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Defining Trauma in the Early Years

Trauma- Focused Child-Parent Psychotherapy In Infancy and Early Childhood Alicia F. Lieberman, Ph. D. Professor of Medical Psychology University of California San Francisco. Defining Trauma in the Early Years. Child’s direct experience or witnessing of an event or events that involve:

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Defining Trauma in the Early Years

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  1. Trauma- FocusedChild-Parent PsychotherapyIn Infancy and Early ChildhoodAlicia F. Lieberman, Ph. D.Professor of Medical PsychologyUniversity of California San Francisco

  2. Defining Traumain the Early Years • Child’s direct experience or witnessing of an event or events that involve: Actual or threatened death or serious injury to child or others Threat to psychological or physical integrity of child or others (DC:0-3R, Zero to Three, 2004)

  3. Violence As Paradigm of Trauma In the Early Years • Child abuse is leading cause of death in the first year of life • Half of child abuse victims are under age 7 • 85% of abuse fatalities are under age 6 • U. S. ranks THIRD among 27 industrialized countries in child deaths due to maltreatment (Gentry, 2004; UNICEF, 2003; HHS Children’s Bureau, 2003)

  4. Convergence of Types of Violence • Children exposed to domestic violence • 15 times more likely to be abused than the national average • 30-70% overlap with child abuse • At serious risk of sexual abuse • Battered women • Twice more likely to abuse their children than comparison groups (Osofsky, 2003; Edleson, 1999; Margolin & Gordis, 2000; McCloskey, 1995)

  5. Impactof Trauma in the Early Years • Loss of developmental expectation of protection from the parent • Disrupted mental representations • Affect Dysregulation • Impairment in Readiness to Learn

  6. Impact of Trauma on Parents • Loss of internal security • Changes view of self/other • Victim • Persecutor • Non-helpful bystander • Traumatic reminders • Traumatic expectations

  7. Changes in Child-Parent Relationship after Trauma • Impaired affect regulation • Negative Mutual Attributions • Traumatic Expectations • Parent and child may serve as traumatic reminders for one another

  8. Domestic Violence in Infancy and Early Childhood • Shattering of developmental expectation of protection from the attachment figure • The protector becomes the source of danger • “Unresolvable fear”: Nowhere to turn for help • Contradictory feelings toward each parent (Pynoos, 1993; Main & Hesse, 1990; Lieberman & Van Horn, 1998)

  9. Maternal Attributions • Fixed beliefs about the child’s existential core • Perceived as objective truth • Reflect maternal fantasies, including fears, conflicts, and wishes about the child (Lieberman, 1997)

  10. Maternal Attributions and Child Sense of Self • Mother attunes selectively to the child’s feelings • Maternal responses shape the child’s sense of what he/she is permitted to feel • Child internalizes the maternal attribution (Lieberman, 1997, 1999)

  11. Young Children Need to Be Seen in the Context of Their Relationships

  12. Treating Young Children • Young children develop in relationships • Young children use relationships with caregivers to • Regulate physiological response • Form internal working models of relationships • Provide secure base for exploration and learning • Model accepted behaviors

  13. Caregiver as Protective Shield

  14. Child-Parent PsychotherapyTheoretical Target • The system of jointly constructed meanings in the child-parent relationship. • These meanings emerge from each partner’s representations of themselves and each other. • These representations are expressed through individual or interactive language, behavior, and play.

  15. Child-Parent Psychotherapy Goals • Encouraging normal development: engagement with present activities and future goals • Maintaining regular levels of affective arousal • Establishing trust in bodily sensations • Achieving reciprocity in intimate relationships

  16. Child-Parent Psychotherapy Trauma-related Goals • Increased capacity to respond realistically to threat • Differentiation between reliving and remembering • Normalization of the traumatic response • Placing the traumatic experience in perspective

  17. Balancing Trauma Treatment with Other Goals • Trauma lens: Trauma reminders, expectations and affects • Attachment lens: Protection and safety • Developmental lens: Age-appropriate pursuits • Cultural lens: Ecological context

  18. Integration of Theoretical Approaches • Developmentally Informed • Attachment • Trauma • Psychoanalytic theory • Social learning theory • Cognitive Behavioral Interventions • Culturally Informed

  19. ASSESSMENT

  20. Multidimensional Approach to Assessment • Child’s Individual Functioning • Family Context • Community and cultural values

  21. “Best Practices” For Assessment • 3-5 45-minute assessment sessions • Developmental history before/after trauma • Observation of child • Observation of child-parent relationship • Child’s trauma narrative • Collateral information

  22. Assessment as Form of Treatment • “Psychological first aid” - Developmentally appropriate intervention - Immediate emotional relief • Information gathering • Assessment-treatment feedback loop • Incorporates developmental changes

  23. Assessment Domain: Child’s Trauma Experience • Circumstances and Sequence ofTrauma What Who How When Where • Nature of Child’s Involvement • Each Parent’s Presence and Participation • Events Following the Trauma

  24. Can Young Children Remember Trauma? • Implicit Memory - Engages early-maturing brain regions - Non-verbal - Functions outside awareness - Experimentally shown in infants • Explicit Memory - Focalattention for encoding - Subjective recollection for retrieval - Verbal recall (Schachter, 1987)

