Tag Archives: Joy Osofsky

Day 2 of Joy Osofsky at IPMH

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The following day Joy Osofsky talked about trauma. She outlined ways in which children can be traumatized by adverse childhood experiences as noted in the “ACE” study, in the 1990’s, . She talked about how trauma affects children’s cognition, behaviors, emotions, and brain architecture. Finally, she described several ways traumatic sequelae can be healed. I would like to think of these issues in terms of a spectrum from normative stress, which can be positive, to trauma, with “tolerable” and “toxic stress” in the middle. I will explain more about this spectrum later on, but I want to introduce the idea of a spectrum of stress at this point, because I believe that much of what Joy was talking about in terms of trauma can also be true in situations of high stress – especially when it is prolonged – that do not reach the level of actual trauma.

Children are traumatized by child maltreatment; exposure to community violence in their neighborhoods and in their schools; exposure to domestic violence in their homes; exposure to or hearing about unusual traumatic events such as accidents, terrorist attacks, or hurricanes; military children when their parents are deployed; and exposure to violence in media (usually the effects of an earlier trauma will be exacerbated by subsequent exposure to media).

Joy and her husband were leaders in the psychological response to Katrina in New Orleans. She notes that the psychosocial impact of natural disasters can be similar to that of trauma. The impact is related to the disruption of family structures, changes in the ways people and communities relate to each other, and the taxing effect on the individual, family, school, and community infrastructure. The psychological referral rate for students was very high after Katrina and then declined, but subsequent smaller spikes seem to reflect retraumatization from other hurricanes, oil spills, etc. A child in my hospital clinic began waking up with nightmares after hearing Donald Trump on television saying that all Mexican immigrants should be deported, because she feared that she would lose her parents.

Interestingly, in New Orleans, the children who were integrated into East Baton Rouge schools had higher depression rates than the children who were able to return to their New Orleans schools. This seems to relate to the importance of a “sense of place”. Another window into trauma is the child welfare system, where children have experienced family violence, substance abuse, sexual abuse, removal from primary caregiver, subsequent placement in foster care, and physical abuse.

Trauma alters the developmental trajectory of the child. Joy referred to the children’s book, The Little Engine That Could. She said that trauma pushes the train off the track, and our job as mental health professionals is to help put the little train back on the track. Joy noted the continuum from stress to trauma, starting with normative, developmentally appropriate stress, then emotionally costly stress, sometimes called “toxic stress”, and finally trauma. Positive stress is necessary to healthy development. It occurs in the context of stable, supportive relationships and results in brief increases in heart rate and mild changes in stress hormone levels. Tolerable stress includes stress responses that could disrupt brain architecture but are buffered by supportive relationships that make it possible for the brain to heal. Toxic stress involves a strong, prolonged activation of the body’s stress response system in the absence of the buffering protection of adult support. Toxic stress can damage the developing brain architecture and create a short fuse for the body’s stress response systems, leading to lifelong problems in learning, behavior, and both physical and mental health.

IPMH Joy Osofsky Weekend

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I am catching up on my infant parent postings by writing about a wonderful weekend with Joy Osofsky last month. In her first day of her teaching Joy began by introducing us to three evidence based interventions for very young children – Attachment and Bio-behavioral Catch-up (ABC),  Parent Child Interaction Therapy (PCIT), and Child-Parent Psychotherapy (CPP),  Although not exclusively used for this purpose, these interventions were designed to treat traumatized young children and their parents.

ABC is an intervention for parents of young children who have experienced adversity that helps parents recognize their children’s problematic coping strategies and recognize their own problematic parenting behaviors, so that they can create a caregiving environment that promotes their children’s bio-behavioral regulation. The intervention takes place in 10 sessions that target key issues for traumatized children and is manualized, though the relationship between the clinician and the parent is crucial to the success of the treatment. This intervention is particularly useful for foster parents of infants of toddlers 1-3-years old, high risk birth parents of infants and toddlers, and parents adopting internationally.

Two main emphases of ABC intervention are that (1) some children reject their caregivers even though they need nurturance, and (2) parents can sometimes behave in ways that frighten children, often without realizing it. When traumatized children behave in rejecting ways, their parents must learn to re-interpret their signals so that they can respond to them with effective nurturance. Also, parents who have been traumatized or frightened as young children will sometimes display an angry or frightened face to their child or even “tune out” (“dissociate”) in a way that may frighten a child. Parents with troubled past histories may also misinterpret their children’s expressions of distress and fail to respond in a comforting way. This intervention teaches parents to recognize patterns such as these in their own behavior and in that of their children so that they can learn optimal patterns of parenting behavior. These optimal behaviors include following the child’s lead with delight, attending to the child’s signals, supporting the child’s agency, and the importance of touch.

