*
Developmental, Neurophysiological,
Diagnostic, Therapeutic and Prognostic
aspects
Sam Tyano, M.D.
Tel Aviv university Sackler school of medicine.
*
*1977: MacLean publishes the first case of a
child who suffered a life-threatening
experience and was evaluated prior to 48
months of age.
*1979: Terr's major pioneering work on
PTSD in children.
*1988: Terr (JAACAP, 1988) retrospective study
on early memories of trauma in 20
youngsters who had suffered psychic
trauma before age 5 years.
*
*At any age, behavioral
memories of trauma
remain quite accurate
and true to the events
that stimulated them.
Terr studied prospectively children & adolescents
who experienced life-threatening events, and
defined two clinical types of PTSD:
*
Type I trauma: Full, detailed memories, "omens",
and misperceptions;
Type II trauma: Denial and numbing, selfhypnosis and dissociation, and rage.
*
“Any direct or
witnessed event
that threatened
his/her own and/or
his/her caregiver’s
physical and/or
emotional
integrity”.
*
Decreasing order:
1. Domestic violence is the worst because the
trauma is generated by the attachment
figure.
2. Terror trauma: Unpredictability, indefinite
threat, profound effect on adults and
community, media wide coverage.
3. Natural disaster
Still, much was left unknown
concerning the response of children
under 3 years of age to traumatic
events.
*
Drell, Siegel & Gaensbauer (1993):
*
Infants and toddlers perceive and remember
traumatic events (mostly implicit memory, which
does not require conscious awareness or recall of
a retrieved memory) and do develop PTSD, with
many symptoms similar to those of older children
and adults.
*
Significant impact of developmental skills on the
extent to which events become traumatic for an
infant and on the phenomenology of traumatic
reactions.
*
Pynoos proposed criteria for PTSD in
children:
*1. Experiencing an event that would be
distressing almost for everyone.
*2. Re-experiencing the trauma in various
ways.
*3.Psychological numbing/avoidance.
*4. Increased arousal.
*
*1995: Scheeringa et al (JAACAP) showed
that criteria for diagnosing PTSD in
standard nosologies needed revision for
use with children younger than 48
months of age.
*At least one of the 4 main following
criteria:
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
1. Re experiencing:
Repetitive post-traumatic play
Distress with reminders
Dissociation episodes
2. Numbing of responsiveness, or interference with developmental
momentum:
Social withdrawal
Restricted affect
Loss of skills
3. Increased arousal
Sleep disorder
Short attention span
Hyper vigilance
Startle response
4. New fears and aggression
Aggressive behavior
Clinging behavior
Fear of toileting and/or others.
*
41 children under 48 months of age in relation to
variables of the trauma and of the children:
* The most potent trauma variable that
predicted the development of PTSD in these
children was not an event that was directed to
their own body, but whether they had
witnessed a threat to their caregiver.
* Children who were older than 18 months of age
at the time of trauma, and suffered acute
trauma, developed more re experiencing
symptoms than those who were younger.
*
*Father’s PTSD with externalizing and
depressive symptoms.
*Traumatized mother’s internal
representations as a protective figure.
*Poor general family functioning.
*Low SES.
*Gender: girls.
*Age: the younger child is at higher risk.
*Difficult child’s temperament.
*
*Positive parental
relationship.
*Parental constructive
coping mechanism
*Physical proximity of
child to parent.
*Social support
*Community support
*
*Overwhelming experiences in the first
years of life raises questions about shortterm and long-term effects on
neurobiological systems and
neurohormones (e.g., norepinephrine,
serotonin and HPA axis) involved in arousal
regulation.
*Perry et al (1995, 1998): Two main stressresponse patterns in infancy and
childhood: hyperarousal and dissociation.
*
- The younger the child, the more likely
there will be primary dissociative
adaptations.
- There is a continuum of dissociative
responses, beginning from distraction, to
avoidance, numbing,daydreaming,fugue,
depersonalization, and up to fainting or
catatonia.
