April 3, 2014-Trauma in Young Children Under 4-Years of Age: Attachment, Neurobiology, and Interventions

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Welcome to the  
Military Families Learning Network Webinar: 
Trauma in Young Children Under 4 Years of Age: Attachment,
Neurobiology, and Interventions"
This material is based upon work supported by the National Institute of Food and Agriculture, U.S. Department of Agriculture,
and the Office of Family Policy, Children and Youth, U.S. Department of Defense under Award Numbers 2010-48869-20685 and 2012-48755-20306.

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Today’s Presenter:
Kimberly Renk, Ph.D. is currently an Associate Professor of Clinical
Psychology and the Director of the Clinical Psychology Ph.D. program at the University of
Central Florida as well as a licensed Psychologist in the state of Florida. She earned her
Bachelor’s degree in Psychology from the University of Illinois, her Master’ s degree in
Clinical Psychology from Illinois State University, and her Ph.D. in Clinical Psychology
from the University of South Florida with a pre-doctoral internship at Louisiana State
University Health Sciences Center in New Orleans, Louisiana. Although Dr. Renk has
diverse clinical experience with young children, school-age children, adolescents, and
adults in a variety of psychological settings, the majority of Dr. Renk’s work has
addressed the needs of young children who are already experiencing emotional and
behavioral problems, particularly due to stressors in their families. Throughout her
graduate students and her postdoctoral work, Dr. Renk has worked with traumatized
children in a variety of settings, including the completion of Infant Mental Health
Fellowship training while at the Louisiana State University Health Sciences Center. Most
recently, Dr. Renk has been working with Neil Boris, M.D., of Nemours Children’s Hospital
to integrate evidence-based parenting interventions into the child welfare system in the
Central Florida region.
INSERT
PHOTO

Trauma in Young Children
Under 4-Years of Age:
Attachment, Neurobiology,
and Interventions
Kimberly Renk, Ph.D.
Associate Professor of Clinical Psychology
Director of Clinical Training
University of Central Florida
Department of Psychology
Orlando, Florida

Disclosures
•  Support for initial exploration of this topic was provided via the CHIPS
(Child Intervention, Prevention, and Services) Fellowship Program,
National Institute of Mental Health.
•  Other support for work regarding correlates of psychological symptoms
in young children was provided by the UCF In-House Research
Program and the National Institute of Health Loan Repayment Program.
•  Thanks to my current grad students, Brea, Catherine, Jayme, Meagan,
Amanda, and Annelise; to all my former students whose hard work helped
propel us forward; to my research collaborator, Neil Boris, M.D.; to my husband,
Rob; and my two sweet boys. =)

Objectives
•  Review developmental concepts that are related to how young
children connect to caregivers and ultimately will process trauma.
•  Understand the signs and symptoms of trauma as well as the
diagnostic criteria of Posttraumatic Stress Disorder for young
children.
•  Discuss the neurobiological underpinnings of trauma for young
children.
•  Begin to consider the evidence-based treatments that are currently
available and adaptations that may need to be made to
accommodate young children.

Important Characteristics of Early
Childhood
(Lawson & Quinn, 2013)
•  Young children are developing communication, empathy,
relationships, self-awareness, self-regulation, and a
basic sense of self.
•  Inconsistency in caregiver provisions undermines healthy
child development.
–  Co-regulation of emotions is critical, with attachment being
particularly important.
•  Young children are especially vulnerable to the impact of
trauma (especially from a family member).

Species Expectable Versus
Experience Dependent
(Twardosz & Lutzker, 2010)
•  Species Expectable: A range of conditions that support
typical human development.
–  Protection and nurturance from adults.
–  Opportunities to explore and learn from the
environment.
–  Versus experiences that are outside of the range of
human experience (e.g., abuse, trauma).
•  Experience Dependent: An individual’s particular
experiences are encoded in the brain through learning
and memory.

Attunement Affects
Brain Development
•  During interactions characterized by
attunement, caregivers and their infants
synchronize neural activity in the right
cortex of each brain (McHale, 2013).
– Attachment allows brain rhythms to be in tune
and ultimately for infants to manage stress.
– Attunement is critical for later emotional
regulation, with this skill guided by the right
prefrontal cortex (Peck, 2003).

Borrowed from Neil
Boris, M.D.; based on
Andrew Meltzer’s work
on infant imitation.