An interesting feature of this intervention is that of encouraging the parent to provide nurturance even if it doesn’t come naturally – “fake it until you make it”, as I say. We know that practicing a behavior can build new neural circuits in the brain, and ABC attempts to override the parents’ own problematic tendencies by building good nurturing behaviors that are practiced and reinforced in the relationship with the clinician. In this intervention, the parent’s problematic past is directly addressed as it is currently represented in the parent’s behavior towards her child.

PCIT is an intervention in which the clinician behind a two-way mirror coaches the parent through a bug in the parent’s ear. This is a strictly behavioral approach that incudes elements of family systems theory, learning theory, and traditional play therapy. The emphasis is on restructuring parent-child patterns, rather than modifying target behaviors. PCIT is designed to be most effective in treating disruptive behaviors. In this intervention, parents are not blamed but are given responsibility for improving their child’s behavior.

Decisions about family preservation, reunification, or permanency need to be made prior to beginning a course of PCIT, which takes place in 14-21 weekly sessions. Some of the limitations of PCIT are that it focuses on the child’s behavioral problems and parent skills but not on domestic violence, substance abuse, or parent psychopathology.

The third intervention, CPP, focuses on current stress and trauma as well as “ghosts from the nursery” in the past of the parents. This phrase is the title of a famous paper by Selma Fraiberg, a pioneer of parent-infant mental health and refers to traumatic experiences in the parents’ past that haunt them when they become parents themselves (Fraiberg, Adelson, & Shapiro, 1987). This intervention is also manualized and multi-theoretical.
The intervention uses play, physical contact, and language to further the child’s development. Symbolic play is used to create a “trauma narrative”. Games are used to help with emotional and physical regulation – such as blowing, patting, and breathing games. Mazes and other games are used to help a child gain a sense of his body in space, and touch is used to restore trust in physical contact. Another way of describing this intervention is that it is a combination of play and “unstructured developmental guidance”. Important feature of this guidance are to help the parent understand appropriate developmental expectations of their young child and to help both parent and child name and cope with strong feelings. In addition to modeling good parenting behaviors and offering concrete assistance, such as with safe housing, the clinician makes interpretations linking present to past and distant past, “ghosts in the nursery”. These interpretations create the “trauma narrative”.

An interesting and I think important study of the factors disrupting and facilitating emotion regulation is being conducted by a group in New York and Geneva. They suggest that the child’s helplessness, fear, and rage can elicit traumatic memory traces in the mother with PTSD (“ghosts in the nursery”) and propose to help the mother change her behavior in a similar way to the ABC protocol but with videotape feedback. Since I am familiar with videotape feedback and a big believer in its effectiveness, I am awaiting the results of this study with anticipation (Schachter and Rusconi Serpa, 2014).
Fraiberg, S., Adelson, E., & Shapiro, V. (1987). Ghosts in the nursery: A psychoanalytic approach to the problems of impaired infant– mother relationships. In S. Fraiberg (Ed.), Selected writings of Selma Fraiberg (pp. 101–136). Columbus: Ohio State University Press.

Schechter D, Rusconi Serpa S (2014). Understanding how traumatized mothers process their toddlers’ affective communication under stress: towards preventive intervention for families at high risk for intergenerational violence, in R Emde and M Leuzinger-Bohleber, Eds., Early Parenting and Prevention of Disorder, Karnac Press, pp. 90-117.

 

Helping a Child Manage Violent Events

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As promised, I have given more thought to the question of what to tell children about the recent tragic events in Boston. I have talked to teachers and other clinicians and listened to children and read information on the Internet and in published material. One of the good things I read was the American Academy of Child and Adolescent Psychiatry guidelines on talking to children about terrorism and war. http://www.aacap.org/cs/root/facts_for_families/talking_to_children_about_terrorism_and_war. Another is an excellent link provided by Dr. Heidi Ellis from Boston Children’s Hospital –
http://www.nctsn.org/content/pfa-mobile

In general, sensible guidelines for helping children through these troubled times include talking to children about the events, communicating comfort with emotions about the events (both child’s emotions and parents’ emotions), and emphasizing safety.

