Trauma- Focused
1 / 64

Defining Trauma in the Early Years - PowerPoint PPT Presentation

  • Uploaded on

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:

I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
Download Presentation

PowerPoint Slideshow about 'Defining Trauma in the Early Years' - fairfax

An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.

- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
Slide1 l.jpg

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

Defining trauma in the early years l.jpg
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)

Violence as paradigm of trauma in the early years l.jpg
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)

Convergence of types of violence l.jpg
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)

Slide5 l.jpg

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

Impact of trauma on parents l.jpg
Impact of Trauma on Parents

  • Loss of internal security

  • Changes view of self/other

    • Victim

    • Persecutor

    • Non-helpful bystander

  • Traumatic reminders

  • Traumatic expectations

Changes in child parent relationship after trauma l.jpg
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

Domestic violence in infancy and early childhood l.jpg
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)

Maternal attributions l.jpg
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)

Maternal attributions and child sense of self l.jpg
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)

Treating young children l.jpg
Treating Young Children Relationships

  • 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

Child parent psychotherapy theoretical target l.jpg
Child-Parent Psychotherapy RelationshipsTheoretical 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.

Child parent psychotherapy goals l.jpg
Child-Parent Psychotherapy RelationshipsGoals

  • 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

Child parent psychotherapy trauma related goals l.jpg
Child-Parent Psychotherapy RelationshipsTrauma-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

Balancing trauma treatment with other goals l.jpg
Balancing Trauma Treatment with Other Goals Relationships

  • Trauma lens: Trauma reminders, expectations and affects

  • Attachment lens: Protection and safety

  • Developmental lens: Age-appropriate pursuits

  • Cultural lens: Ecological context

Integration of theoretical approaches l.jpg
Integration of Theoretical Approaches Relationships

  • Developmentally Informed

  • Attachment

  • Trauma

  • Psychoanalytic theory

  • Social learning theory

  • Cognitive Behavioral Interventions

  • Culturally Informed

Assessment l.jpg
ASSESSMENT Relationships

Multidimensional approach to assessment l.jpg
Multidimensional Approach to Assessment Relationships

  • Child’s Individual Functioning

  • Family Context

  • Community and cultural values

Best practices for assessment l.jpg
“Best Practices” For Assessment Relationships

  • 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

Assessment as form of treatment l.jpg
Assessment as Form of Treatment Relationships

  • “Psychological first aid”

    - Developmentally appropriate intervention

    - Immediate emotional relief

  • Information gathering

  • Assessment-treatment feedback loop

  • Incorporates developmental changes

Assessment domain child s trauma experience l.jpg
Assessment Domain: Relationships Child’s Trauma Experience

  • Circumstances and Sequence ofTrauma






  • Nature of Child’s Involvement

  • Each Parent’s Presence and Participation

  • Events Following the Trauma

Can young children remember trauma l.jpg
Can Young Children Remember Trauma? Relationships

  • 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)

Can young children remember trauma25 l.jpg
Can Young Children Remember Trauma? Relationships

  • “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)

Assessment domain child s functioning l.jpg
Assessment Domain: Relationships 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

Assessment domain child parent relationship l.jpg
Assessment Domain: Relationships 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

Assessment domain traumatic reminders l.jpg
Assessment Domain: Relationships 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

Assessment domain continuity of daily routines l.jpg
Assessment Domain: Relationships Continuity of Daily Routines

  • Predictability supports emotional regulation

  • Trauma disrupts daily routines

  • Secondary adversities add new stress

Assessment domain family ecological niche l.jpg
Assessment Domain: Relationships Family Ecological Niche

  • Family Circumstances

    Primary caregiver

    Who holds the holding environment

    Concrete supports

  • Family Belief Systems

  • Cultural Values

Making a clinical diagnosis traumatic stress response l.jpg
Making a Clinical Diagnosis Relationships 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

Making a clinical diagnosis co morbidity l.jpg
Making a Clinical Diagnosis: Relationships Co-Morbidity

  • Prevalent in traumatic response

    across development

  • In young children, related to immature

    expressive repertoire

  • The same behavior can signify different


Treatment l.jpg
Treatment Relationships

Child parent psychotherapy intervention modalities l.jpg
Child-Parent Psychotherapy RelationshipsIntervention 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

Ports of entry l.jpg
Ports of Entry Relationships

Possible ports of entry l.jpg
Possible Ports of Entry Relationships

  • 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

Ports of entry37 l.jpg
Ports of Entry Relationships

  • 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

Ports of entry38 l.jpg
Ports of Entry Relationships

  • Begin from simplicity

  • Safety and trust as organizing concepts

  • Developmental guidance may suffice

  • If unsuccessful, explore resistance

Traumatic bereavement in infancy and early childhood40 l.jpg
Traumatic Bereavement in Infancy and Early Childhood Relationships

“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)

Dual lens grief and trauma l.jpg
Dual Lens: Grief and Trauma Relationships

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.

