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Supporting Children & Supporting Children & Families in the Face of Families in the Face of TraumaTraumaCatherine Ayoub, Ed.D.Catherine Ayoub, Ed.D.
September 2006September 2006
Thanks to Kurt Fischer, Gabrielle Schlichtmann, Erin Thanks to Kurt Fischer, Gabrielle Schlichtmann, Erin O’Connor, O’Connor,
Elizabeth Nelson, Pamela Raya, Claire Russell, William Elizabeth Nelson, Pamela Raya, Claire Russell, William Beardslee, Beardslee,
Mary Watson Avery, Caroline Watts, & Donald Pfieffer Mary Watson Avery, Caroline Watts, & Donald Pfieffer
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Developmental ProcessesDevelopmental Processes (Erikson, & Piaget) (Erikson, & Piaget)
Trust v. MistrustTrust v. Mistrust Autonomy v. Shame and DoubtAutonomy v. Shame and Doubt Industry v. InferiorityIndustry v. Inferiority Identity v. identity diffusionIdentity v. identity diffusion
Sensory motorSensory motor Pre-operationalPre-operational Concrete OperationsConcrete Operations Formal OperationsFormal Operations
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Positivity Bias & Natural Positivity Bias & Natural Integrative Cognitive ProcessesIntegrative Cognitive Processes I am safe & nurturedI am safe & nurtured The world is safe & nurturingThe world is safe & nurturing Others are good so they will be good to Others are good so they will be good to
me.me. I am goodI am good
I can make connections & delineate I can make connections & delineate details in more complex ways as I grow.details in more complex ways as I grow.
I will connect the development strands I will connect the development strands of my domain-specific knowledge of my domain-specific knowledge
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Trauma is like a Trauma is like a Hole in the WorldHole in the World
In & out of that hole – In & out of that hole – anything goesanything goes
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Definition: Definition: Childhood TraumaChildhood Trauma
The mental result of one sudden The mental result of one sudden external blow or a series of external blow or a series of
blows, rendering the young child blows, rendering the young child temporarily helpless and temporarily helpless and
breaking past ordinary coping breaking past ordinary coping and defensive operationsand defensive operations
(Terr, 1991).(Terr, 1991).
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Trauma Types Trauma Types (Lenore Terr, 1991)(Lenore Terr, 1991)
Type I TraumaType I Trauma:: Single, traumatic event; Single, traumatic event; More often associated with acute post- More often associated with acute post- traumatic stress disorder symptomstraumatic stress disorder symptoms
Type II TraumaType II Trauma: Prolonged, repeated : Prolonged, repeated Trauma; more often associated with Trauma; more often associated with complex PTSD & characterological complex PTSD & characterological changes changes
Cross over TraumaCross over Trauma:: Single event so Single event so powerful that it results in the effects of powerful that it results in the effects of Type IIType II
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Response to Response to Childhood TraumaChildhood Trauma
Attempt to regain masteryAttempt to regain mastery & & controlcontrol..
AdaptiveAdaptive & & accommodating accommodating reactionreaction to loss of control to loss of control
ResponseResponse is conceptualized & is conceptualized & incorporated within the child's incorporated within the child's
cognitive & self structures cognitive & self structures (Ayoub, Fischer (Ayoub, Fischer & O’Connor, 2003).& O’Connor, 2003).
