Sensory Modulation Disorders Among Children With a History of Trauma: A Frame of Reference for Speech-Language Pathologists

Purpose

The purpose of this article is to present definitions and concepts about sensory modulation, illustrate behavioral aspects of sensory modulation disorders, describe a framework for assessment and intervention, and present advances in research.

Method

A review of descriptive and evidence-based literature related to the impact of exposure to both prenatal and postnatal trauma on sensory modulation is provided, with additional information gleaned from recent assessment data on children with a history of trauma who are served by the Southwest Michigan Children’s Trauma Assessment Center (CTAC).

Clinical Implications

The review of the literature indicates support for the presence of sensory modulation disorders among traumatized children. In addition, the emerging data now being gathered on children who have been assessed by CTAC indicate a significant prevalence of sensory modulation disorders among children with a history of trauma alone, and those with both trauma and a diagnosis of fetal alcohol spectrum disorder (FASD). Awareness, recognition, and identification of behaviors associated with this disorder, and referral to appropriate professionals, is essential to ensure effective preventive and intervention services.

A Model for Caregiving of Adopted Children After Institutionalization

TOPIC

Optimizing caregiving for newly adopted postinstitutionalized children.

PURPOSE

To consider a template of care for postinstitutionalized children based on experiences that physiological measures suggest are expected by infants postbirth.

SOURCES

Published literature and clinical experience.

CONCLUSION

Based on an understanding of physiologically expected care postbirth, special care for postinstitutionalized adopted children might include: close physical contact via use of a sling and cosleeping; breastfeeding or nurturing through food; and responsive caregiving. In replicating earlier missed experiences, parents may assist emotional development in their child and promote attachment development.

Natural Parenting — Back to Basics in Infant Care

This review examines an age-old approach to parenting recently rediscovered in Western industrialized societies and known by names such as natural parenting, attachment parenting, and instinctive parenting. Its leading principle is utmost sensitivity to the child's innate emotional and physical needs, resulting in extended breastfeeding on demand, extensive infant carrying on the caregiver's body, and cosleeping of infant and parents. The described practices prevailed during the evolutionary history of the human species and reflect the natural, innate rearing style of the human species to which the human infant has biologically adapted over the course of evolution. An overview of research from diverse areas regarding psychological as well as physiological aspects of early care provides evidence for the beneficial effects of natural parenting. Cross-cultural and historical data is cited to reveal the widespread use of the investigated parenting style. It is concluded that the described approach to parenting provides the human infant with an ideal environment for optimal growth both psychologically and physiologically. It is yet to be determined how much departure from this prototype of optimal human parenting is possible without compromising infant and parental wellbeing. The review also invites a critical reevaluation of current Western childrearing practices.

Psychological distress and coping in breast cancer patients and healthy women whose parents survived the Holocaust

Psychological distress levels of breast cancer patients whose parents were Holocaust survivors ('second-generation Holocaust' patients) were previously shown to be significantly higher than those of a matched group of patients with non-traumatized parents. In this study, we investigated whether this effect reflects only the generally higher distress levels of second-generation Holocaust women or whether breast cancer patients with traumatized parents also present lower adaptation abilities, which result in increased distress to the breast cancer diagnosis. We assessed psychological distress and measures of coping in 193 second-generation Holocaust patients diagnosed with breast cancer, 164 breast cancer patients with non-traumatized parents, 176 healthy second-generation Holocaust women, and 143 healthy women with non-traumatized parents. The main effect of cancer and the main effect of second-generation Holocaust survivor on psychological distress were found to be significant. These two factors (cancer x second generation) had a synergistic effect on the levels of depression and psychoticism. These results support the hypothesis that, at least on some psychological measures, the cumulative distressing effect of having traumatized parents and breast cancer diagnosis is higher than the effect of each factor alone.

A review of neuroimaging studies in PTSD: heterogeneity of response to symptom provocation

Different experiential, psychophysiological, and neurobiological responses to traumatic symptom provocation in posttraumatic stress disorder (PTSD) have been reported in the literature. Two subtypes of trauma response have been hypothesized, one characterized predominantly by hyperarousal and the other primarily dissociative, each one representing unique pathways to chronic stress-related psychopathology. Recent PTSD neuroimaging findings in our own laboratory support this notion and are consistent with the view that grouping all PTSD subjects, regardless of their different symptom patterns, in the same diagnostic category may interfere with our understanding of posttrauma psychopathology. This review will integrate findings of different experiential, psychophysiological, and neurobiological responses to traumatic symptom provocation with the clinical symptomatology and the neurobiology of PTSD.

Evidence base for practice: reduction of restraint and seclusion use during child and adolescent psychiatric inpatient treatment

BACKGROUND

Restraint and seclusion of children has great potential for harm. Since the mid-1980s, psychiatric inpatient personnel for children and adolescents have put considerable energy in reducing the use of extreme measures of aggression management. While the use of restraints is a particular problem in the United States, aggression management and means of control in psychiatric settings is an international issue.

APPROACH

The core question of this review was: What is the current state of the evidence supporting restraint reduction efforts with children and adolescents? Studies were reviewed and critiqued that related to programs of restraint reduction, restraint reduction methods, and aggression management. Internationally, there seems to be more emphasis on reducing coercive measures by understanding the context of their use. Thus, studies exploring staff perceptions and decisions concerning coercive measures were also examined.

