Supporting Children & Supporting Children & Families in the Face of Families in the Face of TraumaTraumaCatherine Ayoub, Ed.D.Catherine Ayoub, Ed.D.

September 2006September 2006

Thanks to Kurt Fischer, Gabrielle Schlichtmann, Erin Thanks to Kurt Fischer, Gabrielle Schlichtmann, Erin O’Connor, O’Connor,

Elizabeth Nelson, Pamela Raya, Claire Russell, William Elizabeth Nelson, Pamela Raya, Claire Russell, William Beardslee, Beardslee,

Mary Watson Avery, Caroline Watts, & Donald Pfieffer Mary Watson Avery, Caroline Watts, & Donald Pfieffer

Developmental ProcessesDevelopmental Processes (Erikson, & Piaget) (Erikson, & Piaget)

Trust v. MistrustTrust v. Mistrust Autonomy v. Shame and DoubtAutonomy v. Shame and Doubt Industry v. InferiorityIndustry v. Inferiority Identity v. identity diffusionIdentity v. identity diffusion

Sensory motorSensory motor Pre-operationalPre-operational Concrete OperationsConcrete Operations Formal OperationsFormal Operations

Positivity Bias & Natural Positivity Bias & Natural Integrative Cognitive ProcessesIntegrative Cognitive Processes I am safe & nurturedI am safe & nurtured The world is safe & nurturingThe world is safe & nurturing Others are good so they will be good to Others are good so they will be good to

me.me. I am goodI am good

I can make connections & delineate I can make connections & delineate details in more complex ways as I grow.details in more complex ways as I grow.

I will connect the development strands I will connect the development strands of my domain-specific knowledge of my domain-specific knowledge

Trauma is like a Trauma is like a Hole in the WorldHole in the World

In & out of that hole – In & out of that hole – anything goesanything goes

Definition: Definition: Childhood TraumaChildhood Trauma

The mental result of one sudden The mental result of one sudden external blow or a series of external blow or a series of

blows, rendering the young child blows, rendering the young child temporarily helpless and temporarily helpless and

breaking past ordinary coping breaking past ordinary coping and defensive operationsand defensive operations

(Terr, 1991).(Terr, 1991).

Trauma Types Trauma Types (Lenore Terr, 1991)(Lenore Terr, 1991)

Type I TraumaType I Trauma:: Single, traumatic event; Single, traumatic event; More often associated with acute post- More often associated with acute post- traumatic stress disorder symptomstraumatic stress disorder symptoms

Type II TraumaType II Trauma: Prolonged, repeated : Prolonged, repeated Trauma; more often associated with Trauma; more often associated with complex PTSD & characterological complex PTSD & characterological changes changes

Cross over TraumaCross over Trauma:: Single event so Single event so powerful that it results in the effects of powerful that it results in the effects of Type IIType II

Response to Response to Childhood TraumaChildhood Trauma

Attempt to regain masteryAttempt to regain mastery & & controlcontrol..

AdaptiveAdaptive & & accommodating accommodating reactionreaction to loss of control to loss of control

ResponseResponse is conceptualized & is conceptualized & incorporated within the child's incorporated within the child's

cognitive & self structures cognitive & self structures (Ayoub, Fischer (Ayoub, Fischer & O’Connor, 2003).& O’Connor, 2003).

