1. The Effects of Trauma on Young Children Stacey Ryan, LCSW Angela M. Tomlin, Ph.D. IAITMH 2006

2. Types of Trauma Witnessing violence (domestic and other) Natural disaster Terrorism Accidents Abuse/Neglect Loss of caregiver

3. Do Young Children Experience Trauma? Children under 12 months account for 44% of deaths from child abuse and neglect Persistent crying is an important risk factor in abuse of very young children, related to shaken infant syndrome

4. Young children and sexual abuse Infants and toddlers may account for as many as 10% of substantiated sexual abuse Appearance of sexualized behavior is more likely than physical findings The younger the child when abused, the more likely sexualized behavior appears

5. Young children and domestic violence Child sees attachment figure injured Attachment figure cannot protect self; child is unsure if she can protect him Attachment figure may in turn injure the child

6. Assessing severity of trauma Closeness of people involved to the child What the child saw Child’s developmental level Reactions of important adults

7. How Young Children Understand Traumatic Events and Experiences Cognitive and emotional capacity determines how child experiences trauma Level of understanding can also affect memory 2-3 year olds do not understand the finality of death Young children may believe they caused a traumatic event

8. Clinical Patterns in Abused/Neglected Infants Gaensbauer & Mrazek (1981) observed 4 clinical patterns: Developmentally and Affectively retarded group Depressed Group (sad and sensitive to change) Ambivalent Group (rapid shifts in emotion) Angry Group (emotional intensity and low frustration tolerance)

9. Effects of Trauma Can appear immediately or after days, weeks May remind young child of previous traumas, making reaction more severe

10. Effects of Trauma Physical & Self-Regulation Effects Traumatic Reminders Development Play Behavior Relationship

11. Physical and Self-Regulation Effects Self-regulation is important task of infancy In babies and young children, problems with self-regulation look like: Sleep problems Eating problems Exaggerated startle Hypervigilance

12. Physical and Self-Regulation Effects Exposure to traumatic events seems to change the way the infant reacts to future stressors Animal and human studies shows changes in hormones and brain chemicals after trauma These brain changes can be long lasting, leading the child to feel numb or anxious

13. Traumatic reminders Can be difficult to identify in nonverbal child Sensory (siren, smell) Dreams Re-experiencing the event Irrational fear of benign objects

14. Developmental Effects of Trauma Developmental delays are expected— developmental assessment is advised Problems may occur in development of attachments and other social emotional skills Regression is possible

15. Effects on Play Skills Repetitive actions Driven quality Constricted quality Preoccupation with separation, loss, and reunion

16. Effects on Behavior—infants and toddlers Increased irritability/inability to soothe Sleep disturbance Emotional distress; sadness Fears of being alone; clinging; refusal to separate Motor agitation Temper tantrums

17. Effects on Behavior—toddlers and preschoolers Being too clingy with adults Not able to be comforted when upset Problems with exploration: either reckless or too inhibited Aggression toward caregivers, peers, animals Angry noncompliance

18. Effects on Relationship Difficulty forming positive relationships Poor sense of self Lowered self esteem Expectation of being treated poorly Loss of secure base Loss of sense of trust

19. Long Term Effects of Trauma Persistent grief reactions (Bowlby) Protest: efforts to find the parent through crying, calling, and searching Despair: lethargy, sadness, emotional withdrawal, loss of interest in activities Detachment: apparent indifference to reminders; selective forgetting*

20. Long Term Effects of Trauma Increased risk for academic problems Substance use and abuse Early pregnancy Criminal involvement Psychiatric symptoms and disorders Experiencing abuse as a child is linked to abusing one’s own child

21. Abused children as parents Harsh discipline Failure to respond to child’s needs Inconsistent limit setting Inability to express affection Inability to enjoy interactions with child Minimize or deny child’s painful experiences