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TRAUMA SPECIFIC RESPONSESTRAUMA SPECIFIC RESPONSES Disruption in safety & trust (worldview)Disruption in safety & trust (worldview)
Disruption in attachments/relationshipsDisruption in attachments/relationships
Alternative cognitive schemas (thinking) Alternative cognitive schemas (thinking)
Altered emotional responsiveness Altered emotional responsiveness (feeling)(feeling)
Fragmentation of self system (self Fragmentation of self system (self perception, memory) perception, memory)
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ATTITUDES & BELIEFSATTITUDES & BELIEFS The World is ThreateningThe World is Threatening
I Cannot really Be Loved I Cannot really Be Loved
I Deserve My Life Because I was BadI Deserve My Life Because I was Bad
It is ALWAYS/NEVER My faultIt is ALWAYS/NEVER My fault
I Will NEVER/ALWAYS SucceedI Will NEVER/ALWAYS Succeed
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Two Fundamental Two Fundamental Developmental ChangesDevelopmental Changes
Malignant feelings of inner badness
Positive vs. negative
Basic fractionation/fragmentation of self & others
Dissociation, splitting & polarization
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Disorganized Attachment Disorganized Attachment asas
Trauma Dance Trauma Dance
Adaptive fight, flight, freeze in Adaptive fight, flight, freeze in response to traumaresponse to trauma
From approach avoidance toFrom approach avoidance to– Control through aggressionControl through aggression– Control through nurturing Control through nurturing
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Impact of TraumaImpact of TraumaDoes not result in Does not result in delay or fixationdelay or fixation of of developmental developmental processesprocesses
Fundamentally Fundamentally altersalters social-emotional social-emotional developmentdevelopment & leads to & leads to alternative alternative developmental developmental pathwayspathways
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Dysfunctional Dysfunctional Developmental Developmental
PathwaysPathwaysA different but consistent pattern of A different but consistent pattern of
developmental integration that developmental integration that becomes increasingly complex as becomes increasingly complex as the individual gains cognitive skills the individual gains cognitive skills
over time.over time.
Pathways are often called deviant, Pathways are often called deviant, psychopathological, or alternative.psychopathological, or alternative.
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Early Development & Early Development & Trauma ResponsesTrauma Responses
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INFANT DEVELOPMENTINFANT DEVELOPMENT1. Sensorimotor understanding of 1. Sensorimotor understanding of
the worldthe world
2. Somatic memory2. Somatic memory
3. Functional affective system3. Functional affective system
4. Dependent upon others for 4. Dependent upon others for regulatory functioningregulatory functioning
No capacity to store memories No capacity to store memories to be retrieved in chronological to be retrieved in chronological sequence or even in a present sequence or even in a present oriented "picture " form. oriented "picture " form. Therefore cannot integrate Therefore cannot integrate trauma & "play it out“.trauma & "play it out“.
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TASKS OF INFANCYTASKS OF INFANCYEstablish trust In:Establish trust In:
PHYSICAL PHYSICAL EMOTIONAL/TOUCHEMOTIONAL/TOUCH
Self-regulation of:Self-regulation of:AFFECTAFFECTPHYSICAL FUNCTIONINGPHYSICAL FUNCTIONING
Attachments:Attachments:SELF/OTHER SELF/OTHER RELATIONSHIPSRELATIONSHIPS
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DEVELOPMENT OF EMOTIONDEVELOPMENT OF EMOTION
Early object relations directly Early object relations directly influence the emergence of the influence the emergence of the frontolimbic system in the right frontolimbic system in the right
hemispherehemisphere
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MILESTONES IN MEMORY MILESTONES IN MEMORY DEVELOPMENTDEVELOPMENT
MYELINATION FOR LONG TERM MEMORY ENCODING AT 9 MONTHS.
REPRESENTATIONAL COGNITION AT 14-18 MONTHS
LANGUAGE BASED EXPLICIT MEMORY AT 2 YEARS
AUTOBIOGRAPHICAL MEMORY – 3 YEARS (I STORIES)
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NARRATIVE /DECLARATORY/EXPLICIT NARRATIVE /DECLARATORY/EXPLICIT MEMORY = SPOKEN OR BEHAVIORAL MEMORY = SPOKEN OR BEHAVIORAL MEMORY OF THINKING/CONSCIOUS MEMORY OF THINKING/CONSCIOUS EVENTS EVENTS
