Supporting Children & Families in the Face of Trauma

1. Supporting Children & Families in the Face of Trauma Catherine Ayoub, Ed.D. September 2006 Thanks to Kurt Fischer, Gabrielle Schlichtmann, Erin O’Connor, Elizabeth Nelson, Pamela Raya, Claire Russell, William Beardslee, Mary Watson Avery, Caroline Watts, & Donald Pfieffer

2. Developmental Processes (Erikson, & Piaget) • Trust v. Mistrust • Autonomy v. Shame and Doubt • Industry v. Inferiority • Identity v. identity diffusion • Sensory motor • Pre-operational • Concrete Operations • Formal Operations

3. Positivity Bias & Natural Integrative Cognitive Processes • I am safe & nurtured • The world is safe & nurturing • Others are good so they will be good to me. • I am good • I can make connections & delineate details in more complex ways as I grow. • I will connect the development strands of my domain-specific knowledge

4. Trauma is like a Hole in the World In & out of that hole – anything goes

5. Definition: Childhood Trauma The mental result of one sudden external blow or a series of blows, rendering the young child temporarily helpless and breaking past ordinary coping and defensive operations (Terr, 1991).

6. Trauma Types (Lenore Terr, 1991) • Type I Trauma:Single, traumatic event; More often associated with acute post- traumatic stress disorder symptoms • Type II Trauma: Prolonged, repeated Trauma; more often associated with complex PTSD & characterological changes • Cross over Trauma: Single event so powerful that it results in the effects of Type II

7. Response to Childhood Trauma Attempt to regain mastery & control. Adaptive & accommodating reaction to loss of control Response is conceptualized & incorporated within the child's cognitive & self structures (Ayoub, Fischer & O’Connor, 2003).

8. TRAUMA SPECIFIC RESPONSES • Disruption in safety & trust (worldview) • Disruption in attachments/relationships • Alternative cognitive schemas (thinking) • Altered emotional responsiveness (feeling) • Fragmentation of self system (self perception, memory)

9. ATTITUDES & BELIEFS • The World is Threatening • I Cannot really Be Loved • I Deserve My Life Because I was Bad • It is ALWAYS/NEVER My fault • I Will NEVER/ALWAYS Succeed

10. Two Fundamental Developmental Changes Malignant feelings of inner badness Positive vs. negative Basic fractionation/fragmentation of self & others Dissociation, splitting & polarization

11. Disorganized Attachment as Trauma Dance • Adaptive fight, flight, freeze in response to trauma • From approach avoidance to • Control through aggression • Control through nurturing

12. Impact of Trauma Does not result in delay or fixation of developmental processes Fundamentally alters social-emotional development & leads to alternative developmental pathways

13. Dysfunctional Developmental Pathways A different but consistent pattern of developmental integration that becomes increasingly complex as the individual gains cognitive skills over time. Pathways are often called deviant, psychopathological, or alternative.

14. Early Development & Trauma Responses

15. INFANT DEVELOPMENT 1. Sensorimotor understanding of the world 2. Somatic memory 3. Functional affective system 4. Dependent upon others for regulatory functioning No capacity to store memories to be retrieved in chronological sequence or even in a present oriented "picture " form. Therefore cannot integrate trauma & "play it out“.

16. TASKS OF INFANCY Establish trust In: PHYSICAL EMOTIONAL/TOUCH Self-regulation of: AFFECT PHYSICAL FUNCTIONING Attachments: SELF/OTHER RELATIONSHIPS

17. DEVELOPMENT OF EMOTION Early object relations directly influence the emergence of the frontolimbic system in the right hemisphere

18. MILESTONES IN MEMORY DEVELOPMENT • MYELINATION FOR LONG TERM MEMORY ENCODING AT 9 MONTHS. • REPRESENTATIONAL COGNITION AT 14-18 MONTHS • LANGUAGE BASED EXPLICIT MEMORY AT 2 YEARS • AUTOBIOGRAPHICAL MEMORY – 3 YEARS (I STORIES)

19. NARRATIVE /DECLARATORY/EXPLICIT MEMORY = SPOKEN OR BEHAVIORAL MEMORY OF THINKING/CONSCIOUS EVENTS VERSUS IMPLICIT MEMORY = SKILLS, HABITS, EMOTIONAL RESPONSES, REFLEXIVE ACTIONS, CLASSICALLY CONDITIONED RESPONSES

20. TRAUMA RESPONSES IN INFANCY • MOTOR & PERCEPTUAL WITHDRAWL • AVOID INTERACTIONS • DISREGULATION • PASSIVE OR ACTIVE SADNESS

21. DEVELOPMENT OF TODDLERS & PRESCHOOLERS • REPRESENTATIONAL • CONCRETE THINKING • PRESENT TIME SENSE • ANAMISTIC THINKING • ARTIFICIALISM • EGOCENTRICITY • LINKING UNRELATED EVENTS • SPLITTING POSITIVE & NEGATIVE

22. TRAUMA RESPONSES IN EARLY CHILDHOOD • DISORDERED ATTACHMENT & INTERACTIONS • REENACTMENT & MODELING • DISREGULATION & HYPERVIGILANCE • FAILURE TO ID INTERNAL STATES • NEGATIVE WORLD VIEW • SADNESS & DEPRESSION