22. Young children and neglect Failure to provide for child’s physical and emotional needs Leaving child alone for long periods Leaving child for long periods with varied and unreliable caregivers Effects of neglect can be as devastating as physical or sexual abuse

23. Effects of neglect Lack of play and other developmental skills May hoard food Unfamiliar with things we take for granted Expects to take care of self or siblings Challenges adult authority Lacks trust in adults Avoids adults when upset; hard to soothe

24. Expected difficult reactions to placement in foster care Previous relationship failures lead the child to behave in ways that alienate foster parents Caregivers misread behaviors and respond in ways that increase problems Child responds to loss of attachment figure with behavioral, emotional, and physiological dysregulation

25. Expected difficult behaviors of children in care Acting like they do not need caregivers, even under threatening conditions Acting angry when adult makes efforts to soothe Turning away when hurt Behaving aggressively toward caregivers Behaving aggressively toward peers Problem behavior after visits

26. Why do we see behavior problems after visits with family? Visits with parents are traumatic reminders of events that led to the separation or of the separation itself Both the child and parent may feel anxious and angry Supervised visits increasing parents feelings of incompetence Child feels safer expressing angry feelings toward foster parent/family

27. How Foster Care Helps One of the most important things a foster parent can do is to help young children have positive relationships Doing this will help with development and behavior To do it right, you have to pay attention to attachment

28. Arousal-Relaxation Cycle Child experiences a need Child feels upset Adult satisfies need Child feels content

29. Are there children with no attachments? There are children with no attachments It is more likely that a child have an attachment problem rather than no attachment at all The child will develop an attachment with the adult that is available

30. Why do children form attachments to abusive parents? Children’s need for survival and safety results in attachment to any available adult, even those who abuse or threaten them Children prefer the familiar, even when what is familiar is frightening

31. Insecure Attachments Avoidant patterns (turning away from the caregiver when distressed) develop when caregivers reject baby’s request for nurturance. Resistant patterns (fussy, resistant behavior) develops when caregivers inconsistently respond to the baby

32. Insecure Attachments Infants show disorganized pattern when adults demonstrate frightening or frightened behavior with them Infant is afraid of the person they look to for reassurance and nurturance Infant behavior is unorganized and bizarre These patterns are common when children are abused or they witness domestic violence

33. Long term Effects of Disorganized Attachments Aggression with peers Dissociative behaviors

34. Role of Foster Parent in Attachment Help the child develop a healthy attachment Help child extend attachment to you and improved behaviors to birth family, new foster family, or adoptive family

35. How Foster Parents Can Help Work with the parents Avoid judgments about the biological parents Provide transitional objects to child Provide family pictures Have a plan for the first visit

36. How Foster Parents Can Help Responding to parent anger Listen Be non-reactive Acknowledge how difficult it is to be away from child

37. How Foster Parents Can Help Recognize that the child needs you, even when they do not show it Understand rejecting behaviors as old coping methods Listen Put words to behaviors Attend to your own reactions Encourage touch, but do not force it

38. How Foster Parents Can Help at Home Safety Routine that shows an adult is “in control” Soothing sensory activities Stop activities that result in re-enactment (including television) Advocate to reduce moves to provide continuity

39. Question and Answer

40. Factors in Determining Types of Interventions, (Osofsky & Fenichel, 1994) Safety and Stability of Current Living Situation Child’s Developmental Capacities to Make Use of Certain Types of Interventions Quality of Pre-Traumatic and Current Care-Giving Environment Type of Violent Event or Situation Acuteness vs. Chronicity of Trauma Actual and Psychological Proximity of the Violent Events Post Traumatic Symptoms in Child and Caregiver Strengths and Protective Factors in Infant

41. Goals for Intervention (Lieberman & Van Horn, 2005) Return to Normal Development Increase Capacity to Respond to Trauma. Maintain Regular Levels of Arousal Re establish Trust in Bodily Sensations Restore Reciprocity in Close Relationships Normalize Reactions to Trauma Encourage a Differentiation Between Reliving and Remembering Place the Traumatic Experience in Perspective

