al., 2011). These effects are two to five times

greater among children and adolescents who receive multiple antipsychotics at the same time, as

many foster children do (Brenner et al., 2014). There is, however, emerging evidence that

TBRI’s purely psychosocial approach is just as effective – if not more so – than medications.

Therefore, it was hypothesized in this study that TBRI would be a more efficacious treatment for

foster youth with emotional and behavioral disorders.


In this study, eight articles were found in support and four were found in refute. The

strongest articles on the support side were about TBRI and its positive effects after it was

implemented in a case study, a seminar for families, and a charter school. These articles had

astounding results. The problem behaviors decreased significantly in all of the youth who were

studied that received TBRI either through their caregivers, schoolteachers, or the researchers

themselves. The articles in refute were various studies or analyses about certain psychotropic

medications and the benefits that they have. All of these were average in strength because none

of them referred directly to foster youth. Unfortunately, there are not any articles that explicitly

compare the effects of purely pharmaceutical treatment to pure TBRI. That being said, the

studies that were found all point to psychosocial therapy as the more beneficial and safe of the

two treatment styles, and the results of the studies on TBRI clearly point to its effectiveness in

healing. Overall, research is starting to suggest a decrease in the amount of medications

prescribed and greater focus on treatments like TBRI. Therefore, the hypothesis can be accepted

because TBRI and other psychosocial treatments are better treatments for foster and at-risk youth

with emotional and behavioral difficulties.

There were some limitations of the articles utilized for this study. Of the four

articles about TBRI interventions, two did not use a p-value to test any significant changes post-

intervention (Parris et al., 2015; Purvis et al., 2014). Even though statistical significance is

desirable to validate a treatment method, it cannot be denied that the changes that took place in

both studies were quite large. The articles about TBRI also neither controlled for any usage of

pharmaceuticals nor made any mention of which participants were medicated at the time (Parris

et al., 2015; Purvis et al., 2007; Purvis et al., 2014; Purvis et al., 2015). This could mean the

children who were involved in the intervention did not improve only through TBRI, but through


the confounding variable of prescription medications. Nevertheless, the article about the TBRI

parent intervention is one of the strongest articles because it utilized a randomized sample, pre-

post design with a control group, and the results displayed significant effects for the treatment

group (Purvis et al., 2015). The support articles that were given a score of either a four or a five

were rated highly because the methods used and results that followed created certainty that TBRI

can be generalized to all traumatized youth between the ages of 3 and 14. The samples of each

article represented boys and girls of many races and ethnicities within that age range. It cannot

be generalized to older teens and adults because more research needs to be done to test the

effects of TBRI on this population.

One of the main flaws in the articles that refuted the hypothesis was that the data used to

help draw conclusions came from studies prior to the year 2000 (Emslie et al., 2002; Donnelly,

2003; Seedat et al., 2002; Walsh et al., 2004). This was especially apparent in the analysis of

pharmacologic treatment for children with PTSD (Donnelly, 2003). These four articles can

almost be disregarded because it is quite difficult to find any research after the year 2000 that

condones pharmacologic treatment for traumatized youth.

These analyses are crucial for the safety and well-being of foster youth in the United

States. If it wasn’t for the analysis of the available data, foster youth would continue receiving

medications that are both under-supported by research and unapproved by the FDA. Even the

studies and analyses in refute of the hypothesis recognize the lack of specific data on the long-

term effects of psychotropic medications in traumatized youth (Emslie et al., 2002; Donnelly,

2003; Seedat et al., 2002; Walsh et al., 2004). Unfortunately, many medical professionals

continue to prescribe strong drugs for children without strong support from research.


Inspection of the refute articles caused another question to emerge: what is the intended

purpose of medications in a pediatric setting? Ideally, the child takes a medication for the brief

period of time that is needed to heal. They should not take medications indefinitely, yet this is

what is occurring. Children certainly should not become dependent on strong psychotropic drugs

because their developing bodies can be impaired. Data from a TBRI study showed how certain

effects that were thought to only take place through medication (changes in neurotransmitter

levels) could also occur through psychosocial therapy (Purvis, McKenzie, Becker, Cross, &

Buckwalter, 2014). This is extremely important to the area of psychology because it is now

known that alterations in brain chemistry are possible without pharmaceuticals. This is only

logical because the original changes that occurred in traumatized youth’s brains were a result of

interpersonal interactions. Thus, the best way to undo the damage that was done is through the

same way it happened in the first place.

Fortunately, the overmedication of foster children and adolescents has been brought to

the attention of society as a whole. Laws have been passed that limit the distribution of

psychotropic drugs to foster youth (Korry, 2015). This is a step forward, but even though there is

an increase in awareness of overmedication, there needs to be an increased redirection of

treatment. Limiting prescription medications is helpful, but it does not solve the difficulties

foster youth face. There needs to be greater focus on the benefits of psychosocial therapies like

TBRI. TBRI is a relatively new treatment method that should be publicized. One way this can

be done is through further research utilizing TBRI in order to make medical professionals and

insurance companies cognizant of its efficacy.

There are many studies that can ensure that this awareness occurs. First, research should

be done comparing the cost of pharmaceuticals to the cost of implementing the TBRI program.


The only cost would be the initial seminar to teach parents and schoolteachers how to

incorporate TBRI into their own homes or classrooms. In comparison to the cost of each refill of

a psychotropic drug, the expense would be extremely low. Second, an experiment should be

conducted to compare the long-term behavioral and emotional changes of foster youth taking

pharmaceuticals versus youth involved in TBRI. Last, there should be a longitudinal study on

foster youth following the initial implementation of TBRI. This would make it possible to see

how long the TBRI principles continue to have an effect on the difficulties that foster youth

have. Clearly, there is still much to be done to make TBRI a common practice, but this new

direction of treatment for foster youth is one that will restore peace and security in their lives.


References

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Medications Among Youth in Treatment Foster Care. Journal Of Child & Family

Studies, 23(4), 666-674.

Correll, C. U. (2009). Multiple antipsychotic use associated with metabolic and cardiovascular

adverse events in children and adolescents. Evidence Based Mental Health, 12(3), 93.

Donnelly, C. L. (2003). Pharmacologic treatment approaches for children and adolescents with

posttraumatic stress disorder. Child And Adolescent Psychiatric Clinics Of North

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dosReis, S., Yoon, Y., Rubin, D., Riddle, M., Noll, E., & Rothbard, A. (2011). Antipsychotic

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tbri thesis

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