Bene?ts of Child?Parent for Recovery From Traumatic Loss An Example 0th6 Family?s MICHELLE B. MOORE JOY D. OSOFSKY Louisiana State University Health Sciences Center he Louisiana State University Health Sciences Center, Harris Center for Infant Mental Health, funded by the Irving Harris Foundation and known as the Harris Program, provides mental health services to infants and toddlers from birth to 5 years old. The Harris Program aims to raise awareness of mental health problems that can affect young children and their families as well as to provide prevention, intervention, and treatment services at an early age in order to have a positive impact on development. The program provides training, education, and supervision to predoctoral and postdoctoral child fellows, and social workers in order to increase knowledge among clinicians about ways to treat mental health problems that may arise in young children. The primary treatment modality used in the training program is Child?Parent Lieberman 8: Van Horn, 2005, 2008). CPP was the primary intervention used in the treatment described in this article. CPP is an evidence?based treatment for chil? dren from birth to 6 years old who have been exposed to interpersonal Violence and multi- ple traumatic events. Treatment focuses on improving the relationship between a par- ent or caregiver and young child. The goals of treatment are to strengthen the attachment between the parent (or caregiver) and child, help them regain a sense of safety, and help the child resume a normal developmental tra- jectory. The family learns more about how the child may respond to a traumatic event, including potential changes in behavior, delays in reaching developmental milestones, and inability to regulate emotions. The child together with the parent is given the oppor- tunity to retell their story of the trauma that was experienced through words or in play, using a trauma narrative. Through this ther? apeutic process, an opportunity is provided Abstract Child?parent (CPP) can strengthen the relationship and attachment between caregivers and children. Young children who have experienced multiple traumas, such as the destruction caused by a natu- ral disaster and the sudden. traumatic loss of parents, depend on support of other caregivers for recovery and resil- ience. The case presentation describes the course of CPP for a young child and his maternal aunt who was also impacted by the loss of her sister and brother-in-law. The relationship-based treatment helped the child develop a secure, nurturing relationship with his aunt that gave them both the strength to keep moving forward following their losses. This case illustrates not only ways that young children can recover from trauma, but also the impact that the trauma can have on a family and steps that are needed to support resilience. July 2014 Zero to Three 9 PHOTO: When Hurricane Katrina hit the Gulf Coast in August 2005, the entire community where Sam?s family was living ?ooded. for them to strengthen their relationship with one another (Lieberman 8: Van Horn, 2005, 2008). Presenting Problem A VIETNAMESE and Asian?American boy, was 32 months old (2 years and 8 months) when he was referred to the Harris Program for evaluation and treatment. The referral came from the young child?s day care center and his maternal aunt after Sam witnessed his parents being murdered. Following the loss of his parents, his aunt reported that he had been having dif?culty sleeping at night, had a poor appetite, became withdrawn at day care, and stopped speaking even though he had already developed language skills. His aunt spoke Vietnamese and some English. In initiating the treatment, it was important to be sensitive to issues related to the reluctance of many Asian-Americans to use mental health services because of cultural issues, language barriers, and lack of awareness of resources. Many individuals from Vietnamese communities are reluctant to talk about their personal issues with others outside of their families, preferring to manage mental health concerns inside their own community. Sam had lived with his biological parents and younger sister for the ?rst 21/2 years of his life. Sam?s grandparents and his aunt and uncle lived in their own homes on the same street. The family was very close and enjoyed having dinner together every weekend. The small neighborhood where the family lived was a predominately Catholic Vietnamese ?Name has been changed to protect the anonymity of the patient and his family. 10 Zero to Three July 2014 American community in the eastern part of New Orleans (Leong, Airriess, Li, Chia- Chen Chen, 8: Keith, 2007). When Hurricane Katrina hit the Gulf Coast in August 2005, the entire community where Sam?s family was living ?ooded. Before the hurricane made landfall and the family?s house ?ooded, they evacuated to northern Louisiana. The entire family lost their homes and belongings in the destruction caused by Hurricane Katrina and the breaching of the levees. Vietnamese families were among the ?rst to return to New Orleans and start rebuilding their com- munity. This close?knit community was described as being self-suf?cient and hav? ing hard workers especially in a time of chaos when there were few resources available (Hill, 2006). Sam?s family returned to New Orleans approximately 1 year later and rebuilt their homes in the same neighborhood. They re-established their family business and began to move forward with their lives. After the family returned to