First, the talking: Talking can be very helpful, but only in the child’s own “language” and time frame. Too much talking can be at best confusing to children and at worst can be alarming. It is of course essential to speak in words the child can understand. Discussing frightening events is best done at the initiation of the child, usually in response to his questions. The rule of thumb I usually use is to answer the child’s question briefly and without elaboration, then stop. If the child wants to know more, she will ask. Moving back and forth in this turn taking rhythm gives the child the chance to feel adaptively in control of the information gathering, to find the answers he or she needs and to avoid unnecessarily alarming or confusing information. A 9-year old boy, hunched over a video game told me in response to my simple question about his experience of the attack, “When bad things happen, I just don’t pay attention and wait for them to go away.” When I did not challenge him, he later told me about how some kids in his class were scared and talked a lot about the attack and its aftermath.

It is also important to remember that you do not have to answer all your child’s questions. Repetitive questions can often indicate the child’s wish for reassurance about safety more than his desire for specific answers. Instead of responding concretely to a question about the type of weapon used, for example, the parent may instead say something like, “What I do know is that the policemen are working hard to find out the information they need to protect us.” (Now some parents will insist that their child will “not let them get away with” an indirect answer like that. What I would say about this is that the child is trying to find reassurance in what seems like an out of control world through controlling the parent with his questioning, and in the long run a calm parent who declines to answer the questions he thinks inappropriate will make the child feel safer.)

Children also give other cues besides questions to communicate their concerns. For example, a young child may tell a parent that he had a scary dream, or an older child may say that she feels like staying home from school that day. In these cases, the parent may choose to ask about the dream or the child’s wish to stay home from school without bringing up the event specifically. Or, the parent may say something about the dream or the wish to stay home reminding them of the scary event. “Your scary dream reminded me of the scary things that happened in Boston yesterday,” or “Your not wanting to go to school reminds me of how I don’t want to go to work today after all the frightening things that have been going on!” In both cases, the parent isn’t pressuring the child to “take on” the frightening thoughts but joining the child in her concerns. It is important to hang around, to be available to talk. Tell the truth because child will know if you are being dishonest. Be prepared to answer questions multiple times in different ways, since children put together information in bits and pieces depending on the context and on their mood and state of concentration. This is different from the perseverative questioning I mentioned before.

Second, communicating comfort about emotions: All children – young and older –respond not only to the frightening event but also to the emotions of the people around them. Remember that a picture is worth a thousand words, so that the image of a parent’s anguished face will tell a child more than her reassuring words. It is important for parents to take care of their own emotions first in order to prepare themselves to be available to their child, just as the flight crew tells you to put the oxygen mask on your own face first and then on the child’s, in case of an emergency on an airplane. When your own feelings are under control, acknowledge them – fear, anger, sadness.

Children may tend to revert to earlier behaviors in response to frightening events, just as they do after other stresses. For example, when I went into a classroom yesterday morning, one 3-year old boy that I know well greeted me with baby talk. Of course, his affectation may not have been directly related to the crisis. Still, given the context of current events, it occurred to me that his baby talk might have been a response to fears about those events, and that awareness alerted me to the state of his mind on that day. In another classroom, two 5-year old boys at the lunch leaned in towards me when a third boy brought up the subject of the bombings. All children need and deserve extra tolerance and comfort in times of crisis.

Children will respond differently to frightening events, depending on their unique circumstances and personalities. Kids whose parents are separating, children who have had a recent move or other transition, or children who have lost a relative or friend, would be expected to react more strongly to danger in their environment.

Finally, emphasizing safety. Parents can stress safety by containing the stimulation of television, radio, and adult conversations. Remember that when children are anxious they listen more carefully to communication that is intended to be for adults alone. Limit the amount of television in the home at these times, and if you turn on the t.v., watch it with your children so that you can help them make sense of what is being broadcast.

They can support a feeling of security by maintaining comforting routines at home and in school. After Katrina, one of the first acts taken by Joy and Howard Osofsky in their rescue efforts was to create a school for the displaced children (Joy Osofsky, Personal Communication, 2010).

Parents can also help their child feel secure by scaffolding the child’s own efforts to create a feeling of safety. Some children will want to play firefighters or choose rescue vehicles instead of the usual racing cars or trucks. In a 3-year old classroom today, the children were playing with rescue vehicles, making them so strong and magical that they could fly through the air to rescue people. No explicit mention was made of the bombing, but the children could in their play experience an enhanced sense of their own strength and master that will protect them against some of the adverse effects of traumatic events. Older children may want to make some kind of restitutive action such as writing letters or giving gifts to the first responders. Regardless of how unrealistic the child’s ideas might be, parents should treat them with respect. One 5-year old boy told me Monday that he had a plan to throw blueberries at the bad guys, and I just nodded with interest.