Still Face Example
hIp://www.youtube.com/watch?v=apzXGEbZht0

Why Is Attunement So Important?
1.  Selection of neuronal
pathways
2.  Emotions—development
and regulation
3.  Shaping of Internal
Working Models/
Representations
(Schore, 1999)

Attachment
•  Enduring emotional tie between
infant and caregivers that
develops through repeated
interaction over time.
•  Explanations for attachment.
–  Freud: Drive Reduction.
–  Erikson: Psychosocial
Explanation.
–  Harlow: Animal Models.
–  Lorenz: Imprinting.
–  Bowlby: Evolutionary Explanation.

Stages of Attachment
•  By 2 weeks of age, infants prefer the human voice.
•  By 4 weeks of age, infants prefer their mothers’ voice.
•  In the second month, eye contact is established.
•  From 3 to 6 months, infants start having a social smile.
•  From 6 to 9 months, infants start having a preference for
their own caregiver and a preferential smile.
–  Separation anxiety and stranger anxiety tend to start.
•  From 12 to 24 months, proximity seeking is needed.
•  Around 3 years of age, attachment becomes more
reciprocal.

Assessment of Attachment
•  Ainsworth’s Strange Situation: Presents infants with a
series of social stressors so that the manner in which the
infants cope can be observed.
–  Eight episodes:
•  Caregiver, baby, observer in play room (30 sec).
•  Caregiver, baby, observer (3 min).
•  Caregiver, baby, stranger (3 min).
•  Caregiver leaves (3 min).
•  Caregiver returns; stranger leaves (3 min).
•  Caregiver leaves (3 min).
•  Stranger returns (3 min).
•  Caregiver returns and stranger leaves (3 min).
•  Other Measures of Attachment Include:
–  The Still-Face Procedure.
–  The Crowell Paradigm/Parent-Child Relationship
Assessment.

Attachment Classifications
(Ainsworth et al., 1978; Main & Solomon, 1986)
•  Securely Attached.
•  Insecurely Attached.
– Anxious/Avoidant.
– Anxious/Resistant.
– Disorganized/Disoriented.
•  Attachment can help to ensure that the brain
structures involved with social cognition are
organized appropriately and that children are
prepared to interact with others.

Attachment Example
hIp://www.youtube.com/watch?v=2iQ3b1-‐43J4

Resilience to Trauma
•  The concept of resilience can be important
in understanding trauma and the results of
maltreatment.
– The focus is on the processes by which
children develop into well-adjusted adults
despite adverse circumstances (Houshyar & Kaufman,
2005).
– Brain plasticity: The ability of the brain to
respond to experience by modifying its
structure and function (Twardosz & Lutzker, 2010).

Adverse Childhood Experiences Study
(acestudy.org)
•  A large study with approximately 18,000 participants
conduced by the Kaiser Permanente group.
•  This study examined the health and social effects of
adverse childhood experiences (e.g., abuse, household
dysfunction) over individuals’ lifetimes.
•  Poor outcomes (e.g., suicide attempts, drug use)
increased as the number of adverse experienced
increased.

Defining Trauma
(Rice & Groves, 2005)
•  Trauma is an exceptional experience.
•  Trauma overwhelms individuals’ capacity to
cope.
–  The child’s age and developmental stage affect the
impact of trauma.
–  The circumstances of the trauma matter.
–  The social environment affects impact.
•  Trauma can be acute or chronic.
•  Trauma can alter children’s perception that
parents can provide protection and safety.

Will You Know
When It Is Trauma?
hIp://www.youtube.com/watch?v=pSe40tX-‐oTA

Events Related to Trauma
(Finkelhor, Ormrod, Turner, & Hamby, 2005)
1.  Bullying.
2.  Assault with injury.
3.  Assault with a weapon.
4.  Exposure to shooting, bombs, riots.
5.  Nonsexual genital assault.
6.  Robbery by a non-sibling peer or adult.
7.  Physical abuse by a caregiver.
8.  Witnessing domestic violence.
9.  Sexual assault.
10.  Murder of someone close to a child.