  25. Can Young Children Remember Trauma? • “Memorability” Unique, dramatic, eliciting intense emotion • Retrieval Verbal children narrate traumatic events that occurred when they were pre-verbal • Accuracy versus misunderstanding (Nelson, 1994; Gaensbauer, 1995; Terr, 1988)

  26. Assessment Domain: Child’s Functioning • Biological rhythms: Eating, sleeping, somatic complaints • Emotional regulation: Age-appropriate anxieties and coping • Social connectedness: Quality of attachment, peer relations • Cognitive functioning: Developmental milestones, readiness to learn

  27. Assessment Domain: Child-Parent Relationship • Trauma shatters child’s trust Parental failure to protect Parent as attacker • Trauma disrupts parent’s mental health Traumatic response Self-blame • Trauma disrupts family bonds Mutual blame Emotional alienation

  28. Assessment Domain: Traumatic Reminders • Neutral stimuli trigger traumatic memories • Intrusive imagery and sensory experiences • Operating outside consciousness • Associated with secondary stresses • Parent as traumatic reminder • New fears

  29. Assessment Domain: Continuity of Daily Routines • Predictability supports emotional regulation • Trauma disrupts daily routines • Secondary adversities add new stress

  30. Assessment Domain: Family Ecological Niche • Family Circumstances Primary caregiver Who holds the holding environment Concrete supports • Family Belief Systems • Cultural Values

  31. Making a Clinical Diagnosis Traumatic Stress Response • Re-experiencing the trauma Post-traumatic play; distress at reminders; recollections outside of play; flashbacks; dissociation; nightmares • Numbing Social withdrawal; loss of milestones; play constriction • Increased arousal Hypervigilance, attentional problems, startles • New symptoms

  32. Making a Clinical Diagnosis: Co-Morbidity • Prevalent in traumatic response across development • In young children, related to immature expressive repertoire • The same behavior can signify different experiences

  33. Treatment

  34. Child-Parent PsychotherapyIntervention Modalities 1. Promote developmental progress through play, physical contact, and language 2. Unstructured/reflective developmental guidance 3. Modeling protective behaviors 4. Interpretation: linking past and present 5. Emotional support 6. Concrete assistance, case management, crisis intervention

  35. Ports of Entry

  36. Possible Ports of Entry • Child’s or parent’s behavior • Parent-child interaction • Child’s representation of self or of parent • Parent’s representation of self or of child • Mother-father-child interaction • Inter-parental conflicts • Child-therapist relationship • Parent-therapist relationship • Child-parent-therapist relationship

  37. Ports of Entry • Immediate object of clinical attention • Chosen on basis of emotional immediacy and clinical need • Not driven by a priori theory, but by therapist’s assessment of potential for positive change

  38. Ports of Entry • Begin from simplicity • Safety and trust as organizing concepts • Developmental guidance may suffice • If unsuccessful, explore resistance

  39. TRAUMATIC BEREAVEMENT IN INFANCY AND EARLY CHILDHOOD

  40. Traumatic Bereavement in Infancy and Early Childhood “There are no peaceful deaths for parents of young children. Whenever we say ‘his parent died’, we leave out the inevitable horror and tragedy that such a death entails” (Furman, 1974)

  41. Dual Lens: Grief and Trauma The child cannot mourn successfully when traumatic reminders interfere with the memory of the parent. The child’s work of mourning is facilitated when the traumatic circumstances of the death recede in the child’s mind.

  42. Factors Affecting the Child’s Response to Parental Death • Child’s developmental stage: understanding of death • Circumstances of the death: Sudden? Violent? Witnessed by child? • Quality of parent-child relationship • Availability of another parental figure • Emotional support

  43. Is Parental Death Always Traumatic for the Young Child? Continuum of traumatic experience: Milder: Increased child maturity Anticipatory guidance Child is not witness Severest: Sudden, violent Witnessed by child

  44. Developmental Impact of Parental Death Disruptions in: • Regulation of bodily rhythms • Modulation of emotion • Formation and socialization of relations • Learning from exploration

  45. Manifestations of Grief and Mourning • Protest Crying, searching, rejecting comfort • Sadness and emotional withdrawal Lethargy; awaiting reunion • Anger at self and others

  46. Manifestations of Grief and Mourning • Intensification of normative anxieties • Regressions in development • New fears • Denial, self-blame, idealization

  47. Responses to Witnessing Violent Death • Horror • Powerlessness • Intrusive mental images • Fear for personal safety • Dissociation • Responses to traumatic reminders

  48. Assessment Guidelines • Circumstances of the death What the child witnessed What the child knows Traumatic reminders • Current family circumstances • Child’s functioning: before and after

  49. Assessment Guidelines • Child’s Relationship with Dead Parent • Current Caregiver & Continuity of Routines • Family Response to the Death • Cultural and family traditions and beliefs

  50. Does Child Have a Clinical Diagnosis? Using DC:0-3 Prolonged Bereavement/Grief Reaction • Crying, calling, searching • Emotional withdrawal with lethargy • Disruption of biological rhythms • Developmental regression • Restricted affective range • Detachment • Extreme sensitization to loss reminders

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