VERSUSVERSUS
IMPLICIT MEMORY = SKILLS, HABITS, IMPLICIT MEMORY = SKILLS, HABITS, EMOTIONAL RESPONSES, REFLEXIVE EMOTIONAL RESPONSES, REFLEXIVE ACTIONS, CLASSICALLY ACTIONS, CLASSICALLY CONDITIONED RESPONSESCONDITIONED RESPONSES
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TRAUMA RESPONSES IN TRAUMA RESPONSES IN INFANCYINFANCY
MOTOR & PERCEPTUAL MOTOR & PERCEPTUAL WITHDRAWLWITHDRAWL
AVOID INTERACTIONSAVOID INTERACTIONS
DISREGULATIONDISREGULATION
PASSIVE OR ACTIVE PASSIVE OR ACTIVE SADNESSSADNESS
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DEVELOPMENT OF DEVELOPMENT OF TODDLERS & PRESCHOOLERSTODDLERS & PRESCHOOLERS REPRESENTATIONALREPRESENTATIONAL CONCRETE THINKINGCONCRETE THINKING PRESENT TIME SENSEPRESENT TIME SENSE ANAMISTIC THINKINGANAMISTIC THINKING ARTIFICIALISMARTIFICIALISM EGOCENTRICITYEGOCENTRICITY LINKING UNRELATED EVENTSLINKING UNRELATED EVENTS SPLITTING POSITIVE & NEGATIVESPLITTING POSITIVE & NEGATIVE
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TRAUMA RESPONSES IN TRAUMA RESPONSES IN EARLY CHILDHOODEARLY CHILDHOOD
DISORDERED ATTACHMENT & DISORDERED ATTACHMENT & INTERACTIONSINTERACTIONS
REENACTMENT & MODELINGREENACTMENT & MODELING DISREGULATION & DISREGULATION &
HYPERVIGILANCEHYPERVIGILANCE FAILURE TO ID INTERNAL STATESFAILURE TO ID INTERNAL STATES NEGATIVE WORLD VIEWNEGATIVE WORLD VIEW SADNESS & DEPRESSIONSADNESS & DEPRESSION
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Why look at paternal & family risk, Why look at paternal & family risk, child attributes & program effects child attributes & program effects
over timeover time?? Conceptualizing parent, family & program Conceptualizing parent, family & program
characteristics & child attributes as a characteristics & child attributes as a dynamic and integrated set of systems that dynamic and integrated set of systems that change over time in ways that predictchange over time in ways that predict
stability & variation withinstability & variation within the larger stable set of the larger stable set of systems allows for a systems allows for a
complex complex study of changes study of changes in childin child development over time.development over time.
program
parent & family
child
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Attachment vs. Trauma-Bond Attachment vs. Trauma-Bond RelationshipsRelationships
AttachmentAttachment Bond BondTrauma BondTrauma Bond
LoveLove TerrorTerrorTakes timeTakes time InstantaneousInstantaneousReciprocity & caringReciprocity & caring Domination & fearDomination & fearPerson essential forPerson essential for Person essential for Person essential for
survivalsurvival survivalsurvivalProximity = safetyProximity = safety Proximity = conflictProximity = conflictSeparate dependentSeparate dependent Not separate, other’sNot separate, other’s
need extensionneed extensionSelf-MasterySelf-Mastery Mastery by othersMastery by othersAutonomy-individuationAutonomy-individuation Obedient to will of Obedient to will of
other other
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Working in Early Childhood Working in Early Childhood SettingsSettings
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Psychopathology is a succession of Psychopathology is a succession of adaptations of persons to their adaptations of persons to their
environments environments (Alan Stroufe, 1997)(Alan Stroufe, 1997)
Treatment is building the Treatment is building the scaffolding to support positive scaffolding to support positive
functioning through the functioning through the vulnerabilities & the relationship vulnerabilities & the relationship
through which functional through which functional adaptation is crafted. adaptation is crafted.
(Ayoub & Fischer, 2006)(Ayoub & Fischer, 2006)
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Considering Risk in Considering Risk in Strength-Based ProgramsStrength-Based Programs
Objective assessment of strengths Objective assessment of strengths & problems& problems
Extended engagement strategies Extended engagement strategies for families at higher riskfor families at higher risk
Honest, non-judgmental Honest, non-judgmental relationship buildingrelationship building
Real supports for meaning needsReal supports for meaning needs Continuity & liaison systemsContinuity & liaison systems Holistic view of family in context Holistic view of family in context
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CRISIS THEORY CRISIS THEORY (Caplan)(Caplan)
Level of functioning
CRISIS!!!
