Trauma and Infants

Marion DohertyKoanga Tupu (ADHB)

&

Chie YumotoWhakatupu Ora (CMDHB)

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Outline

Unique aspects of trauma in infancy and young childhood

Development of attachment and its role in managing the impact of trauma

Tips and resources for CAMHS clinicians

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“It is an ultimate irony that at the time when the human is most vulnerable to the effects of trauma – during infancy and childhood – adults generally presume the most resilience.”

Bruce Perry, M.D., Ph.D.

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At what age can children begin to feel fearful?

A) 3 months

C) 9 months

B) 6 months

D) 12 months

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At what age can children begin to feel fearful?

A) 3 months

Zero to Three National Parent Survey Report (2016)

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At what age can children give an explanation in terms of cause and effect?

A) 18 months

C) 36 months

B) 24 months

D) 48 months

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At what age can children give an explanation in terms of cause and effect?

C) 36 months

California Department of Education (2005)

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“Babies remember traumatic events in their bodies” – Alicia Lieberman

Babies and toddlers are directly affected by trauma

They are also affected if their main caregiver is suffering consequences of the trauma

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Types of Trauma

Accidents Physical Trauma Child Abuse and Neglect (including Emotional) Exposure to Domestic or Community Violence Natural Disasters Traumatic or Sudden Death in the Family Medical Procedures War, Terrorism, Crime

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Common Reactions in Infants Unusually high levels of distress when separated

from their primary caregiver “Frozen watchfulness”— a ‘shocked look’ Appears to be numb and a bit “cut off” Loss of playful and engaging behaviour Loss of eating skills, poor appetite, low weight Sleep difficulties or nightmares Being more unsettled and more difficult to soothe Slipping back in their physical skills & language Becoming more aggressive

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Contributing Factors

Single incident or Repetitive? Reminders or not? Any physical injuries? Any secondary stresses? Emotional support before, during or right

after traumatic experience? Quality of the relationship with caregiver prior

to trauma

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Video clip - Developing Brain

“Toxic Stress Derails Healthy Development”

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Cerebral Cortex

Memory Attention

Thinking

Language

PerceptualAwareness

Reasoning

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Positive Tolerable Toxic

Brainwave (2015)

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"There is no such thing as a baby ... if you set out to describe a baby, you will find you are describing a baby and someone. A baby can not exist alone, but is essentially part of a relationship '' (Winnicott, 1947)

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Infants experience trauma through relationship

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Parent as Emotional Mirror

Mirror neurons – present from birth – parts of our brain that react “as if” we’ve experienced/done something -

Heart racing when watching sport Stomach turning when seeing someone else disgusted Recoiling when someone else hit

Allow us to learn about emotions and ourselves and empathise with others

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Mirroring –Reflection versus Distortion

Marked Mirroring – parents using their own subtle facial expressions to mirror the baby and then ‘marks’ this expression with a reassuring expression

No marking – not containing and can be traumatising because it is overwhelming

Incongruent mirroring – baby’s sense of themselves is affected – development of false self

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Video clip – Mirroring

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Infant Attachment

• A secure attachment is the most desirable outcome for the infant – the knowledge that their caregiver will consistently respond when they are distressed

• “..what is believed to be essential for mental health is that the infant and young child should experience a warm, intimate and continuous relationship with his mother (or permanent mother substitute) in which both find satisfaction and enjoyment” (Bowlby, 1973)17/11/2016 21

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Infants adapting their responses

By the age of one, infants learn to adapt their emotional displays – in response to what is most comfortable for the caregiver

Infants can dial down their distress to stay in relationship with their caregivers

Cortisol and stress are still high despite looking “fine”

Case example - daughter turning away from Mother when distressed

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Infants can also increase their displays of distress/neediness in order to stay in relationship with their caregivers.

Parents can cue infants to look after their own emotional needs – not attuned

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Disorganised Attachment

Abuse and scary behaviour from a care-giver feels life-threatening for the child. The care-giver should be the source of safety but instead is the source of fear and terror.

The child is stuck in an awful dilemma: her survival instincts tell her to flee to safety (the attachment figure), but safety may be in the very person who is frightening her.

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“Disorganized attachment arises from fright without solutions. Parents can frighten their children in different, often unconscious, ways. It might be through abuse or neglect, but it could also be through unresolved trauma and loss in the parent’s own life that leaves him or her feeling afraid, which unintentionally scares the child”. http://www.youngminds.org.uk/17/11/2016 26

Video clip- Dr Dan Siegel

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Therapy/Support

Therapeutic assessment – to pull the whole story together and acknowledge loss and pain

Relationship therapy for Mother and child Individual therapy for father Work with couple to support their

relationship

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Outcome

Father less stressed and more able to parent “with joy”

Mother able to both take control and soothe child

Parents now looking at their relationship and the future

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Tips & Resources

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Identifying Trauma

Clinical assessment should review the specifics of the traumatic experiences: Reactions of the child and caregivers Changes in the child’s behaviour Resources in the environment to stablise the child Quality of the child’s primary attachment

relationships Ability of caregivers to facilitate the child’s healthy

development

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Instruments for Assessment

Traumatic Stress in Children: Child Behaviour Checklist (CBCL): Aged 1 ½ – 5 PTSD Semi-Structured Interview and Observation

Record: Aged 0 – 4 Traumatic Events Screening Inventory- Parent

Report Revised: Aged 0 – 6

Parenting Stress and Strengths: Parenting Stress Index Life Stressor Checklist- Revised

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What can CAMHS clinicians do?

Goal = Help caregivers re-establish security and stability for the child and the family Avoid any unnecessary separations from

important caregivers Maintain the child’s routines and schedules Answer the child’s questions in language they can

understand Learn to recognise and manage the child’s signs of

stress and understand cues for what is going on

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What can CAMHS clinicians do?

Expect the child may temporarily regress in their development or become ‘clingy’

Help the child expand their “feelings” vocabulary Avoid exposing the child to reminders of the

trauma, where possible Show love and affection Find ways to have fun and relax together Accept support and take time out to recharge

themselves

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Resources for Caregivers

National Child Traumatic Stress Network: http://www.nctsn.org/resources/audiences/paren

ts-caregivers

After the Injury: https://www.aftertheinjury.org/

Center on Social and Emotional Foundations for Early Learning “Family Tools”: http://csefel.vanderbilt.edu/resources/family.html

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When to seek more help…

Impact of trauma is preventing development of close relationship between the child and the caregiver

The child continues to slip backwards in development

If the trauma is severe or chronic If the caregiver is emotionally unwell with

stress, grief, anxiety or depression

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Self-Care

Take care of yourself!! Get supervision

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“Ki te kore nga putake e mākukungia e kore te rakau e tupu”- If the roots of the tree are not watered the tree will never grow

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