Abuse and Neglect
in Young Children
•  Approximately 772,000 children were abused and/or
neglected in the U.S. in 2008 (U. S. Department of Health and Human
Services, 2011).
–  Abuse and neglect cost our society $103.8 billion annually, with
approximately $33 billion of this estimate being the result of lost
productivity to society (Wang & Holton, 2007).
•  The youngest of our children are overrepresented and
are most vulnerable to abuse and neglect experiences
(Fantuzzo, Brouch, Beriama, & Atkins, 1997; Osofsky & Lieberman, 2011).
–  Approximately of 56% of maltreatment victims were younger
than 7-years of age (U.S. Department of Health and Human Services, 2009).
–  The U.S. ranks third among 27 industrialized nations for number
of child deaths from maltreatment (UNICEF, 2003).

Parenting in the Midst of
Substance Misuse
•  Almost 70 million children live with one parent who
abused or was dependent on alcohol or an illicit
substance.
–  The youngest of children are over-represented in this
sample (SAMHSA, 2009).
•  Substance misuse by parents is present in 25 to 80
percent of cases in the child welfare system (e.g., Child Welfare
Information Gateway, 2003).
•  Parents who misuse substances are the least likely to be
reunified successfully with their children and are the
most likely to have children with long stays in foster care
once children enter the child welfare system (Gregoire & Schultz,
2001).

So Why Should We Be
Concerned with These Parents?
•  Parents who misuse substances often engage in
impaired or inadequate parenting practices (Mayes &
Truman, 2002).
–  Abuse and neglect (Kelley, 1998).
–  Verbal and physical aggression (Ammerman, Kolko, Kirisci, Blackson, &
Dawes, 1999).
–  Behaviors prompted by emotional dysregulation (Khantzian,
1999).
–  Poor attachment, attunement, responsiveness, and
adaptability (Hans, Bernstein, & Henson, 1999).

Understanding
Symptoms

in
Young
Children

(Carter
et
al.,
2004;
Egger
&
Angold,
2006;
Zeanah
et
al.,
1997)

•  Understanding symptoms in this population has lagged behind our
understanding of older children and adolescents.
–  Resistance to thinking about symptoms in young children.
–  Stigma that goes along with diagnosing young children.
–  Challenges in making diagnoses in young children.
–  Lack of developmental sensitivity in current criteria.
–  Limited availability of sound assessment measures.
–  Rapid developmental changes in young children.
–  Cognitive and communication immaturity.
–  Unique role of the parent-child relationship.
•  Children’s experience of parents’ trauma is qualitatively and quantitatively different than
direct exposure.

Signs of Trauma
•  Psychological Effects.
–  Dysregulation of affect.
–  Aggressive or sexualized/provocative behavior.
–  Fearfulness.
–  Regression or falling behind in development and behavior/effects on
learning.
–  Relationships with parents and others may suffer/avoidance of
intimacy/attachment problems.
•  Physical symptoms.
(Lowenthal,
1998;
Rice
&
Groves,
2005)

Symptom Correlates for Trauma
in Young Children
(De Young, Kenardy, & Cobham, 2011; Finkelhor et al., 2005; Lieberman & Knorr, 2007;
Scheeringa & Zeanah, 2008; Scheeringa et al., 2003)
•  Posttraumatic stress disorder.
•  Emotional difficulties, such as anxiety and depression.
•  Behavioral difficulties, such as ADHD and Oppositional
Defiant Disorder.
•  Attachment difficulties with caregivers and interaction
difficulties with family members.
•  Difficulties achieving developmental tasks.
•  Difficulties coping and with frustration tolerance.
•  Comorbid socioecological conditions (e.g., poverty) may
be likely.

Main Categories of
Trauma Symptoms
(Rice & Groves, 2005)
•  The child relieves or re-experiences the
traumatic event.
– Posttraumatic play.
– Preoccupation with the traumatic event.
– Triggers that remind the child of the trauma.
– Nightmares and sleep disturbances.
•  Hyperarousal.
•  Withdrawn or avoidant behavior (or both).

Posttraumatic Stress Disorder
a la the DSM-IV-TR
(APA, 2000)
1.  The individual has been exposed to a traumatic event that
includes:
1.  Experiencing, witnessing, or confronting an event (or events) that
involved actual or threatened death, serious injury, or a threat to
physical integrity.
2.  A response involving intense fear, helplessness, or horror.
2.  The traumatic event is persistently re-experienced in one or more
of the following ways:
1.  Recurrent, intrusive recollections of the event(s).
2.  Recurrent distressing dreams.
3.  Acting or feeling as if the traumatic even were recurring.
4.  Intense psychological distress with cue exposure.
5.  Physiological reactivity with cue exposure.