Adaptation
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The ChildThe Child Universal screening Universal screening Clinical team provides classroom Clinical team provides classroom
observation and assessment, individual observation and assessment, individual play therapy, social skills groups, play therapy, social skills groups, behavioral support in classroomsbehavioral support in classrooms
Teachers provide primary attachment Teachers provide primary attachment models & connections to outside worldmodels & connections to outside world
Model of pair play therapy is relational, Model of pair play therapy is relational, encouraging attachment and promoting encouraging attachment and promoting emotional safety for childrenemotional safety for children
““Contextual” approachContextual” approach
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The Classroom: Key The Classroom: Key concepts for teachersconcepts for teachers
Positive attachment promotionPositive attachment promotion Responsiveness to individual cuesResponsiveness to individual cues Respect for children’s style, Respect for children’s style,
expression, playexpression, play Positive, clear, & child-specific limit Positive, clear, & child-specific limit
settingsetting Flexible curriculum in the context of Flexible curriculum in the context of
predictable classroom structurepredictable classroom structure Supportive assessment & response Supportive assessment & response
to traumatogenic coping strategies to traumatogenic coping strategies
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The Child: Pair Play The Child: Pair Play TherapyTherapy
A developmental intervention A developmental intervention designed to help at-risk toddlers & designed to help at-risk toddlers & preschoolers develop & sustain preschoolers develop & sustain friendships.friendships.
A relational intervention that A relational intervention that supports and facilitates age-supports and facilitates age-appropriate perspective-taking appropriate perspective-taking skills in toddlers and preschoolers.skills in toddlers and preschoolers.
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Therapeutic Guidelines for Therapeutic Guidelines for Pair Play TherapyPair Play Therapy
To provide a safe and nurturing environment
To enhance children’s readiness for peer interaction
To prompt children’s use of communication Create opportunities for interaction opportunities for interaction Work though conflictWork though conflict Model & reinforce cooperationModel & reinforce cooperation Model non-aggressive responsesModel non-aggressive responses Establish clear boundariesEstablish clear boundaries Adapt & use the ecological settingAdapt & use the ecological setting Build & maintain friendshipsBuild & maintain friendships
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Evaluation of Pair Play Evaluation of Pair Play Therapy StudyTherapy Study
(N = 52)(N = 52)
Does children’s readiness for peer Does children’s readiness for peer interaction increase over time after interaction increase over time after controlling for age and proximity to controlling for age and proximity to abuse event?abuse event?
What is the interface between What is the interface between children’s interactions and children’s interactions and therapists interventions in Pair Play therapists interventions in Pair Play Therapy?Therapy?
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PEER INTERACTION CODINGPEER INTERACTION CODING
Factors relating to peer Factors relating to peer interaction include:interaction include:
proximityproximitycooperationcooperationfriendship & perspective friendship & perspective takingtaking
verbal interactionverbal interaction
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Case Study Example:Case Study Example:MothersMothers
Mid Twenties – Mid Twenties – Early ThirtiesEarly Thirties
African American African American WomenWomen
Low SES-Low SES-Welfare Welfare
DependantDependant
Involved with Involved with Child Protective Child Protective
ServicesServices
ChildrenChildrenTanisha - 2 years, 3 mo.Tanisha - 2 years, 3 mo.Christina - 1 year, 7 mo.Christina - 1 year, 7 mo.
Physical abuse & Physical abuse &
neglect neglect
In foster care for a In foster care for a period of timeperiod of time
Interaction DifficultiesInteraction DifficultiesParticipated in Pair play Participated in Pair play
therapy for 19 therapy for 19 sessionssessions
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The highest interaction level The highest interaction level displayed by Tanisha and Christina displayed by Tanisha and Christina
in PPT: COOPERATIONin PPT: COOPERATION
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Tanisha
0
1
2
3
4
5
Interaction Level
PPT Session Number
Tanisha Christina
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Highest interaction level displayed Highest interaction level displayed by Tanisha and Christina in PPT: by Tanisha and Christina in PPT:
CONFLICTCONFLICT
0
1
2
3
4
5
Interaction Level
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Tanisha
PPT Session Number
Tanisha Christina
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Is this the working phase Is this the working phase of therapy?of therapy?
