Transcript POsT-tRAUMATIC STRESS IN THE NICU PARENT MARK …

POST-TRAUMATIC STRESS IN
THE NICU PARENT
MARK BERGERON, MD, MPH
ASSOCIATES IN NEWBORN MEDICINE, PA
CHILDREN’S HOSPITALS AND CLINICS OF MINNESOTA
ASSISTANT PROFESSOR, PEDIATRICS
UNIVERSITY OF MINNESOTA MEDICAL SCHOOL
36TH ANNUAL MINNESOTA PERINATAL ORGANIZATION CONFERENCE
SEPTEMBER 23, 2010
Disclosures
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I will not be discussing any experimental or offlabel uses for any therapies during this
presentation.
I have no relevant financial relationships to disclose.
Objectives
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Describe features by which parents in the NICU with
post-traumatic stress may be recognized.
Describe effective and supportive communication
strategies when encountering NICU families in crisis.
Identify three resources available to NICU families
suffering from emotional trauma.
Format
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Review what’s known about NICU parents and posttraumatic stress
Discuss future areas of potential research in this area
Review supportive communication strategies
Discuss resources available to NICU parents and former
NICU parents (especially local resources)
Open discussion of personal experiences (poignant
examples, successes, community needs, etc.)
All slides are available on our website
(www.newbornmed.com)
One last disclaimer…
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I am by no means an expert on mental health or
psychological trauma.
I
am a neonatologist who bears witness to the stress the
NICU environment exerts on babies, their parents, and
families.
What is trauma?
Trauma?
Trauma?
Trauma?
Yes! (For some.)
Trauma
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“Experience of a threatening situation that goes
beyond the bounds of the individual coping strategies
and is accompanied by a sense of helplessness and
defenseless abandonment.” (Yehuda, 2002).
Post-traumatic Stress Disorder (PTSD)
(DSM-IV-TR)
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A: Exposure to a traumatic event
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B: Persistent re-experiencing
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These are all physiological response issues, such as difficulty falling or staying asleep, or problems with anger,
concentration, or hypervigilence.
E: Duration of symptoms for more than 1 month
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This involves a sufficient level of:
 avoidance of stimuli associated with the trauma (thoughts, feelings, or talking about the event(s);
 avoidance of behaviors, places, or people that could lead to distressing memories;
inability to recall major parts of the trauma(s), or decreased involvement in significant life activities;
decreased capacity to feel certain feelings;
an expectation that one's future will be somehow constrained in ways not normal to other people.
D: Persistent symptoms of increased arousal not present before
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One or more of these must be present in the victim:
 Flashback memories, recurring distressing dreams, subjective re-experiencing of the traumatic event(s), or intense
negative psychological or physiological response to any objective or subjective reminder of the traumatic event(s).
C: Persistent avoidance and emotional numbing
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(a) loss of "physical integrity", or risk of serious injury or death, to self or others, and
(b) an intense negative emotional response.
If all other criteria are present, but 30 days have not elapsed, the individual is diagnosed with Acute Stress Disorder.
F. Significant impairment
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The symptoms reported must lead to "clinically significant distress or impairment" of major domains of life activity, such
as social relations, occupational activities, or other "important areas of functioning”
Fundamental question #1
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Are all criteria necessary for the traumatic event(s)
to be important to a parent’s ability to cope and
function?
Fundamental question #2
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How commonly are features of post-traumatic stress
experienced by NICU parents?
Impact of NICU experience on parents
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Sense of loss of personal control over events
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Especially related to infant survival
Loss of role as decision maker and care giver
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When is this regained?
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Appearance of fragile or sickly infant
Elevated distress leading to
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discharge or beyond?
Depression and anxiety
ASD and PTSD
Emotional distress correlated with
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Infant maturity and Complications (DeMeier, RL et al. (1996))
Literature Review
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“Post Traumatic Symptomatology in Parents with
Premature Infants: A Systematic Review of the
Literature” Karatzias A, et al. Journal of Prenatal
and Perinatal Psychology and Health (2007)
Analyzed studies quantitative, qualitative, and
mixed quantitative qualitative designs
Systematic review
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Search criteria
 English
 Published
in peer-reviewed journals
 Participants: parents/caregivers of premature infants
 Related to
 Post-traumatic
symptomatology following preterm birth
 Traumatic experiences of parents with premature infants
and/or
 Effectiveness of interventions/treatment of post-traumatic
symptomatology in parents following preterm birth
Systematic review
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Five studies identified
 All
published after 1997
 Primary research papers
 No
reviews or meta-analyses
Wereszczak et al. (1997)
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Objective:
 Study
vividness of memories primary caregivers recall
after 3 years post preterm birth
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Method:
 Qualitative:
Semi-structured interviews of 44 mothers or
grandmothers
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Findings:
 At
3 years post-birth, caregivers report vivid memories
related to infant appearance and behavior, pain,
procedures, illness severity, and uncertainty of outcomes
Pierrhumbert et al. (2003)
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Objective:
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Methods:
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Examine effects of PTSD reactions of parents on sleeping and
eating problems of former preterm infants.