a la the DSM-IV-TR
(Continued)
3.  Persistent avoidance of stimuli associated with the
trauma and numbing of responsiveness, as indicated
by three of the following:
1.  Efforts to avoid things associated with the trauma.
2.  Efforts to avoid things that arouse recollections of the trauma.
3.  Inability to recall an important aspect of the trauma.
4.  Markedly diminished interest or participation in usual activities.
5.  Feeling detached or estranged from others.
6.  Restricted range of affect.
7.  Sense of a foreshortened future.

a la the DSM-IV-TR
(Continued)
4.  Persistent symptoms of increased arousal, including
two of the following:
1.  Difficulty falling or staying asleep.
2.  Irritability or outbursts of anger.
3.  Difficulty concentrating.
4.  Hypervigilance.
5.  Exaggerated startle response.
5.  Duration of the symptoms for more than one month.
6.  The disturbance causes clinically significant distress or
impairment in social, occupational, or other important
areas of functioning.

General Problems With Using the
DSM In Young Children
•  DSM makes no assumption that each disorder is a
completely discrete entity.
•  Individuals may not fit cleanly in a diagnostic category or
be alike in important ways, even in the same diagnosis.
•  DSM gives less attention to disorders of infancy and
childhood than to those of adulthood.
•  DSM has a relative lack of emphasis on situational and
contextual factors (e.g., the parent-child relationship)
contributing to disorders.

Problems with the DSM’s PTSD
Diagnosis In Young Children
•  Diagnostic criteria for developmentally appropriate behavioral
manifestations are needed (Lieberman et al., 2011).
–  None of the traumatized children examined by Scheeringa et al.
(2003) met criteria (although 26% did with developmentally
appropriate accommodations).
•  Diagnostic criteria that do not depend on verbalizations from the
individual are needed (Scheeringa, 2007).
–  Adult observers may help but may not know completely if
symptoms are occurring.
•  Symptoms that indicate an internal experience may not be
detectable, even by an informed observer (Scheeringa, 2007).

An Alternate System:
The DC: 0-3
(Zero to Three, 2005)
•  DC: 0-3 was developed by the Diagnostic
Classification Task Force of the Zero to
Three/National Center for Clinical Infant
Programs.
•  It is currently in its second edition.
•  It is intended to provide a comprehensive
system for classifying problems during the
first 3-4 years of life.
•  It also is based on a multi-axial system.

An Alternate System:
The DC: 0-3
(Continued; Zero to Three, 2005)
•  Axis I: Primary Diagnosis.
•  Axis II: Relationship Classification.
•  Axis III: Physical, Neurological, and
Developmental Conditions.
•  Axis IV:Psychosocial Stress.
•  Axis V: Functional Emotional
Developmental Level.

Posttraumatic Stress
in Young Children via the DC:0-3R
100. Posttraumatic Stress Disorder
(Zero to Three, 2005)
1.  The child has been exposed to a traumatic event.
2.  The child shows evidence of re-experiencing the
traumatic events by at least one of the following:
1.  Posttraumatic play.
2.  Recurrent and intrusive recollections of the traumatic event.
3.  Repeated nightmares.
4.  Physiological distress.
5.  Recurrent flashbacks or dissociation.

Posttraumatic Stress
in Young Children via the DC:0-3R
3. The child experiences a numbing of responsiveness or
development problems, with at least one of the following:
1.  Increased social withdrawal.
2.  Restricted range of affect.
3.  Diminished interest or participation in activities.
4.  Efforts to avoid recollection triggers.
4. The child experience increased arousal as noted by at least two
of the following:
1. Difficulty going to sleep.
2. Difficulty concentrating.
3. Hypervigilance.
4. Exaggerated startle response.
5.  Increased irritability, anger, or tantrums.
5. The pattern of symptoms persist for at least one month.

DSM-5 Criteria for Children Who
Are 6-Years of Age or Younger!
(American Psychological Association, 2014; Scheeringa et al., 1995)
A. Exposure to actual or threatened death, serious injury, or sexual violence in
one or more of the following ways:
1.  Directly experiencing trauma.
2.  Witnessing traumatic events occurring to others.
3.  Learning that trauma occurred to parents or caregivers.
B. Intrusive symptoms (one or more of the following):
1.  Recurrent, involuntary, and intrusive distressing memories of the trauma.
2.  Recurrent distressing dreams related to the trauma.
3.  Dissociative reactions (flashbacks) in which the child acts as if the trauma
is recurring.
4.  Intense or prolonged psychological distress at exposure to cues that
symbolize the trauma.
5.  Marked physiological reactions to reminders of the trauma.