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 1718 19
20
Tanisha
0
1
2
3
4
5
0
1
2
3
4
5
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
TanishaChristina
COOPERATION CONFLICT
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Highest interaction level displayed Highest interaction level displayed by Tanisha and Christina in PPT: by Tanisha and Christina in PPT:
FRIENDSHIP &PERSPECTIVE TAKINGFRIENDSHIP &PERSPECTIVE TAKING
0
1
2
3
4
5
Interaction Level
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Tani
sha
Chr
istin
a
PPT Session NumberTanisha Christina
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Highest interaction level displayed by Highest interaction level displayed by therapists during PPT: therapists during PPT:
THERAPISTS INTERVENTIONSTHERAPISTS INTERVENTIONS
1 2 3 4 5 6 78 9 10
1112 13
14 1516
1718
1920
0
1
2
3
4
5
6
7
Interaction Level
PPT Session Number
Therapists behavior towards Tanisha Therapists behavior towards Christina
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Pair Play Therapy Findings:Pair Play Therapy Findings: Children increased cooperative & friendship Children increased cooperative & friendship
perspective-taking interactions over time.perspective-taking interactions over time.
Children did express more conflict in the Children did express more conflict in the working phase of therapy including working phase of therapy including scratching, hitting, kicking & name-calling.scratching, hitting, kicking & name-calling.
Therapists’ behaviors & interventions Therapists’ behaviors & interventions involved the re-structuring of negative involved the re-structuring of negative interactions & were associated with the interactions & were associated with the elicitation of cooperative behaviors, including elicitation of cooperative behaviors, including friendship & perspective taking.friendship & perspective taking.
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““Touch functions on many levels of Touch functions on many levels of adaptation, first to make survival adaptation, first to make survival
possible, then to make life possible, then to make life meaningful.” meaningful.”
(Brazelton, 1990 p.561)(Brazelton, 1990 p.561)
The Use of The Use of TherapeutiTherapeuti
c Touch c Touch StudyStudy
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Therapist Use of Touch, Therapist Use of Touch, Supporting Internal Control Supporting Internal Control
ExternallyExternally
Maltreated children exhibit a Maltreated children exhibit a deregulated stress response system deregulated stress response system such that cortisol (both a ‘stress’ and such that cortisol (both a ‘stress’ and ‘anti-stress’ hormone) may no longer ‘anti-stress’ hormone) may no longer be responsive to the activation of the be responsive to the activation of the stress response, resulting in stress response, resulting in undifferentiated ‘fight, flight or undifferentiated ‘fight, flight or freeze’ reactions to new stressors. freeze’ reactions to new stressors.
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Therapist Use of Touch, Therapist Use of Touch, Supporting Internal Control Supporting Internal Control
ExternallyExternally
Through oxytocin’s inhibitory effects Through oxytocin’s inhibitory effects on several aspects of the neuro-on several aspects of the neuro-hormonal stress system other than hormonal stress system other than cortisol, therapist touch is likely to cortisol, therapist touch is likely to support maltreated participants in support maltreated participants in achieving ‘internal’ control over their achieving ‘internal’ control over their stress response during stressful peer stress response during stressful peer interaction over the course of PPT. interaction over the course of PPT.
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Therapist Touch StudyTherapist Touch Study(Schlichtmann & Ayoub, 2004)(Schlichtmann & Ayoub, 2004)
Does change in social competence Does change in social competence over the course of Pair Play Therapy over the course of Pair Play Therapy for toddlers & preschoolers differ for toddlers & preschoolers differ according to therapist use of positive according to therapist use of positive touch?touch?
Does the effect of therapist use of Does the effect of therapist use of positive touch on the rate of change positive touch on the rate of change in social competence vary as a in social competence vary as a function of maltreatment status?function of maltreatment status?
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6
8
10
12
14
1 2 3 4 5 6 7 8 9 10
Session
Estim
ated
Soc
ial C
ompe
tenc
e .
90th Percentile, 13 TouchesPer Session50th Percentile, 4 TouchesPer Session10th Percentile, 1 TouchPer Session
Fitted average growth trajectories describing the effect of Fitted average growth trajectories describing the effect of the number of times a participant is touched by a the number of times a participant is touched by a
therapist per session for maltreated children on the therapist per session for maltreated children on the change in social competence over time for 3 year old change in social competence over time for 3 year old
participants (n=60).participants (n=60).
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