TRAUMA SPECIFIC RESPONSESTRAUMA SPECIFIC RESPONSES Disruption in safety & trust (worldview)Disruption in safety & trust (worldview)

Disruption in attachments/relationshipsDisruption in attachments/relationships

Alternative cognitive schemas (thinking) Alternative cognitive schemas (thinking)

Altered emotional responsiveness Altered emotional responsiveness (feeling)(feeling)

Fragmentation of self system (self Fragmentation of self system (self perception, memory) perception, memory)

ATTITUDES & BELIEFSATTITUDES & BELIEFS The World is ThreateningThe World is Threatening

I Cannot really Be Loved I Cannot really Be Loved

I Deserve My Life Because I was BadI Deserve My Life Because I was Bad

It is ALWAYS/NEVER My faultIt is ALWAYS/NEVER My fault

I Will NEVER/ALWAYS SucceedI Will NEVER/ALWAYS Succeed

Two Fundamental Two Fundamental Developmental ChangesDevelopmental Changes

Malignant feelings of inner badness

Positive vs. negative

Basic fractionation/fragmentation of self & others

Dissociation, splitting & polarization

Disorganized Attachment Disorganized Attachment asas

Trauma Dance Trauma Dance

Adaptive fight, flight, freeze in Adaptive fight, flight, freeze in response to traumaresponse to trauma

From approach avoidance toFrom approach avoidance to– Control through aggressionControl through aggression– Control through nurturing Control through nurturing

Impact of TraumaImpact of TraumaDoes not result in Does not result in delay or fixationdelay or fixation of of developmental developmental processesprocesses

Fundamentally Fundamentally altersalters social-emotional social-emotional developmentdevelopment & leads to & leads to alternative alternative developmental developmental pathwayspathways

Dysfunctional Dysfunctional Developmental Developmental

PathwaysPathwaysA different but consistent pattern of A different but consistent pattern of

developmental integration that developmental integration that becomes increasingly complex as becomes increasingly complex as the individual gains cognitive skills the individual gains cognitive skills

over time.over time.

Pathways are often called deviant, Pathways are often called deviant, psychopathological, or alternative.psychopathological, or alternative.

Early Development & Early Development & Trauma ResponsesTrauma Responses

INFANT DEVELOPMENTINFANT DEVELOPMENT1. Sensorimotor understanding of 1. Sensorimotor understanding of

the worldthe world

2. Somatic memory2. Somatic memory

3. Functional affective system3. Functional affective system

4. Dependent upon others for 4. Dependent upon others for regulatory functioningregulatory functioning

No capacity to store memories No capacity to store memories to be retrieved in chronological to be retrieved in chronological sequence or even in a present sequence or even in a present oriented "picture " form. oriented "picture " form. Therefore cannot integrate Therefore cannot integrate trauma & "play it out“.trauma & "play it out“.

TASKS OF INFANCYTASKS OF INFANCYEstablish trust In:Establish trust In:

PHYSICAL PHYSICAL EMOTIONAL/TOUCHEMOTIONAL/TOUCH

Self-regulation of:Self-regulation of:AFFECTAFFECTPHYSICAL FUNCTIONINGPHYSICAL FUNCTIONING

Attachments:Attachments:SELF/OTHER SELF/OTHER RELATIONSHIPSRELATIONSHIPS

DEVELOPMENT OF EMOTIONDEVELOPMENT OF EMOTION

Early object relations directly Early object relations directly influence the emergence of the influence the emergence of the frontolimbic system in the right frontolimbic system in the right

hemispherehemisphere

MILESTONES IN MEMORY MILESTONES IN MEMORY DEVELOPMENTDEVELOPMENT

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)

NARRATIVE /DECLARATORY/EXPLICIT NARRATIVE /DECLARATORY/EXPLICIT MEMORY = SPOKEN OR BEHAVIORAL MEMORY = SPOKEN OR BEHAVIORAL MEMORY OF THINKING/CONSCIOUS MEMORY OF THINKING/CONSCIOUS EVENTS EVENTS

VERSUSVERSUS

IMPLICIT MEMORY = SKILLS, HABITS, IMPLICIT MEMORY = SKILLS, HABITS, EMOTIONAL RESPONSES, REFLEXIVE EMOTIONAL RESPONSES, REFLEXIVE ACTIONS, CLASSICALLY ACTIONS, CLASSICALLY CONDITIONED RESPONSESCONDITIONED RESPONSES