- The exact neurobiology of dissociation is
still unknown, though opoid, dopaminergic,
and HPA axis systems seem to be involved
interactively.
*
The most useful sequences to elicit
diagnostic information were:
*Free play with the caregiver
*Examiner-guided trauma reenactments.
The least useful ones were:
*Free play with the examiner
*Observation of the children while the
caregivers were interviewed about their
own reactions to the trauma.
*
Still, optimal specific procedures for diagnosing
PTSD in infants have yet to be determined.
It has to include the evaluation of:
* The caregiver's own psychic strengths and
weaknesses,
* The infant's developmental features.
* The quality of the interaction.
*
* Soothing techniques aimed at reducing autonomic
arousal. Desensitization techniques.
* Play enactment has been suggested as the
cornerstone of therapeutic process for PTSD.
Terr’s 3 principles (2003): Abreaction, Context,
Correction with overarching mood of “having fun”
* Imperative need to involve the caregivers in the
therapy sessions, to re experience the trauma in an
affectively meaningful way, in the context of a safe
environment.
*
*Verbal capacity to express traumatic memories
depends on whether verbal abilities have developed
sufficiently at the time of trauma:
Terr: - 28 to 36 months as the earliest age most
children could develop such verbal memories.
Sugar (1992): 16 months
*Girls are better than boys at verbalizing parts of
traumas.
*
* Short and single traumas were more likely to
be remembered in words.
* Similar findings were recently found in
Peterson et al's (1996) study of young children's
memory in real-life stressful situations.
*
Nir was 2 yr 3 months at time of referral. the only child of a young
divorced mother. Presenting symptoms:
*Irritability
*Physical aggression towards strangers and familiar
figures, adults and children.
*Repeated spitting on people
*Intermittent refusal to go to kindergarten with
separation anxiety
*Constricted play and withdrawn behavior
*Reduced appetite
*Negative mood
*Difficulty to fall asleep and frequent awakenings with
inconsolable crying.
*
* 5 months before referral, N. came back from a
visit to his father with second- degree burns on
both hands. From that time on, he became
very irritable, would repeat “outch, outch”,
and avoid using his hands and scream whenever
put in the bath. These specific behaviors
disappeared within a month or so, and were
replaced by the symptoms described above.
* The circumstances around the event were
unclear. Father was suspected for abuse, lost
his visitation rights for an unlimited period of
time. At the time of consultation, Nir had no
contact with him, besides sporadic phone calls.
*
* Domestic violence, mainly due to the husband’s
impulsive and suspicious character, started during
pregnancy.
* 1 month after N.’s birth, while the mother wanted to
go out and was holding the baby in her arms, the
husband tried to strangle her. She lost consciousness
and dropped the baby on the floor. Nir was
unconscious for a few hours. Police was involved.
Mother decided to divorce and to return to her
parents’ home with Nir. Father would take the child
for visits. Arguments and shouting over the child’s
head were the rule. When Nir was 6 months old, he
witnessed his father slapping his mother’s face and
spitting on her.
*
* Nir was born after a wanted pregnancy and a
normal delivery. Nir was an easy baby, had no
feeding nor sleep problems. Psychomotor
development was within normal; language
development was delayed: at the time of
referral, he made very few two-word sentences.
* Nir did not have any transitional object, and
always needed his mother’s physical presence to
comfort. He stayed home with mother until the
age of 2, and started to attend kindergarten 2
months after the burn incident.
*
* Nir stayed on mother’s lap, normal appearance.
* He moved his both hands freely, and had no visible
scars
* His affect was sad and anxious. He made eye contact
with the examiner but refused any interaction with
her, repeating “don’t want to, don’t want to” and
kicking his mother’s lap.
* He slapped his mother’s face, she weakly said, “Nir,
this is not nice, I’m angry at you”. She herself looked
anxious and helpless.
* Therapist puts two horses on the table, at Nir’s
proximity. He screamed and hit his mother, threw his
bottle away, and repeatedly said “stupid, stupid”.
