Do I Look Stressed? The Impact of Stress and Trauma in Early Childhood

1. Do I Look Stressed?The Impact of Stress and Trauma in Early Childhood Erin Kinavey , M.Ed. DHSS-OCS Early Intervention Manager Part C Coordinator Neal M. Horen, Ph.D. Co-Director of Training and Technical Assistance Georgetown University Center for Child and Human Development

2. Oh, the places we will go • Big Picture • Systems • Clinical perspective • Case example • One state • Cultural issues • Stump the speaker

3. EARLY CHILDHOOD MENTAL HEALTH SYSTEM OF CARE Fosters the social and emotional well-being of infants toddlers, preschool-age children and their families Promotion Prevention Intervention Services and Supports VALUES Family Voice Child and Family Centered Relationship Based Culturally Competent Infused into Natural Settings and Services Grounded in Developmental Knowledge Supports for Parents and Families Supports for Other Caregivers Services for Children and Families Building Blocks Strategic Planning, Policies, and Procedures Maximized and Flexible Funding Interagency Partnerships Prepared Workforce Outcome Evaluation

4. Systems and Trauma • What happens to a system in a trauma? • What happens to a family who is stressed? • What happened to Charles in Austin?

5. Stress • What could stress a kid? • What stresses you? • How do you cope?

6. PTSD • Pattern of symptoms • Must be understood in context of the developmental level, trauma, temperament, caregiver’s ability to provide protection and safety • 5 criteria

7. Two diagnostic challenges in addressing PTSD in young children • Young children have less well-developed verbal capacities. It’s harder to know their internalized world. • Young children manifest some symptoms differently than older children and adults due to developmental differences. Taken from Scheeringa

8. Download the criteria from. . . • The modified criteria for PTSD (Scheeringa et al., 2003), plus 12 other disorders in young children, have been incorporated into the Research Diagnostic Criteria - Preschool Age (RDC-PA) (Task Force on Research Diagnostic Criteria - Preschool Age, 2003) • Can download the RDC-PA from www.infantinstitute.org

9. The unique influence of the caregiving context for young children • ~20 studies confirm an association between more symptoms in parents and more symptoms in children following trauma to the children (reviewed in Scheeringa & Zeanah, 2001) • Maternal depression mediated treatment outcome for preschool children who were sexually abused (Cohen & Mannarino, 1998) • Is this a causal relationship between parents and children? Or shared genetic vulnerability?

10. Models of parent-child relational patterns following trauma (Scheeringa and Zeanah, 2001)

11. Preliminary data on the longitudinal impact of parenting style on child PTSD symptoms • Higher parent emotional sensitivity significantly associated with children with PTSD diagnosis (p<.05), contrary to expectations. • As parent sensitivity decreased over two years, children’s PTSD symptoms decreased (r=.38, p<.01) (Scheeringa et al., in preparation) , contrary to expectations.

12. Treatment: play therapy • “..re-experience the trauma and its meaning in affectively tolerable doses in the context of a safe environment so that the overwhelming traumatic feelings can be mastered and adaptively integrated into the person’s emotional life”. (Gaensbauer and Siegel, 1995)

13. Evidence based treatments • Two manualized studies on sex-abused preschool children (Cohen & Mannarino, 1996, Deblinger et al., 2001) • Manualized treatment for preschool children who witnessed domestic/interpersonal violence (Alicia Lieberman, PhD, University of California, San Francisco, personal communication)

14. The Preschool PTSD Treatment Manual (Scheeringa, Amaya-Jackson, and Cohen, 2002): A 12-week cognitive-behavioral treatment combined with parent-child relationship treatment. “All-purpose”: treatment can be focused on PTSD symptoms from any type of trauma. Manual requests to: mscheer@tulane.edu

15. Parent-Child Interaction Therapy (PCIT) (www.pcit.org) • PCIT was originally designed and studied for children with behavioral problems aged 2-7 and their parents or caregivers • PCIT is the creation of Dr. Sheila Eyberg of the University of Florida, applying a model of operant conditioning first developed by Dr. Constance Hanf • Eyberg’s PCIT protocol integrates traditional play therapy techniques into operant conditioning

16. Steps in Parent-Child Interaction Therapy • Step 1: Pretreatment assessment of child & family functioning and feedback (1-2 sessions) • Step 2: Teaching behavioral play therapy skills (1 session) • Step 3: Coaching behavioral play therapy skills (2-4 sessions) • Step 4: Teaching discipline skills (1 session) • Step 5: Coaching discipline skills (4-6 sessions) • Step 6: Post-treatment assessment of child & family functioning and feedback (1-2 sessions) • Step 7: Boosters (as needed)

17. Parent-Child Interaction Therapy Stage One: 7 Sessions CDI: Child Directed Interaction PRAISE REFLECT IMITATE DESCRIBE ENTHUSIASM

18. PCIT, Trauma, and Maltreatment Does PCIT help families where children have experienced stress or trauma, such as child sexual abuse, the witnessing of violence, and physical abuse?

19. Advantages of protocol-driven manualized treatment over non-directive play therapy Successful treatment of PTSD must involve: • an emotional re-engagement with the traumatic memories • organization and articulation of a trauma narrative (reviewed in Zoellner et al, 2001) A manual protocol ensures comprehensive coverage of complicated child, parent, and parent-child relational issues, including relaxation training, graded systematic exposure, and homework.

20. Jamaal • 3 year-old living with mother and maternal uncle • Victim of sexual abuse

21. Dante • Living with grandmother and great-grandmother, sisters • Violent neighborhood • Poor • Family medical issues

22. Early Childhood Trauma and Stress Alaska Office of Children’s Services DHSS State of Alaska

23. Alaska demographics Population: 655,000.

24. Day to day challenges

25. Rural and remote

26. Access to Prenatal Care2000 % of births to women who receive late or no prenatal care • 80.5% of Alaskan women had prenatal care in the first trimester • 67.4% had “adequate” care

27. Young Children in Poverty % of children under age 6 living in families with income below the federal poverty level Percent of Alaska’s Children in Low-Income Families (200% FPL)

28. Reports of Harm by Age-August 2004 0-5 Years = 45%

30. Day to day stress • 66% of Alaskan households are supplied water through the public water system. • 31% of rural/remote households had NO plumbing and are required to “pack” water from a local source.

31. Yukon Kuskokwim Subsistence lifestyle Yup’ik, Cup’ik, Athabascan Table 2: from the “Building Blocks” program of the Dept. of Health and Social Services- State of Alaska.

32. Healthy Alaskan 2010 indicators and goals http://www.hss.state.ak.us/dph/targets/ha2010/PDFs/05_Mental_Health.pdf

33. Historical context • Missionaries • TB • Boarding schools • Ongoing debate

34. Weaving history into practice • Recognizing alternative sources of knowledge • Allowing for program flexibility • Drawing on multiple resources to develop protocol

35. Case study • Intergenerational issues • FASD • Stress and Trauma • parental MH issues • Impact on child • Multidisciplinary response