DSM-5 Criteria (Continued)
C. Persistent avoidance of stimuli associated with the
trauma (one or more of the following):
1.  Avoidance or efforts to avoid physical reminders of
the trauma.
2.  Avoidance or efforts to avoid interpersonal situations
that act as reminders of the trauma.
3.  Increased frequency of negative emotional states.
4.  Diminished interest or participation in activities (e.g.,
restriction of play).
5.  Socially withdrawn behavior.
6.  Reduction in the expression of positive emotions.

DSM-5 Criteria (Continued)
D. Alterations in arousal and reactivity associated with the trauma
(two or more of the following):
1.  Irritable behavior and angry outbursts.
2.  Hypervigilance.
3.  Exaggerated startle response.
4.  Problems with concentration.
5.  Sleep disturbance.
E.  Duration of the symptoms for more than one month.
F.  Disturbance causes clinically significant distress or impairment.
G.  Disturbance is not due to a substance or another medical
condition.

Results Using the
PTSD Alternative Criteria
(Scheeringa et al., 2001; Scheeringa et al., 2003; Scheeringa et al., 2005)
•  12% of the diagnostic criteria present in children who were
younger than 48 months were detected via direct observation.
–  Other criteria could be inferred from parent report,
although avoidance criteria were still difficult.
•  26% of young children (20-months to 6-years) met the
alternate criteria (vs. no children meeting the DSM-IV-TR
criteria).
•  Children showed more of the alternative criteria than the
original criteria.
•  These criteria predicted degree of functional impairment one
and two years later as well as diagnostic status two years
later.

The Importance of
DSM-5 Criteria
•  These criteria:
– More adequately describe the
experience of young children with
PTSD.
– Predict long-term functional impairment
in young children.
– Can be assessed using parent report
and via observational assessment.

Mutual
regulation:
Regulated
with the help
of the
caregiver
Self-
regulation
of behavior
and
emotions
Behavior and Emotion Regulation
Across Development
(Slide borrowed from N. Boris)
Trauma May
Impair Both
Mutual and Self-
Regulation

Main Problems with Studying the
Neurological Effects of Trauma
in Young Children
•  Many studies look at adults retrospectively.
–  There is no way to know if a trauma experience
prompted the differences that may be found in
brain anatomy.
•  Precise information about children’s environment and
experiences are not always available.
•  Children often experience multiple types of trauma.
•  Animal models may be helpful but often are not a
perfect model comparison.

The Human Brain
(Twardosz & Lutzker, 2010)
•  Mature brains can be sensitized by
traumatic experiences.
•  But…younger brains can be much more
profoundly affected.
– The immature brain is still organizing itself.
– The immature brain is dependent on
information from the environment.
– Different parts of the brain are responsive at
different sensitive periods.

Neurodevelopment and Neglect
hIps://www.youtube.com/watch?v=bF3j5UVCSCA

Brain Development and Trauma
•  Trauma can affect how the brain functions and the
autonomic nervous system.
–  Young children can continue to show fear symptoms, even if
threatening stimuli are no longer present (McHale, 2013).
–  Young children can show high resting heart rates, high stress
hormones, and poor sleep patterns (McHale, 2013).
–  Prolonged stress of trauma can result in the shrinkage of the
areas of the brain responsible for learning, memory, and
regulation of affect and emotions (Newberger, 1997).
•  Young children’s stress response system develops
rapidly during the first three years of life and can be
altered by stress.
–  Nonetheless, the early postnatal period is a particularly
vulnerable time.

Stress and Brain Development
•  Stress has a substantial impact on the structure
and function of limbic structures (e.g., the
hippocampus, frontal cortex (Bremner, 2005).
– The brain is particularly susceptible during the
early postnatal period (Brunson et al., 2001).
•  Abuse and neglect has been related to
reductions in the volume of the corpus callosum
(Teicher et al., 2004).
•  Hormones (e.g., norepinephrine, cortisol) also
play a significant role in the stress response
(Bremner, 2005).