TRAUMA RESPONSES IN TRAUMA RESPONSES IN INFANCYINFANCY

MOTOR & PERCEPTUAL MOTOR & PERCEPTUAL WITHDRAWLWITHDRAWL

AVOID INTERACTIONSAVOID INTERACTIONS

DISREGULATIONDISREGULATION

PASSIVE OR ACTIVE PASSIVE OR ACTIVE SADNESSSADNESS

DEVELOPMENT OF DEVELOPMENT OF TODDLERS & PRESCHOOLERSTODDLERS & PRESCHOOLERS REPRESENTATIONALREPRESENTATIONAL CONCRETE THINKINGCONCRETE THINKING PRESENT TIME SENSEPRESENT TIME SENSE ANAMISTIC THINKINGANAMISTIC THINKING ARTIFICIALISMARTIFICIALISM EGOCENTRICITYEGOCENTRICITY LINKING UNRELATED EVENTSLINKING UNRELATED EVENTS SPLITTING POSITIVE & NEGATIVESPLITTING POSITIVE & NEGATIVE

TRAUMA RESPONSES IN TRAUMA RESPONSES IN EARLY CHILDHOODEARLY CHILDHOOD

DISORDERED ATTACHMENT & DISORDERED ATTACHMENT & INTERACTIONSINTERACTIONS

REENACTMENT & MODELINGREENACTMENT & MODELING DISREGULATION & DISREGULATION &

HYPERVIGILANCEHYPERVIGILANCE FAILURE TO ID INTERNAL STATESFAILURE TO ID INTERNAL STATES NEGATIVE WORLD VIEWNEGATIVE WORLD VIEW SADNESS & DEPRESSIONSADNESS & DEPRESSION

Why look at paternal & family risk, Why look at paternal & family risk, child attributes & program effects child attributes & program effects

over timeover time?? Conceptualizing parent, family & program Conceptualizing parent, family & program

characteristics & child attributes as a characteristics & child attributes as a dynamic and integrated set of systems that dynamic and integrated set of systems that change over time in ways that predictchange over time in ways that predict

stability & variation withinstability & variation within the larger stable set of the larger stable set of systems allows for a systems allows for a

complex complex study of changes study of changes in childin child development over time.development over time.

program

parent & family

child

Attachment vs. Trauma-Bond Attachment vs. Trauma-Bond RelationshipsRelationships

AttachmentAttachment Bond BondTrauma BondTrauma Bond

LoveLove TerrorTerrorTakes timeTakes time InstantaneousInstantaneousReciprocity & caringReciprocity & caring Domination & fearDomination & fearPerson essential forPerson essential for Person essential for Person essential for

survivalsurvival survivalsurvivalProximity = safetyProximity = safety Proximity = conflictProximity = conflictSeparate dependentSeparate dependent Not separate, other’sNot separate, other’s

need extensionneed extensionSelf-MasterySelf-Mastery Mastery by othersMastery by othersAutonomy-individuationAutonomy-individuation Obedient to will of Obedient to will of

other other

Working in Early Childhood Working in Early Childhood SettingsSettings

Psychopathology is a succession of Psychopathology is a succession of adaptations of persons to their adaptations of persons to their

environments environments (Alan Stroufe, 1997)(Alan Stroufe, 1997)

Treatment is building the Treatment is building the scaffolding to support positive scaffolding to support positive

functioning through the functioning through the vulnerabilities & the relationship vulnerabilities & the relationship

through which functional through which functional adaptation is crafted. adaptation is crafted.

(Ayoub & Fischer, 2006)(Ayoub & Fischer, 2006)

Considering Risk in Considering Risk in Strength-Based ProgramsStrength-Based Programs

Objective assessment of strengths Objective assessment of strengths & problems& problems

Extended engagement strategies Extended engagement strategies for families at higher riskfor families at higher risk

Honest, non-judgmental Honest, non-judgmental relationship buildingrelationship building

Real supports for meaning needsReal supports for meaning needs Continuity & liaison systemsContinuity & liaison systems Holistic view of family in context Holistic view of family in context

CRISIS THEORY CRISIS THEORY (Caplan)(Caplan)

Level of functioning

CRISIS!!!

