Relationship Intervention with Traumatized Infants, Young Children, and their Caregivers

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1 Relationship Intervention with Traumatized Infants, Young Children, and their Caregivers Julie A. Larrieu, Ph.D. Institute of Infant and Early Childhood Mental Health Tulane University School of Medicine

2 Relationship, Relationship, Relationship Relationships can buffer or exacerbate RISK Identifying and strengthening caregiver and family strengths is a fundamental principle in enhancing infant and young child wellbeing (Zeanah, 2009)

3 Relationship Specificity in Maternal Depression Mothers with depression exhibit more negative emotion, less positive engagement, and less sensitivity when interacting with their infants (Zeanah, 2000; Field et al., 1988)

4 Relationship Specificity in Maternal Depression Infants of mothers with depression looked depressed when interacting with their mothers, with unfamiliar nursery school teachers and with unfamiliar mothers who were not depressed (Zeanah, 2000; Field et al., 1988)

5 Relationship Specificity in Maternal Depression These same infants did not look depressed when interacting with their fathers and their familiar nursery school teachers who were not depressed (Zeanah, 2000; Field et al., 1988)

6 What about Trauma? Young children can and do experience trauma The nature of the caregiving relationship can be protective - or not - with regard to the child s experience of the trauma

7 Behavioral Manifestations of Early Trauma Sleep difficulties Somatic symptoms Increased anxiety Increased aggression Increased distractibility and activity level Increased withdrawal/apathy Developmental regression Repetitive talk or play about the event Posttraumatic Stress Disorder

8 Symptoms of PTSD Distressing memories of the trauma May be expressed as play reenactment Distressing dreams in which content and/or affect are related to the trauma May not be possible to tell the frightening content is related to the trauma (DSM-5, 2013)

9 Symptoms of PTSD Dissociative reactions (e.g., flashbacks) child feels or acts as if the trauma is recurring; may occur in play Intense or prolonged distress at exposure to cues that resemble the trauma Marked physiological reactions to reminders of the trauma (DSM-5, 2013)

10 Symptoms of PTSD Avoidance of activities, places, or physical reminders of trauma Avoidance of people, conversations, or interpersonal situations that cause recollections of the trauma (DSM-5, 2013)

11 Increased negative emotions (e.g., fear, guilt, sadness, shame, confusion) Diminished interest or participation in activities, including constriction of play Socially withdrawn behavior Reduction in positive emotions (DSM-5, 2013) Symptoms of PTSD

12 Symptoms of PTSD Irritable behavior, angry outbursts (little or no provocation) Verbal or physical aggression including extreme tantrums Hypervigilance Exaggerated startle reaction Problems with concentration Sleep disturbances (with falling or staying asleep or restless sleep) (DSM-5, 2013)

13 Course of PTSD Children ages 1 year 6 years with PTSD were followed for over 2 years of time There was NO significant decrease in the number of symptoms over these 2 years Important that children get treatment if they have PTSD Important that treatment is provided by someone who understands trauma (Scheeringa et al., 2005)

14 Why Traumatic Experiences in the Early Years Are Important Trauma often impacts the relationship between a caregiver and child and disrupts the child s ability to use relationships with caregivers to: Regulate physiological responses Provide a secure base for exploration and learning Model acceptable and protective behavior (Groves, 2002)

15 Impact of Trauma on Caregiver- When the caregiver has also experienced interpersonal trauma: Her ability to establish and maintain an empathic relationship with the child may be impaired She may have a decreased capacity to recognize danger or stress The child may take the role of caregiver (Groves, 2002) Child Relationship

16 Therapeutic Strategies How to Intervene

17 Preschool Treatment Child-Parent Psychotherapy Evidence-based treatment Treats identifiable event(s) and/or chronic trauma Developed with couples involved in intimate partner violence Excellent when treating trauma and/or concerns about relationship (Lieberman & Van Horn, 2005)

18 Intervention Modalities Play, physical contact, and language Unstructured developmental guidance Modeling positive and sensitive behavior Interpretation Emotional support and empathy Crisis intervention Case management and concrete assistance (Lieberman & Van Horn, 2005)

19 Overview of Child-Parent Psychotherapy The emphasis is on child-parent interaction and each partner s perception of the other The goal is to change dysfunctional behavior patterns by changing each partner s maladaptive perceptions of the self and the other (Lieberman, 1991)

20 Play, Physical Contact, & Language Exploration of danger and safety, autonomy and intimacy is primary Building a vocabulary for feelings can replace child s use of destructive acts to express anxiety, fear, and anger (Lieberman, 1992)

