Do I Look Stressed?The Impact of Stress and Trauma in Early Childhood

Erin Kinavey , M.Ed.DHSS-OCSEarly Intervention ManagerPart C Coordinator

Neal M. Horen, Ph.D.Co-Director of Training and Technical AssistanceGeorgetown University Center for Child and Human Development

Oh, the places we will go

Big PictureSystemsClinical perspectiveCase exampleOne stateCultural issuesStump the speaker

EARLY CHILDHOOD MENTAL HEALTH SYSTEM OF CAREFosters the social and emotional well-being of infants toddlers, preschool-age children and their families

VALUES

Family Voice

Child and Family Centered

Relationship Based

Culturally Competent

Infused into Natural Settings and Services

Grounded in Developmental Knowledge

Prepared Workforce

Interagency Partnerships

Maximized and Flexible Funding

Building Blocks

Promotion Prevention Intervention

Supports for Parents and Families

Supports for Other Caregivers

Services for Children and Families

Services and Supports

Outcome Evaluation

Strategic Planning, Policies, and Procedures

Systems and Trauma

What happens to a system in a trauma?What happens to a family who is stressed?What happened to Charles in Austin?

Stress

What could stress a kid?What stresses you?How do you cope?

PTSD

Pattern of symptomsMust be understood in context of the developmental level, trauma, temperament, caregiver’s ability to provide protection and safety5 criteria

Two diagnostic challenges in addressing PTSD in young children

1 Young children have less well-developed verbal capacities. It’s harder to know their internalized world.

2 Young children manifest some symptoms differently than older children and adults due to developmental differences.

Taken from Scheeringa

Download the criteria from. . .

The modified criteria for PTSD (Scheeringa et al., 2003), plus 12 other disorders in young children, have been incorporated into the Research Diagnostic Criteria - Preschool Age (RDC-PA) (Task Force on Research Diagnostic Criteria - Preschool Age, 2003)

Can download the RDC-PA from www.infantinstitute.org

The unique influence of the caregiving context for young children

~20 studies confirm an association between more symptoms in parents and more symptoms in children following trauma to the children (reviewed in Scheeringa & Zeanah, 2001)

Maternal depression mediated treatment outcome for preschool children who were sexually abused (Cohen & Mannarino, 1998)

Is this a causal relationship between parents and children? Or shared genetic vulnerability?

Models of parent-child relational patterns following trauma (Scheeringa and Zeanah, 2001)

Type ofeffect

Childexperiencedthe trauma

Parentexperienceda trauma

Parentimpacts onchild

Minimal Yes Maybe, notnecessary

Minimal orNone

Moderating Yes Maybe, notnecessary

Yes

VicariousTrauma-tization

No Yes Yes

Compound Yes Yes Yes

Preliminary data on the longitudinal impact of parenting style on child PTSD symptoms

Higher parent emotional sensitivity significantly associated with children with PTSD diagnosis (p<.05), contrary to expectations. As parent sensitivity decreased over two years, children’s PTSD symptoms decreased (r=.38, p<.01) (Scheeringa et

al., in preparation) , contrary to expectations.

Treatment: play therapy

“..re-experience the trauma and its meaning in affectively tolerable doses in the context of a safe environment so that the overwhelming traumatic feelings can be mastered and adaptively integrated into the person’s emotional life”.

(Gaensbauer and Siegel, 1995)

Evidence based treatments

Two manualized studies on sex-abused preschool children (Cohen & Mannarino, 1996, Deblinger et al., 2001)

Manualized treatment for preschool children who witnessed domestic/interpersonal violence (Alicia Lieberman, PhD, University of California, San Francisco, personal communication)

The Preschool PTSD Treatment Manual (Scheeringa, Amaya-Jackson, and

Cohen, 2002): A 12-week cognitive-behavioral treatment combined with parent-child relationship treatment.

“All-purpose”: treatment can be focused on PTSD symptoms from any type of trauma.

