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1 Trauma- Focused Child-Parent Psychotherapy In Infancy and Early Childhood Alicia F. Lieberman, Ph. D. Professor of Medical Psychology University of California.

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Presentation on theme: "1 Trauma- Focused Child-Parent Psychotherapy In Infancy and Early Childhood Alicia F. Lieberman, Ph. D. Professor of Medical Psychology University of California."— Presentation transcript:

1 1 Trauma- Focused Child-Parent Psychotherapy In Infancy and Early Childhood Alicia F. Lieberman, Ph. D. Professor of Medical Psychology University of California San Francisco

2 2 Defining Trauma in 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 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 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 5 Impact of 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 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 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 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 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 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 11 Young Children Need to Be Seen in the Context of Their Relationships

12 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 13 Caregiver as Protective Shield

14 14 Child-Parent Psychotherapy Theoretical 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 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 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 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 18 Integration of Theoretical Approaches Developmentally Informed Attachment Trauma Psychoanalytic theory Social learning theory Cognitive Behavioral Interventions Culturally Informed


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

21 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 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 23 Assessment Domain: Child’s Trauma Experience Circumstances and Sequence of Trauma What Who How When Where Nature of Child’s Involvement Each Parent’s Presence and Participation Events Following the Trauma

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

25 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 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 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 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 29 Assessment Domain: Continuity of Daily Routines Predictability supports emotional regulation Trauma disrupts daily routines Secondary adversities add new stress

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

31 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 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 33 Treatment

34 34 Child-Parent Psychotherapy Intervention 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 35 Ports of Entry

36 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 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 38 Ports of Entry Begin from simplicity Safety and trust as organizing concepts Developmental guidance may suffice If unsuccessful, explore resistance


40 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 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 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 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 44 Developmental Impact of Parental Death Disruptions in: Regulation of bodily rhythms Modulation of emotion Formation and socialization of relations Learning from exploration

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

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

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

48 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 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 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

51 51 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

52 52 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

53 53 Longer Term Treatment Goals Promote Adjustment to Changes Enhance Problem Solving and Conflict Resolution Integrating the Dead Parent into the Child’s Ongoing Sense of Self

54 54 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

55 55 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”

56 56 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

57 57 Everything Can Help Therapeutic Toys Play Games: hide-and-seek, peek-a-boo Movement: Jumping, dance, yoga Putting feelings into words Practicing prosocial behaviors

58 58 Balancing Focus on Trauma and Loss with Continuity of Daily Living

59 59


61 61 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.

62 62 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

63 63 Conflicts of Interest/Disclosures Professional Advisory Board, Johnson & Johnson Pediatric Institute

64 64 Disclosure No medications are discussed in this presentation

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