Perinatal PTSD questionnaire (PPQ, by Quinnell and Hynan,
1999) administered to 50 families (mothers and fathers) of
former preterm infants and 25 families of full term infants at
enrollment and at 6 mos. CGA
Findings:
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67% of mothers of preemies vs. 6% controls exhibited clinical
post-traumatic reactions at 6 mos past expected due date
Intensity of those reactions correlated with eating/sleeping
problems of infants
Holditch-Davis et al. (2003)
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Objective:
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Methods:
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Investigate post-traumatic stress responses of mothers with premature
infants
Mixed qualitative-quantitative design w/ semi-structured interview
screening for PTS features at enrollment and at 6 months corrected age
30 mothers of high-risk preterm infants
Findings:
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All mothers had at least one PTS symptom
12 had two symptoms
16 had three symptoms
Infant illness severity was significantly associated with PTS symptoms
Kersting et al. (2004)
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Objective:
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Investigate PTS responses of mothers of premature infants
Methods:
Prospective longitudinal
 50 mothers of premature infants assessed with Impact of
Events Scale (IES) (Horowitz et al. 1979) at 1-3 days, 14
days, 6 mos. and 14 mos. post-birth vs. 30 mothers of
uncomplicated term infant births
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Findings:
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Higher rates of traumatic symptoms in mothers of preemies
at all time points persisting without reduction at 14 mos. (p
< .05)
Jotzo and Poets (2005)
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Objective:
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Methods:
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Investigate effectiveness of a trauma-preventative psychological
intervention for parents of premature infants during
hospitalization
Sequential control-group design
Single session crisis intervention w/ psychologist w/ additional
support throughout hospitalization when needed
25 mothers in intervention group/25 in control group
Assessment at discharge w/ IES
Findings:
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19 mothers in control group showed symptoms of clinical trauma
post-birth compared to 9 in the intervention group
Systematic review
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Research on the perspectives of NICU parents is limited
Studies had methodological limitations
Small size, high attrition rates
 Little diversity
 Time of assessment
 Mothers vs. fathers
 Lack of control for illness severity
 No clinician-administered assessment tool for PTSD
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Intervention studies are particularly lacking
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Limited information on effective strategies of support
“For Parents in NICU, Trauma May Last”
By Laurie Tarkan
August 25, 2009
Shaw et al. (2009)
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“The Relationship Between Acute Stress Disorder
and Posttraumatic Stress Disorder in the Neonatal
Care Unit”
Shaw et al. (2009)
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Objective:
 Examine
the prevalence of PTSD in parents 4 months
after the birth of preterm or sick infants
 Examine the relationship between PTSD and ASD
symptoms immediately following birth
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Methods:
 18
parents completed completed a self-report
assessment of ASD at baseline
 Self-report assessment for PTSD and depression
completed at 4 months.
Shaw et al. (2009)
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Findings:
 33%
of fathers and 9% of mothers met criteria for
PTSD
 ASD symptoms highly correlated with development of
PTSD and depression
 Fathers showed a more delayed onset in PTSD
symptoms, but were at greater risk by 4 months than
mothers
Future research
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Standardized clinical scales along with open-ended
interview schedules to obtain pre-post birth data
More long-term follow-up data needed
More fathers in sampling, more racial diversity
Infant illness severity should be recorded
Attempt to correlate PTS symptoms with depression
 Enhances
bias recall of events?
Fundamental question #3
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Given a lack of evidence, what strategies of
support/intervention should be offered in the NICU
and after discharge?