Manual requests to: mscheer@tulane.edu

Parent-Child Interaction Therapy (PCIT) (www.pcit.org)

PCIT was originally designed and studied for children with behavioral problems aged 2-7 and their parents or caregivers

PCIT is the creation of Dr. Sheila Eyberg of the University of Florida, applying a model of operant conditioning first developed by Dr. Constance Hanf

Eyberg’s PCIT protocol integrates traditional play therapy techniques into operant conditioning

Steps in Parent-Child Interaction Therapy

Step 1: Pretreatment assessment of child & family functioning and feedback (1-2 sessions)Step 2: Teaching behavioral play therapy skills (1 session)Step 3: Coaching behavioral play therapy skills (2-4 sessions)Step 4: Teaching discipline skills (1 session)Step 5: Coaching discipline skills (4-6 sessions)Step 6: Post-treatment assessment of child & family functioning and feedback (1-2 sessions)Step 7: Boosters (as needed)

Parent-Child Interaction TherapyStage One: 7 Sessions CDI: Child Directed Interaction

PRAISE

REFLECT

IMITATE

DESCRIBE

ENTHUSIASM

PCIT, Trauma, and Maltreatment

Does PCIT help families where children have experienced stress or trauma, such as child

sexual abuse, the witnessing of violence, and physical abuse?

Advantages of protocol-driven manualized treatment over non-directive play therapySuccessful treatment of PTSD must

involve: an emotional re-engagement with the traumatic memories organization and articulation of a trauma narrative (reviewed in Zoellner et al, 2001)

A manual protocol ensures comprehensive coverage of complicated child, parent, and parent-child relational issues, including relaxation training, graded systematic exposure, and homework.

Jamaal

3 year-old living with mother and maternal uncleVictim of sexual abuse

Dante

Living with grandmother and great-grandmother, sistersViolent neighborhoodPoorFamily medical issues

Early Childhood Trauma and Stress

Alaska

Office of Children’s Services DHSS State of Alaska

Alaska demographics Population: 655,000.

Day to day challenges

Rural and remote

Access to Prenatal Care2000

% of births to women who receive late or no prenatal care

80.5% of Alaskan women had prenatal care in the first trimester

67.4% had “adequate” care

Young Children in Poverty% of children under age 6 living in families with

income below the federal poverty level

0%

5%

10%

15%

20%

25%

30%

35%

40%

Under age 6 36% Age 6 & Over 28%

Percent of Alaska’s Children in Low-Income Families (200% FPL)

11-14 Yrs17%

15-17 Yrs7%

6-10 Yrs31%

0-1 Yrs16%

2-5 Yrs29%

0-1 Yrs2-5 Yrs6-10 Yrs11-14 Yrs15-17 Yrs

Reports of Harm by Age-August 2004

0-5 Years = 45%

Day to day stress

66% of Alaskan households are supplied water through the public water system.

31% of rural/remote households had NO plumbing and are required to “pack” water from a local source.

Table 2: from the “Building Blocks” program of the Dept. of Health and Social Services- State of Alaska.

Pop. % of Adults not in the workforce

% Below Poverty level

Women & Children on WIC (12/00)

Pregnant Women in Denali Kidcare (CHIP)

Pop. with TANF in 2000

Pop.with Medic-aid

Poverty of Access?

Alakanuk 622 64 33.8 95 28 140 417 Yes

Chevak 692 75 26.7 79 15 121 533 Yes

Emmonak 700 52 16.2 83 28 100 437 Yes

Marshall 335 48 20.8 47 17 24 226 Yes

Mt. Village 683 58 21.1 83 26 150 443 Yes

Toksook Bay 519 43 26.9 47 13 52 308 Yes

Subsistence lifestyleYup’ik, Cup’ik, Athabascan

Yukon Kuskokwim

Healthy Alaskan 2010 indicators and goals http://www.hss.state.ak.us/dph/targets/ha2010/PDFs/05_Mental_Health.pdf

Historical context

Missionaries

TB

Boarding schools Ongoing debate

Weaving history into practice

Recognizing alternative sources of knowledge

Allowing for program flexibility

Drawing on multiple resources to develop protocol

Case study

Intergenerational issues FASD Stress and Trauma parental MH issues

Impact on child Multidisciplinary response