 

 

 

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Joy Osofsky, IPMH Weekend March 1-2

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It is always a pleasure to have Dr. Joy Osofky present her work in the IPMH program. Her work identifying ways to assess and treat traumatized children has made her a pioneer in the field of child and infant mental health. This time, I found her video demonstrations of preparing families for reunification after separation due to domestic violence riveting.

The first video was of a child who was present when her father violently attacked her mother. The mother and father were both only 20-years old. The mother, who is intellectually challenged and illiterate, had had five pregnancies; the child in the video was the product of the fifth. There is an older brother who is the son of another father, and there were three miscarriages. The father was in trouble with the law since adolescence. When the baby was 2-months old, the father became upset with the mother, beat her, choked her, put her head into the wall, and threw her down the stairs. The father threw the baby out of the way. He went to jail as a consequence of this abuse.

During the time the father was in jail, Joy’s team worked with the mother and baby. The father finally realized his need for help, and he began individual psychotherapy. Then the child was introduced into his psychotherapy, and infant parent psychotherapy was begun. Finally, there were family sessions.

The video showed mother, little girl (now about 11-months), and mother’s sister. The child’s development was pretty much normal. She was content and exploring the toys, warmly engaged with her aunt. She was trying out language. She was not doing a lot of social referencing, though.

The issue of diagnosing PTSD in a child of this age was discussed. This child did meet the criteria in that she had sleep problems, other regulation problems, hypervigilance, and avoidance. We wondered if this were enough. We also wondered if the mother’s presence might reactivate her, since the mother failed to protect her from the father’s violence. It is true that we have good evidence of the memory of events and objects, starting at 4-months. Ed’s study is confirming that fact. If the memory is of domestic violence, and the events of domestic violence are repetitive, one would expect the baby to remember. However, this memory is not brain-localized memory. When terrible events occur in early life when the stress regulatory system is developing, the “memory” is a regulatory problem. The issue of memory is much more complicated when the memories are of events in the caregiving system. For example, in the tape that Joy showed earlier in the day, the mother of an 11-month old beat her, and the baby’s trauma was related not just to the events, but also to the intermediate time when the mother was not being physically abusive, but her care of the baby was inadequate.

Next we saw a video of the child with her father. We saw the first encounter with the father after his incarceration. In the film, she is on his knee and is screaming. We wondered if she were screaming because she remembered the violent attack, or if she were screaming because he was a stranger to her. Ed is doing a study on 4-month olds and the still face. Neurophysiology suggests that there are areas of the brain that are more sensitive to people than to objects. One of the group commented that the therapist might have intervened to calm the distress of the child, for the sake of the parent-child relationship. When the father leaned over to get a new toy, the baby stopped crying temporarily. Then he took her down from his lap, and she turned towards him and reached out her arms.

In another session, the mother entered and she greeted the baby with a big grin. The therapist tried to hand the baby to the mother, but the baby turned away from the mother back to the therapist. We talked about what the therapist might do at this point. We thought the therapist could speak for the baby, “She is not quite ready yet.” Or you could have the baby play with the therapist and check on the mother until she felt the mother was safe. In this session, the father then came into the room. The baby looked interested but pulled close to the therapist. At the time of this session, the baby was living in a good foster home, but the team was working towards reunification. The therapist asks, “Where is Mommy’s nose?” “Where is Daddy’s nose?” The baby points. Then the therapist puts the baby on the couch next to the mother but not in the mother’s lap. The baby looks after the therapist when she goes to another part of the room. The therapist says, “Dad’s doing a really nice job of letting her get readjusted. Takes her a little bit of time, all these transitions. If you let her go at her own pace … “ Then, while the mother is showing the baby her cell phone and its ring, the therapist goes out of the room to get her toys. Berry Brazelton, present at the discussion, said that he wished the therapist had not defused the situation, so that the parents could be helped to understand what was going on with the baby. For example, the baby is able to get interested in a non-human object, which is less stressful for her than a person. The therapist could help the parents understand that. Berry pointed to the fact that there is no substitute for observing behavior. He added that “the ability to observe and describe to the parents” what the baby’s feelings and intentions are, is a powerful tool. When the therapist went out of the room the second time, the father pretended to eat the baby’s hand, and she laughed. The baby looked much more comfortable. Finally, she wanted to get down on the floor to explore the toys.