Brain Development and
Childhood Maltreatment
•  Childhood maltreatment has been related
to reductions in hippocampal volume and
to diagnosable psychiatric illness
(Teicher et al., 2012).
•  Childhood emotional abuse also was
associated with reduced hippocampus
volume in males (Samplin et al., 2013).
– Childhood emotional abuse was associated
with higher levels of subclinical
psychopathology for both males and females.

Brain Development and PTSD
(De Bellis et al., 2002)
•  Maltreated children who were diagnosed
with PTSD (versus those who were not
diagnosed):
–  Had decreased volume in the corpus callosum,
prefrontal cortices, and temporal lobes and smaller
amounts of prefrontal cortical white matter.
–  Had smaller intracranial, cerebral, and prefrontal
measurements.
–  Had increased volume in the superior temporal gyrus.
–  Had larger volumes of cerebrospinal fluid in the frontal
lobes.

Assessment Recommendations
(AACAP, 2010)
•  Routine inclusion of questions regarding trauma
exposure and symptoms of PTSD (particularly given the
particularly damaging effects of cumulative stressors,
(Dube et al., 2003).
•  The inclusion of parents/caregivers in the assessment
process as well as an assessment of the parent-child
relationship given its protective value for young children’s
regulation of symptoms (Gunnar & Quevedo, 2007).
•  The assessment of comorbid disorders.
•  The use of trauma-focused psychotherapies as first line
treatments.
–  Attend directly to trauma symptoms.
–  Enhance functioning and developmental trajectory.

Potential Treatments of Interest
•  Two main types of treatment programs have been showing promise
(Gleason et al., 2007):
–  Child-Parent Psychotherapy (Lieberman & Van Horn, 2008).
–  Cognitive Behavioral Treatments (Trauma-Focused Cognitive-
Behavioral Therapy; Cohen, Berliner, & Mannarino, 2000; Cohen, Mannarino, & Deblinger,
2006).
–  Also… The Circle of Security (Cooper, Hoffman, Marvin, & Powell, 1999).
•  Certainly prevention efforts are warranted, but treatments must
address the sequelae of these experiences in our youngest children
(McKinney et al., 2006; Renk et al., 2002; Renk et al., 2008).
•  It is also worth noting that no single treatment approach will be
applicable to all children (Cohen, Berliner, & Mannarino, 2000).

Child-Parent Psychotherapy
(CPP) (Lieberman & Van Horn, 2005)
•  A relationship-based intervention grounded in psychoanalytic,
attachment, and trauma theory.
–  It includes social learning and CBT interventions for change.
•  Core premise includes the idea that young children rely on their
parents for protection and safety.
–  Trauma can alter the perception that parents can provide these
things.
•  Therapists support the parent-child dyad with play, words, and
interactions to express and respond to emotional needs, breaks the
taboo of silence about the trauma, that modulates unmanageable
traumatic stress, and that restores trust.

Child-Parent Psychotherapy
(CPP) (Lieberman & Van Horn, 2005)
•  Efficacy is supported by several randomized clinical trials
with samples varying in child age, presenting issues, and
backgrounds.
•  Outcomes include:
–  Reductions in child and mother psychological symptoms.
•  PTSD, Depression, Co-Morbid Diagnoses, Behavior
Problems (Ghosh Ippen et al., 2011).
–  More positive child attributions for parents, for themselves,
and for relationships.
–  Improvement in child-mother relationship quality and
attachment.
–  Improvement in child cognitive functioning (Lieberman et al., 2011).

Circle of Security Parenting Program
(Marvin, Cooper, Hoffman, & Powell, 2002)
1.  Welcome to the Circle of Security: Introduction to program.
2.  Exploring Our Children’s Needs All the Way Around the Circle:
Increase parents’ observation and inferential skills.
3.  “Being With” on the Circle: Build a parent-child relationship where
children’s feelings can be shared and a secure attachment can be
built.
4.  Being With Infants on the Circle: Teach attunement to infants’
shifts in attention and emotion.
5.  The Path to Security: Steps to promoting security.
6.  Exploring Our Struggles: Be “bigger, stronger, wiser, and kind”.
7.  Rupture and Repair in Relationships: Learn that children
sometimes act out in an effort to manage their needs.
8.  Summary and Celebration.

