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Real Life Heroes

Real Life Heroes (RLH) is based on cognitive behavioral therapy models for treating posttraumatic stress disorder (PTSD) in school-aged youth. Designed for use in child and family agencies, RLH can be used to treat attachment, loss, and trauma issues resulting from family violence, disasters, severe and chronic neglect, physical and sexual abuse, repeated traumas, and posttraumatic developmental disorder. RLH focuses on rebuilding attachments, building the skills and interpersonal resources needed to reintegrate painful memories, fostering healing, and restoring hope. These goals are accomplished using nonverbal creative arts, narrative interventions, and gradual exposure to help children process their traumatic memories and bolster their adaptive coping strategies.

The protocol components include safety planning, trauma psychoeducation, skill building in affect regulation and problem solving, cognitive restructuring of beliefs, nonverbal processing of events, and enhanced social support. Practitioners use an activity-based workbook and manual. The workbook, built around the metaphor of heroes, provides a structured, phased approach to help children and caring adults rebuild the sense of safety and hope, the attachments, and the skills and resources necessary for trauma therapy. Activities promote the repair of breaks in caring adult-child trust and attunement. The intervention involves anywhere from 6 to 18 months of weekly therapy sessions, the overall duration depending on the child's individual needs and circumstances. Clinicians, typically having an M.S.W. degree, attend a 2-day workshop and participate in consultation groups every other week. Child care staff and foster parents are also involved in training as team members and caring adults.

Descriptive Information

Areas of Interest Mental health treatment
Outcomes Review Date: December 2007
1: Trauma symptoms
2: Problem behaviors
3: Feelings of security with primary caregiver
Outcome Categories Family/relationships
Mental health
Social functioning
Trauma/injuries
Ages 6-12 (Childhood)
13-17 (Adolescent)
Genders Male
Female
Races/Ethnicities Data were not reported/available.
Settings Residential
Outpatient
Home
Geographic Locations Urban
Suburban
Rural and/or frontier
Implementation History Real Life Heroes was first implemented in 1998 and has been used in more than 200 sites in the United States and Taiwan. It is estimated that more than 3,000 children have received the intervention.
NIH Funding/CER Studies Partially/fully funded by National Institutes of Health: No
Evaluated in comparative effectiveness research studies: No
Adaptations In 2006, informal pilot testing was initiated at the Latin American Health Institute in Boston, Massachusetts, to test the applicability of RLH at a center focused on a Hispanic population. Family Services of Northeast Wisconsin, a nonprofit human services agency, also began a similar trial with a more rural population. RLH program materials have been translated into Chinese.
Adverse Effects No adverse effects, concerns, or unintended consequences were identified by the developer.
IOM Prevention Categories IOM prevention categories are not applicable.

Quality of Research
Review Date: December 2007

Documents Reviewed

The documents below were reviewed for Quality of Research. The research point of contact can provide information regarding the studies reviewed and the availability of additional materials, including those from more recent studies that may have been conducted.

Study 1

Kagan, R., Douglas, A. N., Hornik, J., & Kratz, S. L. (2008). Real Life Heroes pilot study: Evaluation of a treatment model for children with traumatic stress. Journal of Child and Adolescent Trauma, 1(1), 5-22.

Outcomes

Outcome 1: Trauma symptoms
Description of Measures The 54-item Trauma Symptom Checklist for Children (TSCC) was administered to children to assess trauma symptoms. Children were asked to rate how often they experienced each emotion or event on a scale from 0 (never) to 3 (almost all the time). Caregivers completed the 18-item Parent Report of Posttraumatic Symptoms (PROPS) to assess caregiver observations of the children's trauma symptoms, rated as "never," "some," or "lots" in the past month.
Key Findings From baseline to 4 months after baseline, children who received the RLH intervention demonstrated a reduction in self-reported trauma symptoms (p < .05).

For caregiver reports, a main effect of time was found when controlling for the number of RLH chapters completed. That is, caregivers tended to report greater reductions in trauma symptoms among those children who had completed more RLH chapters over a 12-month period (p < .001).
Studies Measuring Outcome Study 1
Study Designs Preexperimental
Quality of Research Rating 2.6 (0.0-4.0 scale)
Outcome 2: Problem behaviors
Description of Measures Caregivers completed a revised version of the Conners Parent Rating Scale (CPRS-R) that included 80 items measuring anxiety, attention deficit, and externalizing behaviors. Each caregiver rated how true specific statements were about the child, focusing on the past month.
Key Findings From baseline to 4 months after baseline, caregivers of children receiving the RLH intervention observed fewer problem behaviors in their children (p < .05).
Studies Measuring Outcome Study 1
Study Designs Preexperimental
Quality of Research Rating 2.7 (0.0-4.0 scale)
Outcome 3: Feelings of security with primary caregiver
Description of Measures Children completed the Security Scale (SS), a 15-item self-report measure that assesses children's attachment relationship to their primary caregiver. For each item, children were asked to choose which of two statements described themselves best, and then to indicate whether the description was "sort of true" or "really true" for them. Each item was scored on a 4-point scale, with higher scores indicating perceptions of more secure relationships.
Key Findings A main effect of time was found when controlling for the number of RLH chapters completed. That is, caregivers tended to report greater increases in child-caregiver security/attachment among those children who had completed more RLH chapters over a 12-month period (p < .05).
Studies Measuring Outcome Study 1
Study Designs Preexperimental
Quality of Research Rating 2.7 (0.0-4.0 scale)

Study Populations

The following populations were identified in the studies reviewed for Quality of Research.

Study Age Gender Race/Ethnicity
Study 1 6-12 (Childhood)
13-17 (Adolescent) 		59% Male
41% Female 		Data not reported/available

Quality of Research Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the Quality of Research for an intervention's reported results using six criteria:

For more information about these criteria and the meaning of the ratings, see Quality of Research.