Factors affecting the child s response to parental death l.jpg
Factors Affecting the Child’s Response to Parental Death Relationships

  • 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

Is parental death always traumatic for the young child l.jpg
Is Parental Death Always Traumatic for the Young Child? Relationships

Continuum of traumatic experience:

Milder: Increased child maturity

Anticipatory guidance

Child is not witness

Severest: Sudden, violent

Witnessed by child

Developmental impact of parental death l.jpg
Developmental Impact of Parental Death Relationships

Disruptions in:

  • Regulation of bodily rhythms

  • Modulation of emotion

  • Formation and socialization of relations

  • Learning from exploration

Manifestations of grief and mourning l.jpg
Manifestations of Grief and Mourning Relationships

  • Protest

    Crying, searching, rejecting comfort

  • Sadness and emotional withdrawal

    Lethargy; awaiting reunion

  • Anger at self and others

Manifestations of grief and mourning46 l.jpg
Manifestations of Grief and Mourning Relationships

  • Intensification of normative anxieties

  • Regressions in development

  • New fears

  • Denial, self-blame, idealization

Responses to witnessing violent death l.jpg
Responses to Witnessing Violent Death Relationships

  • Horror

  • Powerlessness

  • Intrusive mental images

  • Fear for personal safety

  • Dissociation

  • Responses to traumatic reminders

Assessment guidelines l.jpg
Assessment Guidelines Relationships

  • Circumstances of the death

    What the child witnessed

    What the child knows

    Traumatic reminders

  • Current family circumstances

  • Child’s functioning: before and after

Assessment guidelines49 l.jpg
Assessment Guidelines Relationships

  • Child’s Relationship with Dead Parent

  • Current Caregiver & Continuity of Routines

  • Family Response to the Death

  • Cultural and family traditions and beliefs

Does child have a clinical diagnosis using dc 0 3 l.jpg
Does Child Have a Clinical Diagnosis? Using DC:0-3 Relationships

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

Does child have a clinical diagnosis using dc 0 351 l.jpg
Does Child Have a Clinical Diagnosis? Using DC:0-3 Relationships

Traumatic Stress Disorder

  • Re-experiencing

  • Numbing of emotional responsiveness

  • Increased arousal

  • New fears

  • Aggression

  • New symptoms

Primary treatment goals l.jpg
Primary Treatment Goals Relationships

  • Creating a Safe, Consistent Environment

  • Supporting Child’s New Attachment

  • Child’s Acceptance of Physical Reality of Parental Death

  • Emotional Regulation to Reminders

Longer term treatment goals l.jpg
Longer Term Treatment Goals Relationships

  • Promote Adjustment to Changes

  • Enhance Problem Solving and Conflict


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

The treatment process l.jpg
The Treatment Process Relationships

  • Creating a Safe Treatment Frame

    Identify Surrogate Primary Caregiver

    Preserve Reassuring Reminders

    Decide on Attendance to Funeral/Wake

    Help Maintain Predictable Routines

The treatment process55 l.jpg
The Treatment Process Relationships

  • 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”

The treatment process56 l.jpg
The Treatment Process Relationships

  • Addressing Traumatic Reminders

    Remove upsetting reminders

    Reassure child of safety

    Explain the meaning of reminders

    Teach to anticipate traumatic response

    Teach self-soothing strategies

Everything can help l.jpg
Everything Can Help Relationships

  • Therapeutic Toys

  • Play

  • Games: hide-and-seek, peek-a-boo

  • Movement: Jumping, dance, yoga

  • Putting feelings into words

  • Practicing prosocial behaviors

Therapist heal thyself l.jpg
Therapist, Heal Thyself! Living

  • 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.

Reflective supervision62 l.jpg
Reflective Supervision Living

  • 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

Conflicts of interest disclosures l.jpg
Conflicts of Interest/Disclosures Living

  • Professional Advisory Board,

    Johnson & Johnson Pediatric Institute

Disclosure l.jpg
Disclosure Living

  • No medications are discussed in this