Transcript Post-Traumatic Stress Disorder of Infancy (0

PTSD OF INFANCY
Developmental,
Neurophysiological,
Diagnostic,
Therapeutic and
Prognostic aspects
Miri Keren, M.D.
History of the concept
 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.
From 1988, we know that….
 At any age,
behavioral
memories of
trauma remain
quite accurate
and true to the
events that
stimulated them.
Two types
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.
Pynoos definition of a traumatic
event for young children (1990)
“Any direct or
witnessed event
that threatened
his/her own
and/or his/her
caregiver’s
physical and/or
emotional
integrity”.
The “worst” traumatic event
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.
Post-traumatic reactions in
children 0 to 3 years of age:
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.
Diagnosis of PTSD in children
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.
Diagnosis of PTSD in infants
 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:
Diagnosis of PTSD in infants
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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.
Risk factors of PTSD in infants
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.
Risk factors of PTSD in infants
 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.
Protective factors
 Positive parental
relationship.
 Parental
constructive coping
mechanism
 Physical proximity
of child to parent.
 Social support
 Community
support
The neurobiology of PTSD in infants
 Overhelming experiences in the first years
of life raises questions about short-term
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.
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.
Assessment issues
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.
Assessment issues - ctd
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.
Treatment
 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.
Developmental issues relevant to
treatment of PTSD in preschoolers
 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.
Developmental issues relevant to
treatment of PTSD in preschoolers
 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.
Clinical vignette: Domestic violence
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.
History
 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.
Developmental history
 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.
Family background
 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.
Psychiatric status at time of
referral
 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. Therapist said “one small horse,
who is afraid, and one big horse who will protect him”.
Nir smiled faintly, touched the small horse, Therapist
said “See, small horse is a little bit less scared”, and the
child gave a bigger smile, but suddenly “out of the blue”,
started to scream and hit his mother, threw his bottle
away, and repeatedly said “stupid, stupid”.
Summary of mental status
 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.
Diagnosis: PTSD of Infancy
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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.
Symptoms of social withdrawal, restricted affect, sleep
disorder, short attention span, hypervigilance, new
aggressive and clingy behavior, and dissociative
behavior.
Anxious/ tense mother-child relationship
PTSD in mother
Treatment
 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.
Goals of the dyadic
psychotherapy
 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.
Outcome
 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.
Clinical vignette: Terror bombing
 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.
Outcome
 1 year follow-up: child did not
develop any PTSD symptoms.
 She does show behaviors that are
secondary to her mother’s chronic
dysfunction.
Preventing abuse-induced PTSD:
1. Early detection of domestic
violence
2. Early treatment of PTSD in infancy
WHY?
Because of the
Transgenerational
transmission of domestic
violence and traumatization:
When the violent parents’ violent
infant/child/adolescent becomes
a parent…
ctd
 Aggressive and violent children are at
higher risk of developing in their
young adulthood, alcohol and drug
abuse, accidents, violent crimes,
depression, suicide attempts, spouse
abuse, and neglectful and abusive
parenting.
Caspi et al (1996); Lavigne (1998)
Mechanisms of transmission
1.Maternal disorganized attachment
representations, via
frightening/frightened behaviors.
2.Poor capacity of regulation of negative
affects and developmental aggression
(Lyons-Ruth, 1996)
3. Identification with the aggressor
Silverman et Lieberman (1999); A. Jones (2006)
Where to find 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
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