Adaptation

The ChildThe Child Universal screening Universal screening Clinical team provides classroom Clinical team provides classroom

observation and assessment, individual observation and assessment, individual play therapy, social skills groups, play therapy, social skills groups, behavioral support in classroomsbehavioral support in classrooms

Teachers provide primary attachment Teachers provide primary attachment models & connections to outside worldmodels & connections to outside world

Model of pair play therapy is relational, Model of pair play therapy is relational, encouraging attachment and promoting encouraging attachment and promoting emotional safety for childrenemotional safety for children

““Contextual” approachContextual” approach

The Classroom: Key The Classroom: Key concepts for teachersconcepts for teachers

Positive attachment promotionPositive attachment promotion Responsiveness to individual cuesResponsiveness to individual cues Respect for children’s style, Respect for children’s style,

expression, playexpression, play Positive, clear, & child-specific limit Positive, clear, & child-specific limit

settingsetting Flexible curriculum in the context of Flexible curriculum in the context of

predictable classroom structurepredictable classroom structure Supportive assessment & response Supportive assessment & response

to traumatogenic coping strategies to traumatogenic coping strategies

The Child: Pair Play The Child: Pair Play TherapyTherapy

A developmental intervention A developmental intervention designed to help at-risk toddlers & designed to help at-risk toddlers & preschoolers develop & sustain preschoolers develop & sustain friendships.friendships.

A relational intervention that A relational intervention that supports and facilitates age-supports and facilitates age-appropriate perspective-taking appropriate perspective-taking skills in toddlers and preschoolers.skills in toddlers and preschoolers.

Therapeutic Guidelines for Therapeutic Guidelines for Pair Play TherapyPair 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 opportunities for interaction Work though conflictWork though conflict Model & reinforce cooperationModel & reinforce cooperation Model non-aggressive responsesModel non-aggressive responses Establish clear boundariesEstablish clear boundaries Adapt & use the ecological settingAdapt & use the ecological setting Build & maintain friendshipsBuild & maintain friendships

Evaluation of Pair Play Evaluation of Pair Play Therapy StudyTherapy Study

(N = 52)(N = 52)

Does children’s readiness for peer Does children’s readiness for peer interaction increase over time after interaction increase over time after controlling for age and proximity to controlling for age and proximity to abuse event?abuse event?

What is the interface between What is the interface between children’s interactions and children’s interactions and therapists interventions in Pair Play therapists interventions in Pair Play Therapy?Therapy?

PEER INTERACTION CODINGPEER INTERACTION CODING

Factors relating to peer Factors relating to peer interaction include:interaction include:

proximityproximitycooperationcooperationfriendship & perspective friendship & perspective takingtaking

verbal interactionverbal interaction

Case Study Example:Case Study Example:MothersMothers

Mid Twenties – Mid Twenties – Early ThirtiesEarly Thirties

African American African American WomenWomen

Low SES-Low SES-Welfare Welfare

DependantDependant

Involved with Involved with Child Protective Child Protective

ServicesServices

ChildrenChildrenTanisha - 2 years, 3 mo.Tanisha - 2 years, 3 mo.Christina - 1 year, 7 mo.Christina - 1 year, 7 mo.