New Orleans, Sam began attending a bilingual (Vietnamese and English) Catholic day care center near his neighborhood. About 1 year later, Sam?s mother went out to the grocery store one evening, and Sam stayed at home with his father and baby sis- ter, who was 3 months old. When his mother returned home, she was approached by two men and held at gunpoint while entering her home. The men followed her in the house and shot both of Sam?s parents, but did not harm either child. About 1 hour later, Sam?s grand- father walked down to their home because they had not answered their phone. When he entered the house, Sam was sitting in between his two parents who were lying dead on the ?oor. He was holding their hands, sit- ting silently with tears running down his face and covered in blood. His baby sister was crying, still lying on the bed in the bed- room where she had been having her diaper changed. These murders occurred in conjunc- tion with a series of robberies and homicides that took place over a 2?week period target? ing this particular neighborhood. Community leaders and local police responded to this violence with an increase in police response time and protection for residents (McCarthy, 2007). After his parents? death, Sam?s maternal aunt and uncle were given custody of both children. Sam also spent a lot of time with his maternal grandparents, who lived across the street, and usually slept over at their house. The family still owned the home where Sam?s parents were murdered but they had not returned inside the home since the incident. When Sam asked where his mom and dad were, his aunt would tell him that they were in heaven because that was what they believed based on their culture and religion. Sam?s daily routine remained the same. He continued to attend day care every day for 5 hours. In the classroom, his teachers reported that he had difficulty sitting still and paying attention. When he was redirected, he was able to focus on what the teacher was saying. He often clung to the teacher during the school day. He had dif?culty communicating with his peers, but did have one close friend at school with whom he played regularly. He also appeared to get along well with the other students in the classroom. His teachers reported that he rarely ate his lunch or snack at school. He started receiving speech? language therapy at school when he was 3 years old and was given an individualized education plan because of the sudden onset of delays in his development. He met with a speech therapist once a week and a special educator went to school for 4 hours to provide specialized instruction. In order to learn more about Sam?s life and development prior to the death of his parents, background information was gathered from Sam?s aunt. She reported that she did not have many details about Sam?s birth history. She knew that his mother received prenatal care during her pregnancy and was looking forward to having a baby. Sam was born full? term and weighed 7lbs, 2023. The aunt was not aware of any complications during deliv- ery or in the ?rst few weeks of life. Sam was reported to have a sweet and easy?going tem- perament as a baby. She reported that his developmental milestones were delayed, including walking alone, speaking in single words or phrases, and being toilet trained. However, she was not able to identify speci?c months when these events took place. Sam?s grandparents spoke primarily Vietnamese; however, his aunt, uncle, and cousins spoke some English at home. Sam did not have any signi?cant medical history and was taking medication for allergies. She reported that he had six to eight ear infections before he was 24 months old, but passed all hearing tests. There were no signi?cant prob- lems reported in the family history. Intervention AM WAS REFERRED to the me while I2 was doing my internship. He was 3 years 7 months old when referred following a year of treatment with another intern who was ?nishing her training. CPP was used in order to help Sam and his aunt be able to work together on gaining an understanding and integrating the traumatic events that led up to the referral, and to strengthen the attachment relation- ship between Sam and his new caregiver. It was agreed at the onset of treatment that sessions would take place at Sam?s day care center where the center director spoke Viet- namese and English and was able to translate for Sam?s aunt. With the aunt?s consent, I shared with the director the purpose of treat- ment and potential bene?ts of therapy in an initial meeting with Sam?s aunt. An important aspect of treatment to consider is being sen- sitive to a family?s culture and using support and resources that are familiar to them. In engaging with a family, it is often helpful and leads to greater success for the clinician to consider the current problem in the context of their cultural background and needs of the family (Ippen 8: Lewis, 2011). When Sam ?rst met me, he was slow to warm up and engage with me. His aunt appeared to be at ease with me, but com- munication was often difficult because of language barriers. Sam and his aunt were very quiet during the ?rst few sessions with Sam saying only short phrases or single words when he wanted to communicate. He often pointed to toys that he wanted instead of using words. At the beginning of each session, Sam would greet me when I arrived at his classroom in the day care center. He walked right up to me when he saw me enter and held my hand as we walked together to the library