Circle of Security Description
hIp://www.youtube.com/watch?v=xH1CbC4No24

•  Protect me
•  Comfort me
•  Delight in me
•  Organize my feelings
Circle of Security
Parent Attending to the Child’s Needs
I need
you to
Support My
Exploration
Welcome My
Coming To You
I need
you to
•  Watch over me
•  Help me
•  Enjoy with me
•  Delight in me
I need
you to
I need
you to
©
Cooper,
Hoﬀman,
Marvin,
&
Powell
(1999)

Trauma-Focused CBT
(Cohen & Mannarino, 2008)
•  A multicomponent model that includes:
–  Parental treatment.
–  Psychoeducation.
–  Relaxation and stress management skills.
–  Active expression and modulation skills.
–  Cognitive coping skills.
–  Trauma narrative and cognitive processing of the
child’s traumatic experience.
–  In vivo desensitization to trauma reminders.
–  Conjoint parent-child sessions.
–  Enhancing safety and future development.

Adapta@ons
that
Are
Required
for

Young
Children

(Scheeringa
et
al.,
2007;
Scheeringa
et
al.,
2011)

•  Scheeringa’s Adaptation to Young Children.
–  Includes both cognitive and behavioral techniques,
but behavioral techniques are emphasized.
–  Sessions 1-4: Teach children about symptoms.
–  Session 5: “Tell the story.”
–  Sessions 6-10: Exposures.
–  Session 11: Relapse prevention.
–  Session 12: Review and graduation.

Other Treatments Being Tested
•  Posttraumatic Parenting (Shelby et al., 2010).
–  Blends parent-child dyadic treatments with trauma-focused interventions
to create an evidence-informed posttraumatic treatment.
–  For 3- to 8-year old children.
•  Intergenerational Trauma Treatment Model (Copping et al., 2001; Lawson & Quinn,
2013).
–  Designed to address complex trauma using cognitive-behavioral
methods.
–  Builds caregivers’ capacity to directly address children’s trauma-related
symptoms (via group sessions), and considers caregivers’ own traumatic
experiences (via individual sessions).
–  Addresses interaction skills.
–  Children from 27 families experienced improvements in children’s
conduct and social relations; caregivers’ depression also improved.

Other Treatments Being Tested
(Continued)
•  Attachment, Self-Regulation, and Competency
Model (Arvidson et al., 2011; Lawson & Quinn, 2013).
–  Developed for the treatment of complex trauma.
–  Treatment is focused on caregiver attachment, children’s self-
regulation, children’s competency, and trauma experience
integration.
–  Informed by attachment theory and building parents’ skills to
assist their children.
–  Children (N=21) should significant improvements on the CBCL.
•  Stepped Care Trauma-Focused Intervention (Salloum, no
date).
–  Parents help to provide the intervention.
–  For 3- to 7-year old children.

Future Directions
•  Trauma is “the largest single preventable cause of mental
illness” (Sharfstein, 2005).
•  More work that examines infants and preschoolers (Lieberman et al., 2011).
•  More examination of trauma in young children (Lieberman et al., 2011)
across service providers (e.g., pediatricians; Lieberman & Knorr, 2007).
•  Having interventions that are applicable to young children and their
families readily accessible (Lieberman et al., 2011), particularly in
community settings (de Arellano et al., 2005).
–  National Child Traumatic Stress Network: www.nctsn.org
•  Understanding how to best address trauma issues when
concurrently experienced by parents and children.
–  Low functioning in parents is related to low functioning in
children after trauma (Kilpatrick & Williams, 1998; Scheeringa & Zeanah, 2001).
–  Trauma has a deleterious impact on parenting (Appleyard & Osofsky,
2003).

A Message About the Long-Term
Effects of Trauma…
hIps://www.youtube.com/watch?v=SPzVUGE3dds

Questions?
“Never doubt that a small group of
thoughtful, committed citizens
can change the world.
Indeed, it’s the only thing that ever has.”
–Margaret Mead

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YouTube Video Links
Still Face (Slide 12): http://www.youtube.com/watch?v=apzXGEbZht0
Attachment (Slide 18): http://www.youtube.com/watch?v=2iQ3b1-43J4
Domestic Violence PSA (Slide 22): http://www.youtube.com/watch?v=pSe40tX-oTA
Science of Neglect (Slide 48): https://www.youtube.com/watch?v=bF3j5UVCSCA
Circle of Security (Slide 58): http://www.youtube.com/watch?v=xH1CbC4No24
Patrick Stewart (Slide 65): https://www.youtube.com/watch?v=SPzVUGE3dds

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