Step one: Recognize the feelings
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Terror
Grief
Impotence
Depression
Jealousy
Anger
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“Even the most well-adapted appearing couple with an
infant in the NICU is undergoing the most stressful crisis of
their lives”
 Rachel, Social Worker
Step two: Validate
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Reassure parents that their emotions are a NORMAL
response to severe stress
 Mothers
 Be
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and fathers are more alike than different
wary of stereotyping
Use communication that focuses on the individual
parent’s experience and emotions
 Empathy
 Encourage
verbalization
A unique parent perspective
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“You are going to be disorganized and upset for
months—some of us for years. We feel crazy, and
we want to return to normal quickly. But that is the
worst thing that we can try to do, because we can’t
stop or reverse the natural, healing process of our
emotional reactions without doing damage to
ourselves. The only things that are normal for highrisk parents are terror, grief, impotence, and
anger… And experiencing these lousy emotions are
signs that we parents are doing well, not poorly.”
A unique perspective
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“… the medical staff can do wonderful things to help angry
parents, even though I know that angry parents are one of the
most troublesome things for you. It is natural for you to want to
avoid angry parents, but please stay with us. When we erupt
and explode, don’t go away, even though you have pressing
obligations. Stay there, nod your heads, and let our anger
blow past you like the desert winds. Then, in the next day or
two, when you sense that we might be more rational, come
back to us and re-establish communications. Go over what we
were mad about, and show us that you believe that our
feelings are important to you. This is crucial. Many times, trust
is the only good feeling a parent has. If that trust ever
disappears, then that is the worst crash on the roller coaster for
parents.”
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Michael Hynan, Ph.D. and parent of ex-preemie
Creating a supportive environment
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Continuity of care
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i.e. primary nurses
Family-centered care practices
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Bedside rounding with families
On-site social workers
Parent-to-parent group
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Advisor/leader (paid vs. volunteer)
Seamless discharge to home transition
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Engage parents in developmental care early
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Encourage parenting competencies
Home nurse visits
Medical Home model
NICU Follow-up clinic
Supporting a family: where to refer?
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Hospital social worker
Other resources
 Pregnancy
and Postpartum Support Minnesota (PPSM)
 http://www.pregnancypostpartumsupportmn.com
 mental
health & perinatal practitioners, service
organizations, and mother volunteers offering emotional
support and treatment to Minnesota families through the
perinatal years
 Perinatal Mental Health Resource List, 4th Ed.
Conclusion
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NICU hospitalization generate a traumatic
experiences for most, if not all, parents
Many will exert signs of acute and post-traumatic
stress
 Manifestations
and likely effects vary among
individuals
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Future research needed to better understand the
nature of ASD and PTSD in NICU parents
References
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Hoditch-Davis, D; Bartlet, TR; Blickman, AL; Shandor Miles, M. (2003). Posttraumatic stress symptoms in
mothers of premature infants. JOGNN, 32, 161-171.
DeMeier, RL; Hynan, MT; Harris, HB; et al. (1996). Perinatal stressors as predictors of symptoms of
posttraumatic stress in mothers of infants at high risk. Journal of Perinatology, 16, 276-280.
Jutzo, M; Poets, CF. (2005). Helping parents cope with the trauma of premature birth: An evaluation of a
trauma-preventive psychological intervention. Pediatrics, 115, 915-919.
Kersting, A; Dorsch, M; Wesselmann, U, et al. (2004). Maternal posttraumatic stress response after the birth
of a very low-birth-weight infant. Journal of Psychosomatic Research, 57, 473-476.
Pierrhumbert, B; Nicole A; Muller-Nix, C; Forcada-Guex, M; Ansermet, F. (2005). Parental post-traumatic
reactions after premature birth: Implications for sleeping and eating problems in the infant. Archives of
Disease in Childhood and Fetal and Neonatal Education, 88, 400-404.
Shaw, RJ; Bernard, RS; DeBlois, T; Ikuta, LM; Ginzburg, K; Koopman, C. (2009). The Relationship between
acute stress disorder and posttraumatic stress disorder in the neonatal intensive care unit. Psychosomatics,
50, 131-137.
Wereszczak, J; Shandor Miles, M; Holditch-Davis, D. (1997). Maternal recall of the neonatal intensive care
unit. Neonatal Network, 16, 33-40.
Yehuda, R. (2002). Clinical relevance of biologic findings in PTSD. Psychiatric Quarterly, 73, 23-33.
References
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With much gratitude to Michael Hynan, Ph.D.,
University of Wisconsin – Milwaukee for his
generous sharing of his insight, personal stories and
research. (https://pantherfile.uwm.edu/hynan/www/)
Discussion