23. Why look at paternal & family risk, child attributes & program effects over time? Conceptualizing parent, family & program characteristics & child attributes as a dynamic and integrated set of systems that change over time in ways that predict stability & variation within the larger stable set of systems allows for a complex study of changes in child development over time. parent & family program child

24. Attachment vs. Trauma-Bond RelationshipsAttachment Bond Trauma Bond Love Terror Takes time Instantaneous Reciprocity & caring Domination & fear Person essential for Person essential for survival survival Proximity = safety Proximity = conflict Separate dependent Not separate, other’s need extension Self-Mastery Mastery by others Autonomy-individuation Obedient to will of other

25. Working in Early Childhood Settings

26. Psychopathology is a succession of adaptations of persons to their environments (Alan Stroufe, 1997) Treatment is building the scaffolding to support positive functioning through the vulnerabilities & the relationship through which functional adaptation is crafted. (Ayoub & Fischer, 2006)

27. Considering Risk in Strength-Based Programs • Objective assessment of strengths & problems • Extended engagement strategies for families at higher risk • Honest, non-judgmental relationship building • Real supports for meaning needs • Continuity & liaison systems • Holistic view of family in context

28. CRISIS THEORY (Caplan) CRISIS!!! Level of functioning Adaptation

29. The Child • Universal screening • Clinical team provides classroom observation and assessment, individual play therapy, social skills groups, behavioral support in classrooms • Teachers provide primary attachment models & connections to outside world • Model of pair play therapy is relational, encouraging attachment and promoting emotional safety for children • “Contextual” approach

30. The Classroom: Key concepts for teachers • Positive attachment promotion • Responsiveness to individual cues • Respect for children’s style, expression, play • Positive, clear, & child-specific limit setting • Flexible curriculum in the context of predictable classroom structure • Supportive assessment & response to traumatogenic coping strategies

31. The Child: Pair Play Therapy • A developmental intervention designed to help at-risk toddlers & preschoolers develop & sustain friendships. • A relational intervention that supports and facilitates age-appropriate perspective-taking skills in toddlers and preschoolers.

32. Therapeutic Guidelines for Pair Play Therapy • To provide a safe and nurturing environment • To enhance children’s readiness for peer interaction • To prompt children’s use of communication • Create opportunities for interaction • Work though conflict • Model & reinforce cooperation • Model non-aggressive responses • Establish clear boundaries • Adapt & use the ecological setting • Build & maintain friendships

34. Evaluation of Pair Play Therapy Study(N = 52) • Does children’s readiness for peer interaction increase over time after controlling for age and proximity to abuse event? • What is the interface between children’s interactions and therapists interventions in Pair Play Therapy?

35. PEER INTERACTION CODING • Factors relating to peer interaction include: • proximity • cooperation • friendship & perspective taking • verbal interaction

36. Mothers Mid Twenties – Early Thirties African American Women Low SES- Welfare Dependant Involved with Child Protective Services Children Tanisha - 2 years, 3 mo. Christina - 1 year, 7 mo. Physical abuse & neglect In foster care for a period of time Interaction Difficulties Participated in Pair play therapy for 19 sessions Case Study Example:

37. The highest interaction level displayed by Tanisha and Christina in PPT: COOPERATION

38. Highest interaction level displayed by Tanisha and Christina in PPT: CONFLICT

39. Is this the working phase of therapy? COOPERATION CONFLICT

40. Highest interaction level displayed by Tanisha and Christina in PPT: FRIENDSHIP &PERSPECTIVE TAKING

41. Highest interaction level displayed by therapists during PPT: THERAPISTS INTERVENTIONS

42. Pair Play Therapy Findings: • Children increased cooperative & friendship perspective-taking interactions over time. • Children did express more conflict in the working phase of therapy including scratching, hitting, kicking & name-calling. • Therapists’ behaviors & interventions involved the re-structuring of negative interactions & were associated with the elicitation of cooperative behaviors, including friendship & perspective taking.

43. “Touch functions on many levels of adaptation, first to make survival possible, then to make life meaningful.” (Brazelton, 1990 p.561) The Use of Therapeutic Touch Study

44. Therapist Use of Touch, Supporting Internal Control Externally • Maltreated children exhibit a deregulated stress response system such that cortisol (both a ‘stress’ and ‘anti-stress’ hormone) may no longer be responsive to the activation of the stress response, resulting in undifferentiated ‘fight, flight or freeze’ reactions to new stressors.

45. Therapist Use of Touch, Supporting Internal Control Externally • Through oxytocin’s inhibitory effects on several aspects of the neuro-hormonal stress system other than cortisol, therapist touch is likely to support maltreated participants in achieving ‘internal’ control over their stress response during stressful peer interaction over the course of PPT.

46. Therapist Touch Study(Schlichtmann & Ayoub, 2004) • Does change in social competence over the course of Pair Play Therapy for toddlers & preschoolers differ according to therapist use of positive touch? • Does the effect of therapist use of positive touch on the rate of change in social competence vary as a function of maltreatment status?

47. Fitted average growth trajectories describing the effect of the number of times a participant is touched by a therapist per session for maltreated children on the change in social competence over time for 3 year old participants (n=60).