42. Common Intervention Needs (Osofsky & Fenichel, 1994) Improving the caregivers ability to attend to and provide for the child’s needs Further develop caregiver’s ability to interpret child’s feelings, reactions and support child Address cognitive distortions child may have regarding trauma Assist the child in re experiencing trauma in affectively tolerable doses Assist the child and caregiver in coping with any losses

43. Results of Interventions Assist Child in Understanding… Stressful body experiences can be alleviated with help of others and coping strategies Adults can support and protect child Child is not to blame Can talk about emotions rather than only acting them out Life can contain elements of mastery, fun and hope

44. Methods for Intervening Using Play, Physical Contact and Language to Promote Developmental Progress Offering Unstructured Reflective Developmental Guidance Modeling Appropriate Protective Behavior Interpreting Feelings and Actions Providing Emotional Support/Empathetic Communication Offering Crisis Intervention and Concrete Assistance

45. Areas of Clinical Concern include… Play Sensorimotor Disorganization Fearful Behavior Self Endangering Behavior Aggression Toward Parent Aggression Toward Peers Parental Use of Physical Discipline Parental Use of Threats, Criticisms of Child Relationship with Perpetrator

46. Play Encouragement of Play with Dyad Help the Parent Understand and Support Use of Play Allow the Parent to Be Main Supporter to Child

47. Sensorimotor Disorganization Help the Parent Understand How these behaviors Affect Them (triggers feelings of rejection, anger and frustration in parent) Develop New Meanings for Parent

48. Child Fears Support Parent Understanding of Fears Bring Attention to Cues Child Gives Regarding Fears Develop with Parents Strategies for Containing Fears

49. Aggression Toward Parent Give Parents Meaning for This Behavior Assist Parents In Containing Feelings Regarding this Behavior Develop Strategies for Controlling Anger/Aggression

50. Aggression Toward Peers Build Understanding of Reasons for Behavior Clinician Gives Resources for Deescalating Behavior Empower Parents to Take Action and Assist Child

51. Parental Use of Physical Punishment Explore with Parent Feelings and Concerns Contain Own Emotions and Reactions Educate on Reasons Physical Punishment May Worsen Symptoms

52. Parental Criticism Focus on Effects of Relationship Acknowledge Parent Issues/Feelings Build Awareness of Child Experience

53. Relationship with Perpetrator Educate on Child Needs/Experiences Support/Listen to Parent Concerns/Feelings Mutually Develop Strategies

54. What Evaluation Research Tells Us (Landy & Menna, 2006) Home Visiting is Critical Component Need to Distinguish Between Early Intervention and Prevention Starting Early is Critical Intensity and Duration Counts Ongoing Assessment is Critical Services Most Effective for Moderate Levels of Risk Need for Well Trained Service Providers Use a Variety of Approaches

55. Treatment Videos Discussion Questions/Comments

56. Experience Case Based Discussion Structured way of thinking and talking about situations with families Method for promoting Reflective Supervision and Further Learning 3 Phases:  Understanding the Experience  Exploring and Sharing the Collective Knowledge and Experience of the Group  Summarizing Discussion and Identifying Next Steps

57. Another Way to Help Speak for the babies..

58. Want to learn more? Indiana Association for Infant and Toddler Mental Health (iaitmh.org) 317/638-3501 EXT 221 Zero to Three (zerotothree.org) The Center for Social and Emotional Foundations for Early Learning (csefel.uiuc.edu)

59. Contact us…. Stacey (yphsdir@cmhcinc.org)yphsdir@cmhcinc.org Angie (atomlin@iupui.edu)atomlin@iupui.edu

61. The Effects of Trauma on Young Children Stacey Ryan, LCSW Angela M. Tomlin, Ph.D. IAITMH 2006