at school where we met his aunt and set up the toys to play. Once Sam became more comfortable in the room with me and his aunt present, he began to explore the toys. He gravitated toward the dollhouse, dolls, and animal ?gures. He generally appeared content while playing with the dolls and dollhouse and was drawn to these toys each week. His aunt sat quietly next him and seemed unsure of how to engage in his 2 Throughout this article, refers to Michelle B. Moore. In engaging with a family, it is often helpful and leads to greater success for the clinician to consider the current problem in the context of their cultural background and needs of the family. play. Several themes emerged in his play. He would set up the furniture and dolls inside the dollhouse and then move on to another toy. The dolls would stay inside the house and very rarely leave the house. One day after all of the dolls and furniture were placed in the house, he had another doll come to the front door of the house. Sam stopped playing suddenly, cleaned up the toys, walked toward the door, and said His aunt walked over to him, gave him a hug, and asked if he wanted to continue playing. Sam continued to stand silently by the door staring outside and did not return to the toys or look back at the dollhouse. Following this session, I provided parental guidance to the aunt, without Sam present, including information about how a child typ- ically reacts to witnessing a traumatic event and also talked to her about her experiences following her sister?s and brother-in-law?s death. His aunt became very emotional when retelling the story of the trauma and expressed the great sadness her entire family felt following their loss. She shared that the family often felt frightened in their neighbor? hood and generally stayed inside their homes. They were unable to move out of the neigh- borhood for lack of ?nancial resources. His aunt expressed a desire to leave the area and the dif?culty of living down the street from the scene of the crime. His aunt reported that Sam asked if he could go inside his house. She was worried that he did not understand that his parents were no longer there. I helped the aunt learn about how young children understand death and how similar questions may emerge as he grows older. About 6 months into treatment, Sam was preparing to celebrate his 4th birthday. He appeared to be very excited about it and told me that he was going to a family?style res? taurant with games and entertainment to celebrate his birthday. At a session after that party, his aunt smiled as she talked about the day they had together and the enjoyment they shared on the outing. His relation- ship with his aunt was strengthening, and he appeared to be feeling more secure with her. Around this point in treatment, Sam began to smile more and make increased contact. His language improved with his vocabulary including words like surprise, Happy Birthday, and pirates. He enjoyed saying ?Happy Birthday? and would have dolls and animal ?gures celebrate birthdays during his play. His aunt seemed more relaxed and was able to enjoy playing with him. Sam wanted to be near his aunt during sessions and would bring books to her for them to read together. They sat together ?ipping through the pages of the book, while they talked about the pictures. For the ?nal 3 months of treatment, ses- sions with Sam and his aunt took place at their home because the day care center was closing for summer break. At this time, the family felt more comfortable with me com? ing to the home. Sam became more active and started to enj 0y building with blocks. He would build towers, knock them down on the ?oor, and laugh. He repeated this activity over and over, and his aunt laughed along with him July 2014 Zero to Three 11 PHOTO: PHOTO: The goals of treatment are to strengthen the attachment between the parent and child, help them regain a sense of safety, and help the child resume a normal developmental trajectory and provided positive responses as he played. He appeared to enjoy this interaction and the time they spent together. One day when I arrived at the home for the session, Sam took my hand and led me to his bedroom. He was eager to show me his toys at home and brought his stuffed animals out for the ses? sion. He gave the animals hugs and passed them to his aunt. When she gave the animals a hug, a huge smile emerged across his face. In the last six to eight sessions, I began to discuss termination of treatment with the family, and his aunt agreed that they were ready for treatment to end. Sam was start- ing kindergarten the next month, and his aunt felt con?dent in her ability to understand his needs and manage his emotions as well as her own feelings following the loss of his parents. During the last few weeks of treat- ment, Sam, his aunt, and I drew a map of the places we had been in treatment together, where Sam would be going to school in the fall, and where I worked. The different places on the map were reviewed each week. Sam Learn More THE NATIONAL CHILD TRAUMATIC STRESS NETWORK RESPONDING To VIOLENCE, DISASTER, AND TRAUMA (2013) Zero to Three, 34 (2). 