In a session soon afterwards, the she leans towards her father and gives him a toy, then gives her mother a toy. The therapist narrates, “Show Daddy. Here, Dad!” The family was eventually reunited. A question from the group asked about prenatal identification of abused or neglected women and their partners so that it might be possible to intervene earlier. Joy mentioned David Old’s “Healthy Families” program. At the time of the birth evaluation, women are offered services.

Joy then talked about “Child-Parent Psychotherapy”, a psychodynamic psychotherapy that has been practiced and studied by Lieberman and Ciccetti, who have demonstrated good evidence of its effectiveness (Osofsky & Lieberman, 2011). CPP aims first of all to help parents to understand how to make appropriate developmental expectations of young children. It also helps parents to help their children name and cope with strong feelings. The group discussed issues related to CPP. For example, how does a therapist deal with the parents’ custom of physical discipline. CPP is not a guidance method, so the therapist would not be expected to tell the parents to not do something. Sometimes physical discipline may be a case of repressed or isolated affect in the parents. In other words, the parent may be angry at the child and unaware of that anger; then she may think she is making a rational decision to spank the child without knowing that she desires to hit him. Physical discipline may also be a learned problem solving behavior on the part f the parents. It may be a cultural issue. It may be related to mental illness (of the parent). The therapist takes all these possibilities into account when considering how to intervene in this situation.

One of the goals of therapy for traumatized children in Joy’s program is to develop a “trauma narrative” that puts the trauma into an acceptable perspective for the child. In her program they use video tapes to help the parents understand their child. For example, they use them to explain to the parents about the child’s sensitivity to sensory stimuli such as noise or lights. Joy is always looking for a “port of entry” into the caregiving relationship. She keeps her eye on the way affect is experienced and expressed in the family and how the family deals with it. What is the range of affect? How does the family achieve and maintain regular and sufficient but not extreme levels of affective arousal? How does the family help the baby establish trust in bodily sensations, so that the child can tell when he is hot or cold, hungry or full, or has to go to the bathroom? She uses the differentiation between “repeating” and “remembering”.

Another goal of the therapy is for the child to develop an increased capacity to respond realistically to threat instead of persisting in reacting with traumatic responses. In one of her examples, the 4-yo child was present when the mother went after the father with a knife. In the therapy session, the child brought a dream about a knife and daddy. The mother froze, but the therapist knew the story of what had happened. The therapist reached out to the mother and asked what she thought of the child’s dream. The mother said she remembered something she had told her about the knife and the dad, but that she did not want to talk about it. The mother had a hard time but finally was able talk to her child about how she had picked up the knife and threatened the father. The mother told the child that she did see this happen and the mother could see how this might have frightened the her. She said, “I was very angry at your Daddy.” The child said, “Maybe you would be very angry at me.” The mother responded, “No, no, I would never do that to you.”

Joy stressed the point that the central principle of intervention in CPP is that no matter which port of entry, modality, or domain you choose, you never intervene without considering the impact of your intervention on both members of the dyad. Outside of this central principal, the method is very flexible. Often you must work with one parent and child and then the other parent and child until you can work with both parents and the child. Joy reminded us that it is the parent who has the rightful place as the child’s guide through life and through this trauma. Your job is to facilitate the parent’s confident assumption of that role.

This reminder stirred in my mind thoughts of the orphanage in El Salvador. Whereas I appreciate the fact that the Salvadoran government implemented the law of LEPINA without offering the families any of the supports that the families in Joy’s program are being offered, I am not entirely convinced about “the parent’s rightful place”. Instead, I have come to believe that some parents are not capable – or will not be capable within the requisite amount of time – to protect and nurture their children, and that the children should not be left in their care. In some cases, attempts should be made to help the parents to change, but in others I believe that such attempts would be futile. That does not mean that the children would never see their parents (though in some cases even visits may retraumatize the child) nor have a relationship with them, but it means that the biological parents would never again have the role of nurturer and protector. Perhaps in these cases, if the parents were available to participate in such an intervention, the most therapeutic approach would be meetings in which both parents and children would be helped to deal with the anger and disappointment in one another and to grieve the loss of their family as able to provide a secure home.

Osofsky J & Lieberman A (eds.) (2011). Clinical Work with Traumatized Young Children. New York:The Guildord Press.