Physical abuse & Physical abuse &

neglect neglect

In foster care for a In foster care for a period of timeperiod of time

Interaction DifficultiesInteraction DifficultiesParticipated in Pair play Participated in Pair play

therapy for 19 therapy for 19 sessionssessions

The highest interaction level The highest interaction level displayed by Tanisha and Christina displayed by Tanisha and Christina

in PPT: COOPERATIONin PPT: COOPERATION

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Tanisha

0

1

2

3

4

5

Interaction Level

PPT Session Number

Tanisha Christina

Highest interaction level displayed Highest interaction level displayed by Tanisha and Christina in PPT: by Tanisha and Christina in PPT:

CONFLICTCONFLICT

0

1

2

3

4

5

Interaction Level

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Tanisha

PPT Session Number

Tanisha Christina

Is this the working phase Is this the working phase of therapy?of therapy?

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 1718 19

20

Tanisha

0

1

2

3

4

5

0

1

2

3

4

5

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

TanishaChristina

COOPERATION CONFLICT

Highest interaction level displayed Highest interaction level displayed by Tanisha and Christina in PPT: by Tanisha and Christina in PPT:

FRIENDSHIP &PERSPECTIVE TAKINGFRIENDSHIP &PERSPECTIVE TAKING

0

1

2

3

4

5

Interaction Level

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Tani

sha

Chr

istin

a

PPT Session NumberTanisha Christina

Highest interaction level displayed by Highest interaction level displayed by therapists during PPT: therapists during PPT:

THERAPISTS INTERVENTIONSTHERAPISTS INTERVENTIONS

1 2 3 4 5 6 78 9 10

1112 13

14 1516

1718

1920

0

1

2

3

4

5

6

7

Interaction Level

PPT Session Number

Therapists behavior towards Tanisha Therapists behavior towards Christina

Pair Play Therapy Findings:Pair Play Therapy Findings: Children increased cooperative & friendship Children increased cooperative & friendship

perspective-taking interactions over time.perspective-taking interactions over time.

Children did express more conflict in the Children did express more conflict in the working phase of therapy including working phase of therapy including scratching, hitting, kicking & name-calling.scratching, hitting, kicking & name-calling.

Therapists’ behaviors & interventions Therapists’ behaviors & interventions involved the re-structuring of negative involved the re-structuring of negative interactions & were associated with the interactions & were associated with the elicitation of cooperative behaviors, including elicitation of cooperative behaviors, including friendship & perspective taking.friendship & perspective taking.

““Touch functions on many levels of Touch functions on many levels of adaptation, first to make survival adaptation, first to make survival

possible, then to make life possible, then to make life meaningful.” meaningful.”

(Brazelton, 1990 p.561)(Brazelton, 1990 p.561)

The Use of The Use of TherapeutiTherapeuti

c Touch c Touch StudyStudy

Therapist Use of Touch, Therapist Use of Touch, Supporting Internal Control Supporting Internal Control

ExternallyExternally

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

Therapist Use of Touch, Therapist Use of Touch, Supporting Internal Control Supporting Internal Control

ExternallyExternally

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

Therapist Touch StudyTherapist Touch Study(Schlichtmann & Ayoub, 2004)(Schlichtmann & Ayoub, 2004)

Does change in social competence Does change in social competence over the course of Pair Play Therapy over the course of Pair Play Therapy for toddlers & preschoolers differ for toddlers & preschoolers differ according to therapist use of positive according to therapist use of positive touch?touch?

Does the effect of therapist use of Does the effect of therapist use of positive touch on the rate of change positive touch on the rate of change in social competence vary as a in social competence vary as a function of maltreatment status?function of maltreatment status?

6

8

10

12

14

1 2 3 4 5 6 7 8 9 10

Session

Estim

ated

Soc

ial C

ompe

tenc

e .

90th Percentile, 13 TouchesPer Session50th Percentile, 4 TouchesPer Session10th Percentile, 1 TouchPer Session

Fitted average growth trajectories describing the effect of Fitted average growth trajectories describing the effect of the number of times a participant is touched by a the number of times a participant is touched by a

therapist per session for maltreated children on the therapist per session for maltreated children on the change in social competence over time for 3 year old change in social competence over time for 3 year old

participants (n=60).participants (n=60).