PTSD OF INFANCY

1. PTSD OF INFANCY Developmental, Neurophysiological, Diagnostic, Therapeutic and Prognostic aspects Miri Keren, M.D.

2. 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.

3. From 1988, we know that…. • At any age, behavioral memories of trauma remain quite accurate and true to the events that stimulated them.

4. 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, self-hypnosis and dissociation, and rage.

5. 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”.

6. 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

7. Still, much was left unknown concerning the response of children under 3 years of age to traumatic events.

8. 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.

9. 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.

10. Diagnosis of PTSD in infants • 1995: Scheeringa et al (JAACAP) showedthat 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:

11. Diagnosis of PTSD in infants • 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.

12. 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 notan 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.

13. 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.

14. Protective factors • Positive parental relationship. • Parental constructive coping mechanism • Physical proximity of child to parent. • Social support • Community support

15. The neurobiology of PTSD in infants • Overhelming experiences in the first years of life raises questions about short-term and long-termeffects on neurobiological systems and neurohormones (e.g., norepinephrine, serotonin and HPA axis) involved in arousal regulation. • Perry et al (1995, 1998): Two main stress-response patterns in infancy and childhood: hyperarousal and dissociation.

16. 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.

17. 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.

18. 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.

19. 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.

20. Developmental issues relevant to treatment of PTSD in preschoolers • Verbal capacity to express traumatic memories depends on whether verbal abilities have developed sufficientlyat the time of trauma: Terr: - 28 to 36 monthsas the earliest age most children could develop such verbal memories. Sugar (1992): 16 months • Girls are better than boys at verbalizing parts of traumas.

21. 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.

22. 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.

23. 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.

24. 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.

25. 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.

26. 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”.

27. 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.

28. Diagnosis: PTSD of Infancy 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

29. 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.

30. 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.

31. 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.

32. 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.

33. 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.

34. Preventing abuse-induced PTSD: 1. Early detection of domestic violence2. Early treatment of PTSD in infancy

35. WHY? Because of the Transgenerational transmission of domestic violence and traumatization: When the violent parents’ violent infant/child/adolescent becomes a parent…

36. 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)

37. 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)

38. 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

39. Poor parent – child relation Dysfunctional family Parental PTSD, Lack of support Traumatic event Domestic violence/abuse PTSD Resensitzation HPA-axisSensitization Resensitization Anxiety Depression New trauma New trauma New trauma New trauma treatment Resolved PTSD PTSD treatment treatment Resolved Resolved PTSD PTSD Personality Disorder Anxiety Depression PTSD Resolved treatment treatment Resolved Resolved treatment Complicated PTSD Personality disorder PTSD treatment Resolved PTSD from Infancy to Adulthood Infancy Childhood Adolescence Adulthood