12 Zero to Three July 2014 learned that even though we would not meet for therapy any longer, we still shared special places together and would always remem? ber each other in the same way that he would always remember his parents. The decision was made to Videotape the second?to?last ses? sion. Sam was given a copy of the tape, so that he could remember the special playtime that was shared. Outcome AM AND HIS aunt were referred for psy- chological evaluation and treatment following the traumatic death of his parents. After Sam witnessed the shooting death of his parents, his aunt, who became his guardian, was concerned about changes in his behaviors and emotions. Sam had dif- ?culty sleeping at night, had a decreased appetite, appeared to be withdrawn, and was not talking as much as he once was. Sam and his aunt began to engage in CPP to help them overcome the loss in their family and to re- establish a sense of safety and nurturance. At the culmination of treatment, Sam?s development and relationships had greatly improved. He was learning new words and using words and sentences to let his fam- ily know what he needed and wanted. He engaged more readily with family mem? bers and classmates, and he was able to sleep through the night in bed by himself. He also shared his feelings openly without being overcome by negative emotions. He pointed to the pictures of his parents on the wall at his aunt and uncle?s home, said ?in heaven,? and smiled. After about 11/2 years of living with his aunt and uncle, Sam started to call his aunt and uncle ?Mom? and ?Dad.? His aunt allowed him to use whatever name felt com- fortable to him and responded when he called her mom. Sam?s aunt expressed her gratitude to me, and to the Harris Program that allowed her to receive treatment with her nephew in a familiar, comfortable environment for her family. Lessons Learned HE FAMILY HAD never sought out I mental health treatment before and had previously handled any problems that had arisen within their own family system. This reaction is common in the Asian- American culture where seeking out mental health treatment is atypical for a family (Meyers, 2006). The maternal aunt, who became the guardian for both of the children, bene?ted greatly from having an opportunity to share her reactions to the traumatic event in a safe and supportive environment. She cried as she told her experience of the event, and she reported that her family very rarely talked about what happened. She shared a sense of relief and appreciation at the end of treatment in being more prepared and capable to raise her nephew and niece. She felt con?dent that they were all going to be okay and be able to move forward in their lives following the losses they had experienced. As a professional, I learned a great deal from this family. I was introduced to the Vietnamese culture in a new way through this therapeutic work and felt accepted coming from a different culture. I also learned ?rst? hand what Vicarious trauma feels like and appreciated the support of my supervisor and team during this experience. Vicarious trauma can be experienced by mental health professionals when working with Victims of trauma where they begin to experience intense emotions, ?ashbacks, feelings of panic, and other that are similar to what the victim of trauma may have experi- enced (Osofsky, 2011; Pearlman 8c Saakvitne, 1995). At the end of treatment when sessions took place at Sam?s aunt?s home, Iwoke up one night with a nightmare. I found myself crouched on the side of my bed in a panic. I had been experiencing a nightmare that someone was in my house, had shot my hus? band in the living room, and was coming down my hallway with a gun. My breath was shallow, my heart was racing, and I felt panic racing through my body. It took a few minutes to calm myself down and to realize that it was just a dream. Later that day, I understood that I was reliving this family?s trauma and had not been able to acknowledge how intense the treatment with this family had been for me as a intern, especially when sessions were taking place on the same street where the murders happened. I shared the expe- rience with my supervisor, who helped me to further process this trauma and the sub- sequent emotions I was experiencing. This experience reminded me of the importance of self-care, supervision, and consultation with colleagues when working with trauma survivors. From this case I learned the impor? tance of acknowledging when treatment can become overwhelming and when, as a thera? pist, I need support to be a better therapist for my patients. MICHELLE B. MOORE, PsyD, is a clinical and clinical assistant professor of at Louisiana State University Health Sciences Center (LS UHS C). Dr. Moore is currently providing therapeutic services in schools and federally quali?ed health centers to children and families in underserved communities around the New Orleans metro area. She received her specialization in infant mental health while training at the LS UHSC Harris Infant Mental Health Program. She continues to offer training and supervision to interns and residents who work with young children who have been exposed to trauma. JOY D. OSOFSKY, is a clinical and developmental and Barbara Lemann Professor in the Departments of Pediatrics and at Louisiana State University Health Sciences Center (LS UHS C) in New Orleans. Dr. Osofsky is head of the Division of Pediatric Mental Health; director of the LS UHSC Early Trauma Treatment Network site, a center in the National Child Traumatic Stress Network,- and director of the LS UHSC Harris Program for Infant Mental Health. She is editor of numerous publications and nationally recognized and awarded for her work in mental health following Hurricane Katrina. She has served as president of ZERO TO THREE and president of the World Association for InfantMental