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

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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)

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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)

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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)

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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

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Impact of Trauma on Parents

  • Loss of internal security

  • Changes view of self/other

    • Victim

    • Persecutor

    • Non-helpful bystander

  • Traumatic reminders

  • Traumatic expectations

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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

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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)

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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)

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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)

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

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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

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Caregiver as Protective Shield

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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.

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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

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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

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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

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Integration of Theoretical Approaches

  • Developmentally Informed

  • Attachment

  • Trauma

  • Psychoanalytic theory

  • Social learning theory

  • Cognitive Behavioral Interventions

  • Culturally Informed

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Multidimensional Approach to Assessment

  • Child’s Individual Functioning

  • Family Context

  • Community and cultural values

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“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

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Assessment as Form of Treatment

  • “Psychological first aid”

    - Developmentally appropriate intervention

    - Immediate emotional relief

  • Information gathering

  • Assessment-treatment feedback loop

  • Incorporates developmental changes

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Assessment Domain: Child’s Trauma Experience

  • Circumstances and Sequence ofTrauma






  • Nature of Child’s Involvement

  • Each Parent’s Presence and Participation

  • Events Following the Trauma

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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)

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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)

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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

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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


  • Trauma disrupts family bonds

    Mutual blame

    Emotional alienation

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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

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Assessment Domain:Continuity of Daily Routines

  • Predictability supports emotional regulation

  • Trauma disrupts daily routines

  • Secondary adversities add new stress

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Assessment Domain:Family Ecological Niche

  • Family Circumstances

    Primary caregiver

    Who holds the holding environment

    Concrete supports

  • Family Belief Systems

  • Cultural Values

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Making a Clinical DiagnosisTraumatic 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

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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


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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

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Ports of Entry

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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

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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

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Ports of Entry

  • Begin from simplicity

  • Safety and trust as organizing concepts

  • Developmental guidance may suffice

  • If unsuccessful, explore resistance

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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)

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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.

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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

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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

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Developmental Impact of Parental Death

Disruptions in:

  • Regulation of bodily rhythms

  • Modulation of emotion

  • Formation and socialization of relations

  • Learning from exploration

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Manifestations of Grief and Mourning

  • Protest

    Crying, searching, rejecting comfort

  • Sadness and emotional withdrawal

    Lethargy; awaiting reunion

  • Anger at self and others

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Manifestations of Grief and Mourning

  • Intensification of normative anxieties

  • Regressions in development

  • New fears

  • Denial, self-blame, idealization

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Responses to Witnessing Violent Death

  • Horror

  • Powerlessness

  • Intrusive mental images

  • Fear for personal safety

  • Dissociation

  • Responses to traumatic reminders

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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

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Assessment Guidelines

  • Child’s Relationship with Dead Parent

  • Current Caregiver & Continuity of Routines

  • Family Response to the Death

  • Cultural and family traditions and beliefs

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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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Does Child Have a Clinical Diagnosis? Using DC:0-3

Traumatic Stress Disorder

  • Re-experiencing

  • Numbing of emotional responsiveness

  • Increased arousal

  • New fears

  • Aggression

  • New symptoms

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Primary Treatment Goals

  • Creating a Safe, Consistent Environment

  • Supporting Child’s New Attachment

  • Child’s Acceptance of Physical Reality of Parental Death

  • Emotional Regulation to Reminders

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Longer Term Treatment Goals

  • Promote Adjustment to Changes

  • Enhance Problem Solving and Conflict


  • Integrating the Dead Parent into the Child’s Ongoing Sense of Self

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The Treatment Process

  • Creating a Safe Treatment Frame

    Identify Surrogate Primary Caregiver

    Preserve Reassuring Reminders

    Decide on Attendance to Funeral/Wake

    Help Maintain Predictable Routines

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The Treatment Process

  • Alleviating Children’s Fears

    “Will other people I love leave me?”

    “Will I die also?”

    “ Who will take care of me?”

    “ Did I cause the death?”

    “ I want to die too to be with mommy”

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The Treatment Process

  • Addressing Traumatic Reminders

    Remove upsetting reminders

    Reassure child of safety

    Explain the meaning of reminders

    Teach to anticipate traumatic response

    Teach self-soothing strategies

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Everything Can Help

  • Therapeutic Toys

  • Play

  • Games: hide-and-seek, peek-a-boo

  • Movement: Jumping, dance, yoga

  • Putting feelings into words

  • Practicing prosocial behaviors

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Balancing Focus on Trauma and Loss with Continuity of Daily Living

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Therapist, Heal Thyself!

  • Working with intensely bereaved and traumatized young children evokes

    strong feelings in the therapist, including hopelessness and rescue fantasies.

  • Self-care is essential to help the child.

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Reflective Supervision

  • Non-judgmental

  • Gives the therapist a setting to reflect on the process of the treatment and on the process of individual sessions

  • Permits reflection on the therapist’s role in the inter-subjective field with the dyad

  • Helps prevent therapist burn-out

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Conflicts of Interest/Disclosures

  • Professional Advisory Board,

    Johnson & Johnson Pediatric Institute

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  • No medications are discussed in this


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