21 Unstructured Developmental Guidance Provides information about the child s age-appropriate behaviors, needs, and feelings as they occur naturally in the treatment sessions Information is tailored to the struggles that are expressed by the child, parent, or in the relationship during the course of treatment (Lieberman & Van Horn, 2005; 2008)

22 Explore Barriers to Healthy Relationship Assist parents to recognize how their earlier traumatic experiences or conflicts are impairing their relationships with their child Also explores current difficulties in functioning that impair parenting ETTN

23 Emotional Support and Empathy Involves demonstrating sensitive responses to the parent s and child s emotional expressions and experiences Involves sharing a range of emotional experiences with the dyad, labeling feelings and inferred emotional states (Lieberman, 1991)

24 Interpretation Involves speaking about the unspoken, symbolic or unconscious meaning of the parent s or the child s behavior The goal is to increase the parent s and the child s understanding of their dysfunctional interaction as well as their own motivations (Lieberman, 1991)

25 Component of Providing Trauma Treatment Child-Parent Psychotherapy has as an essential component reflective practice ETTN

26 Qualities of Reflective Practice Stepping back from the immediate experience to sort through thoughts and feelings about what one is observing and doing with children and caregivers Reflecting on the process of the treatment Slowing down and being present with self and other Reflecting on the emotional reactions that the dyad elicits in each other, and in the clinician

27 Reflective Supervision: Enhances Mindful and Clinically Informed Interventions Reflective supervision gives practitioners the safe space to address their feelings of anxiety, fear, anger, etc. so they can see the caregiver and child in front of them, both their vulnerabilities and their strengths

28 Reflective Supervision: Critical for Sustainability and Self-care Reflective supervision is recommended as a model to address and/or prevent secondary traumatic stress (STS). National Child Traumatic Stress Network, Secondary Traumatic Stress Committee. (2011). Secondary traumatic stress: A fact sheet for child-serving professionals. Los Angeles, CA, and Durham, NC: National Center for Child Traumatic Stress.

29 Conclusions The complexity of maltreatment and trauma in young children must be matched by the comprehensiveness of our efforts to: minimize their suffering enhance their development promote their competence strengthen their relationships with primary caregivers (Zeanah, 2000)

30 QUESTIONS, COMMENTS, FINAL THOUGHTS? THANK YOU! ETTN

31 References Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (2013). Washington, D.C.: American Psychiatric Association. Field, T., Healy, B., Goldstein, S., Perry, S., Bendell, D., Schanberg, S., Zimmerman, E. A., & Kuhn, C. (1988). Infants of depressed mothers show depressed behavior even with nondepressed adults. Child Development, 59,

32 References Groves, B. M. (2002). Children Who See Too Much: Lessons from the Child Witness to Violence Project. Boston: Beacon Press. Lieberman, A. F. (1991). Attachment theory and infantparent psychotherapy: Some conceptual, clinical and research considerations. In D. Cicchetti & S. Toth (Eds.), Rochester Symposium on Developmental Psychopathology, (Vol. 3). Hillsdale, N.J.: Erlbaum. Lieberman, A. F. (1992). Infant-parent psychotherapy with toddlers. Development and Psychopathology, 4,

33 References Lieberman, A. F., & Van Horn, P. (2005). Don't hit my mommy! A manual for child-parent psychotherapy with young witnesses of family violence. Washington, DC: Zero to Three Press. Lieberman, A. F., & Van Horn, P. (2008). Psychotherapy with infants and young children: Repairing the effects of stress and trauma on early attachment. New York: Guilford Press.

34 References Scheeringa, M. S., & Zeanah, C. H. (1995). Symptom differences in traumatized infants and young children. Infant Mental Health Journal, 16, Scheeringa, M. S., Zeanah, C. H., Myers, L., & Putnam, F. (2005). Predictive validity in a prospective followup of PTSD in preschool children. Journal of the American Academy of Child and Adolescent Psychiatry, 44, Zeanah, C. H. (Ed.) (2000). Handbook of infant mental health, 2 nd edition, New York, Guilford Press.

35 References Zeanah, C. H. (Ed.) (2009). Handbook of infant mental health, 3rd edition, New York, Guilford Press. Zeanah, P. D., & Larrieu, J. A. (2007). Psychopathology in infancy. Presented for the Nebraska Department of Health and Human Services and the Nebraska Department of Education, Omaha, NE.

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