Outcome Reliability
of Measures 		Validity
of Measures 		Fidelity Missing
Data/Attrition 		Confounding
Variables 		Data
Analysis 		Overall
Rating
1: Trauma symptoms 3.8 4.0 1.0 2.5 1.5 3.0 2.6
2: Problem behaviors 4.0 4.0 1.0 2.5 1.5 3.0 2.7
3: Feelings of security with primary caregiver 4.0 4.0 1.0 2.5 1.5 3.0 2.7

Study Strengths

All the measures have acceptable psychometric properties, and the child-respondent measures were age appropriate. Clinicians completed checklists to assess progress and fidelity. There was an adequate follow-up period. The intervention was evaluated in a real-world environment with all the issues inherent in conducting such a study; thus, the external validity of the research (i.e., generalizability) should be high. The investigators used analytic techniques (i.e., hierarchical linear modeling) that permitted use of all the follow-up observations, despite the significant attrition of children and families.

Study Weaknesses

Consistency and quality of implementation were variable over time, particularly given the high staff turnover rate. It is unclear what percentage of children completed all eight chapters of the workbook or to what extent caregivers participated in the weekly sessions. Attrition was high. Due to program implementation delays, some children received more than a year of treatment before beginning the intervention. The weak pre/post design with no comparison group was likely to result in a number of threats to internal validity, even with multiple assessments over time. The sample size was small, making it difficult to separate shared variance between time and the intervention. No power analysis was conducted.
Readiness for Dissemination
Review Date: December 2007

Materials Reviewed

The materials below were reviewed for Readiness for Dissemination. The implementation point of contact can provide information regarding implementation of the intervention and the availability of additional, updated, or new materials.

Kagan, R. (2004). Rebuilding attachments with traumatized children: Healing from losses, violence, abuse, and neglect. Binghamton, NY: The Haworth Maltreatment and Trauma Press.

Kagan, R. (2007). Real Life Heroes: A life storybook for children (2nd ed.). Binghamton, NY: The Haworth Press, Inc.

Kagan, R. (2007). Real Life Heroes: Practitioner's manual. Binghamton, NY: The Haworth Press, Inc.

Real Life Heroes One-Two Day Workshop Curriculum

Real Life Heroes Organizational Guidelines

Selected workshop presentations [PowerPoint slides]:

  • Kagan, R. (2007). Engaging caring adults after family trauma. Albany, NY: Author.
  • Kagan, R. (2007). Neuro-biological impact of trauma. Albany, NY: Author.
  • Kagan, R. (2007). Preventing vicarious traumatization. Albany, NY: Author.
  • Kagan, R. (2007). Rebuilding safety and trust with traumatized children. Albany, NY: Author.
  • Kagan, R. (2007). Working with traumatized children: Telling the story with narrative and creative arts. Albany, NY: Author.

Readiness for Dissemination Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the intervention's Readiness for Dissemination using three criteria:

  1. Availability of implementation materials
  2. Availability of training and support resources
  3. Availability of quality assurance procedures

For more information about these criteria and the meaning of the ratings, see Readiness for Dissemination.

Implementation
Materials 		Training and Support
Resources 		Quality Assurance
Procedures 		Overall
Rating
4.0 4.0 4.0 4.0

Dissemination Strengths

Implementation materials are user-friendly and easy to follow. Materials provide significant detail on the theory behind the strategies, step-by-step guidance in delivering the sessions, and troubleshooting guidelines to help clinicians. Thorough training and support resources are available that pay close attention to organization, supervisor, and clinician needs. Organizational support, detailed process checklists, and sample evaluation plans contribute to a complete quality assurance protocol.

Dissemination Weaknesses

No weaknesses were noted by reviewers.
Costs

The cost information below was provided by the developer. Although this cost information may have been updated by the developer since the time of review, it may not reflect the current costs or availability of items (including newly developed or discontinued items). The implementation point of contact can provide current information and discuss implementation requirements.

Item Description Cost Required by Developer
Practitioners manual (includes session summary checklist and assessment and service planning checklists) $40 each Yes
Real Life Heroes: A Life Storybook for Children $30 per child (discounts available for 40 or more copies) Yes
Rebuilding Attachments With Traumatized Children: Healing From Losses, Violence, Abuse, and Neglect (book) About $40 No
3-day, on-site start-up workshop (includes leadership checklists for program directors, supervisors, and peer-to-peer coaches or consultants) $6,000-$8,000 plus travel expenses No
Half-day, on-site leadership workshop $1,000-$1,500 plus travel expenses No
1-day, on-site follow-up workshop for practitioners $2,000-$2,500 plus travel expenses No
Half-day, on-site follow-up leadership workshop $1,000-$1,500 plus travel expenses No
Monthly group telephone consultation $2,250 for nine monthly calls No
Individual telephone consultation $125 per hour for two or three calls per practitioner over 9 months No
Pre-Post Resilience and Trauma Assessment instruments (including UCLA PTSD Index for DSM-IV child and parent versions, Connors Behavior Rating Scales--Parent Long Version, Child Behavior Checklist, Resiliency Scales, Trauma Symptom Checklist for Children, and Security Scale) Varies depending on site needs and instruments selected No

Additional Information

Creative arts materials average $40 per practitioner for approximately 16 children a year.
Replications

No replications were identified by the developer.
Contact Information

To learn more about implementation, contact:
Richard Kagan, Ph.D.
richardkagan@nycap.rr.com

To learn more about research, contact:
Richard Kagan, Ph.D.
(518) 426-2600 ext 2725
kaganr@parsonscenter.org

Consider these Questions to Ask (PDF, 54KB) as you explore the possible use of this intervention.

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