Health. Dr. Osofsky conducts research, intervention, and clinical work with infants, children, and families exposed to trauma as a result of abuse and neglect, community and domestic violence, disasters, and military deployment, and she consults nationally and internationally in these areas. References HILL, L. (2006, January 23). The miracle of Versailles: New Orleans Vietnamese American community rebuilds. New Orleans Louisiana Weekly. IPPEN, C. G., 8: LEWIS, M. L. (2011). ?They just don?t get it:? A diversity-informed approach to understanding engagement. In J. Osofsky (Ed) Clinical work with traumatized young children (pp. 31?52). New York, NY: Guilford. LEONG, K. ., AIRRIESS, C. A., 8c M. (2007). Resilient history and the rebuilding of a community: The Vietnamese American community in New Orleans East. Journal of American History, 94, 77o?779. F., 8: VAN HORN, P. (2005). ?Don?t hit my mommy! manual for child?parent with young witnesses of family violence. Washington, DC: ZERO TO THREE. LIEBERMAN, A. F., 8: VAN HORN, P. (2008). with infants and young children: Repairing the e?"ects of stress and trauma on early attachment. New York, NY: Guilford. MCCARTHY, B. (2007, August 26). Gunmen kill two in home invasion: Five others hurt in attack in reeling Eastern NO. The New Orleans Times-Picayune. Retrieved from MEYERS, L. (2006). Asian?American mental health. Monitor on 37(2), 44. OSOFSKY, J. D. (2011). Vicarious traumatization and the need for self?care in working with traumatized young children. In J. Osofsky (Ed) Clinical work with traumatized young children (pp. 336?348). New York, NY Guilford. PEARLMAN, L. A., 8: SAAKVITNE, K. W. (1995). Trauma and the therapist: Countertransference and vicarious traumatization in with incest survivors. New York, Y: Norton. July 2014 Zero to Three 13 Standing Shoulder to Shoulder With Parents in the Criminal Justice System Advocacy as a Bridge to Understanding and Engagement JACKIE SCHALIT RASHAWNDA LEE-HACKETT BARBARA IVINS UCSF Benioff Children?s Hospital Oakland (California) 1 first met Sean?s mom, Nicole, in a small classroom at Santa Rita County Jail in Dublin, California, where she had been incarcerated for 4 months. After hearing about Families in Recovery program (FIRST) within the Early Intervention Services Department at UCSF Benioff Children?s Hospital Oakland, in her parenting class, she reached out for help for her 5?year-old son. Because the FIRST program has an ongoing collaboration With some of the programs at the jail, I could respond quickly and on site. From the moment Nicole and I began talking, a sea of sorrow opened up for this mother. As she cried, she shared the fact that, midway through Sean?s kindergarten year, he was already being seen by the school as a ?problem?; ?ghting with peers and having major tantrums in class. She said that the school?s idea of ?intervention? was to suspend him and send him home. Nicole knew that this was not right and wanted to receive actual help for her son. She spoke of feeling helpless in jail, as she tried to parent ?from the inside,? and she was worried about the strain on her husband and mother, who were parenting all four of her children (who were 3, 5, 8, and 9 years old) on the outside. Nicole and her husband, Kevin, both African American, had been married for 14 years and were a strong family unit, even though both of them had previously been incarcerated. Nicole was Willing to try therapy, although no one in her family had done so before, because she was desperate for help. By the time I met Nicole, I had grown accustomed to the complexity and challenges of working with families Who were directly affected by the trauma of incarceration. I had been working with the FIRST program since its inception 9 years earlier. The FIRST program, part of the Early Intervention 1 Throughout this article, refers to Jackie Schalit, primary therapist. Rashau/nda Lee-Hackett was the family partner involved, and Barbara Ivins was the consultant. 14 Zero to Three July 2014 Services unit at UCSF Benioff Children?s Hospital Oakland, is committed to serving the hardest?to?reach families?that is, those affected by substance abuse and incarceration and, often, those involved with multiple law enforcement systems, including the criminal justice and child welfare systems. Trauma in these families takes many forms? witnessing parental arrest, experiencing frequent disruptions of family relationships and subsequent transient and unstable living circumstances, exposure to punitive or harsh treatment at the hands of law enforcement, and observing (or, even, being the Victims of Violence in the community. Dif?culties at home and at school are commonplace, and the need for repairing ruptured relationships is often critical. In that ?rst visit at Santa Rita County Jail, Nicole and I addressed Sean?s birth history, early experiences, and the important ?ports Abstract For many hard-to-reach families who have experienced trauma in part related to involvement with public welfare institutions, creating a trusting relationship is the critical first step to finding ports of entry for additional intervention. In particular, parents who have been incarcerated are often profiled and stigmatized by criminal justice and law enforcement systems, which view them only as criminals without seeing their as caring parents. Using a case description, the authors highlight ways in which advocacy across systems and collaboration with a family partner formed a bridge for engagement and treatment.