*
* Severe restriction of play
* Pervasive anger and anxiety
* Clingy and aggressive behavior towards the
mother
were Nir’s main clinical presenting symptoms
across the three assessment sessions.
*
1. Mixture of chronic and acute traumatic experiences:
* An acute threat on physical integrity (burns) plus at least the
lack of paternal protection / care after the “accident”, and
at most seeing the father aggressing him (bath??).
* Enduring witnessing of physical and verbal aggression of his
father towards his main caretaker, i.e. his mother.
* The very early experience of being dropped from his
mother’s arms while she was herself in danger.
2. Symptoms of social withdrawal, restricted affect, sleep
disorder, short attention span, hypervigilance, new
aggressive and clingy behavior, and dissociative behavior.
3. Anxious/ tense mother-child relationship
4. PTSD in mother
*
*N’s very young age, his extreme anxiety
state, the mother’s helplessness and our
knowledge of the importance of the
caregiver's reactions to the traumatic
event, were at the base of our choice for
dyadic mother-child weekly psychotherapy,
rather than individual therapy for mother
and guidance regarding the child.
*Treatment started at age two years and 3
months, lasted for a year, with
interruptions initiated by the mother every
time the child's condition improved.
*
*To integrate the fragmented traumatic
memories into a coherent narrative, and
to desensitize both child and mother to
trauma-related stimuli.
*To strengthen the mother’s self esteem as
protective shield to her child.
*To restore the child's ability for symbolic
play and exploration, and to introduce the
possibility of some repair in his
representation of the father.
*
* Symptomatic improvements, followed by
regressions contingent to reappearance of the
father in Nir’s life.
* Overall behavioral improvement, but shaky
basic trust .
* Mother re-married and relocated. Loss of
follow-up.
*
* 2 years and half girl, caught in the midst of a suicide bomb
attack, was badly injured in her abdomen, stayed conscious,
but did not see her mother’s wound nor the dead and
wounded civilians, did not hear the screams.
* Mother, pregnant, took her at once in her arms and ran to
ambulance.
* Protective factors: Immediate maternal holding, previous
normal functioning. Community support. Father recovered
from ASR.
* Risk Factors: Mother lost function of arm, and developed
PTSD a few months after giving birth to second child.
*
*1 year follow-up: child did not
develop any PTSD symptoms.
* She does show behaviors that are secondary to
her mother’s chronic dysfunction.
*
* PTSD from Infancy to Adulthood
Poor parent – child
relation Dysfunctional
family Parental PTSD,
Lack of support
Traumatic event
Domestic violence/abuse
HPA-axis
Sensitization
Infancy
PTSD
Resolved
New trauma
Childhood
PTSD
Anxiety
Resensitization
PTSD
treatment
Depressio
n
New
trauma
Resolved
Resolved
New trauma
Adolescence
PTSD
Resolved
Resensit
zation
PTSD
Resolved
New trauma
Adulthood
Resolved
PTSD
Complicated
PTSD
PTSD
Personality
Disorder
Anxiety
Resolved
Personality
disorder
Depressi
on
*
* Whatever the type of traumatic event the
infant has been exposed directly or indirectly:
* Don’t assume the infant is too young to
understand…
* Identify the risk and protective factors for
developing PTSD
* Decide for the need of intervention
* If yes, have both the infant and the caregiver in
the treatment room
* To look for the potential
violent parents
There are three main groups of parents at risk for
violent marital and parental behaviors:
* Psychiatrically ill parents
* Drug/Alcohol addicted parent
* Severe Borderline Personality disordered parents
*Targets of
intervention
1.Maternal disorganized attachment
representations ( frightening/ frightened
behaviors).
2.Parents’ poor capacity of regulation of
negative affects and developmental
aggression (Lyons-Ruth, 1996)
3. Child’s identification with the aggressor
Silverman et Lieberman (1999); A. Jones (2006)
4. Social support network
5. Intensivity of intervention