FINDINGS

The evidence supporting restraint reduction methods in the United States comes mainly from case study reports of clinical sites' quality improvement projects. Consequently, a collection of studies is accumulating that supports a multi-strategy approach to restraint reduction. Limited evidence exists for aggression management measures and training in de-escalation techniques. Controversial aggression management techniques such as the use of pro re nata medication and holding continue to be used with very little support for their efficacy.

RECOMMENDATIONS

Recommendations include taking a view of restraint and seclusion as emergency measures to address dangerous aggression, not interventions examined in controlled studies. As such it is suggested that sites pool data on restraint use and reduction efforts to create a database for benchmarking and studying variations among hospitals. Furthermore, attention should also be given to developing additional means for addressing aggressive behaviors.

Following the Affect: Learning to Observe Emotional Regulation

On inpatient psychiatric units, staff deal with children and adolescents whose affect escalates quickly and intensely. These same children experience strong emotions that they can neither understand nor explain. To intervene effectively, inpatient staff must understand the regulation issues underneath the escalated behaviors. Emotion Regulation theory and the developmental line of emotional understanding are useful concepts in assessing and intervening with these children and adolescents. Presented here are criteria to guide inpatient staff's assessment of children and adolescents with emotion regulation difficulties. The assessment cues are based in concepts of Emotion Regulation and emotional understanding and are accompanied by suggested intervention strategies.

Disorders of extreme stress (DESNOS) symptoms are associated with type and severity of interpersonal trauma exposure in a sample of healthy young women

Childhood abuse and other developmentally adverse interpersonal traumas may put young adults at risk not only for posttraumatic stress disorder (PTSD) but also for impairment in affective, cognitive, biological, and relational self-regulation ("disorders of extreme stress not otherwise specified"; DESNOS). Structured clinical interviews with 345 sophomore college women, most of whom (84%) had experienced at least one traumatic event, indicated that the DESNOS syndrome was rare (1% prevalence), but DESNOS symptoms were reported by a majority of respondents. Controlling for PTSD and other anxiety or affective disorders, DESNOS symptom severity was associated with a history of single-incident interpersonal trauma and with more severe interpersonal trauma in a dose-response manner. Noninterpersonal trauma was associated with elevated prevalence of PTSD and dissociation but not with DESNOS severity. Study findings indicate that persistent posttraumatic problems with self-regulation warrant attention, even in relatively healthy young adult populations.

Reduced heart rate responding to trauma reliving in trauma survivors with PTSD: correlates and consequences

The authors investigated whether heart rate (HR) responses to voluntary recall of trauma memories (a) are related to posttraumatic stress disorder (PTSD), and (b) predict recovery 6 months later. Sixty-two assault survivors completed a recall task modeled on imaginal reliving in the initial weeks postassault. Possible cognitive modulators of HR responsivity were assessed; dissociation, rumination, trauma memory disorganization. Individuals with PTSD showed a reduced HR response to reliving compared to those without PTSD, but reported greater distress. Notably, higher HR response but not self-reported distress during reliving predicted greater symptom reduction at follow-up in participants with PTSD. Engagement in rumination was the only cognitive factor that predicted lower HR response. The data are in contrast to studies using trauma reminders to trigger memories, which have found greater physiological reactivity in PTSD. The authors' observations are consistent with models of PTSD that highlight differences between cued or stimulus-driven retrieval and intentional trauma recall, and with E. B. Foa and M. J. Kozak's (1986) hypothesis that full activation of trauma memories facilitates emotional processing.

Recovered memory and the Daubert criteria: recovered memory as professionally tested, peer reviewed, and accepted in the relevant scientific community

Research during the past two decades has firmly established the reliability of the phenomenon of recovered memory. This review first highlights the strongest evidence for the phenomenon itself and discusses the survey, experimental, and biological evidence for the varying mechanisms that may underlie the phenomenon. Routes to traumatic amnesia from dissociative detachment (loss of emotional content leading to loss of factual content) and from dissociative compartmentalization (failure in integration) are discussed. Next, an argument is made that false memory is a largely orthogonal concept to recovered memory; the possibility of one phenomena is largely irrelevant to the potential for the other. Furthermore, some aspects of the false memory research offer supportive data for the recovered memory researcher. Finally, the issue of error rates in making the Daubert case is explored. It is concluded that the weight of the evidence should allow the recovered memory victim to come before the court.

Developmental epidemiology of PTSD: self-regulation as a central mechanism

Epidemiologic and meta-analytic studies point to consistent effects of pretrauma factors on risk for posttraumatic stress disorder (PTSD). However, our understanding of why only some individuals are vulnerable to the adverse effects of traumatic events remains limited. This article argues that a developmentally informed approach to the epidemiology of PTSD is needed to move this understanding forward. However, there are many challenges to such an approach including the historic conceptualization of PTSD as a normative response to traumatic events, the almost exclusive reliance on retrospective self-report of PTSD risk factors, and the lack of attention to current knowledge of human development in selecting risk factors for epidemiologic studies. The developmental construct of self-regulation may provide a key mechanism for understanding the effects of pretrauma factors on the vulnerability to PTSD. Pretrauma factors shown to have consistent effect on risk for PTSD in meta-analytic studies include familial psychopathology, child abuse, and preexisting psychopathology. A preliminary framework integrating these pretrauma factors with self-regulation as a central mechanism in the etiology of PTSD is presented. The implications of a developmentally informed epidemiologic approach to PTSD for theory, research, and practice are discussed.

Developmental Attachment Psychotherapy with Fostered and Adopted Children

Developmental attachment theory and research is now beginning to inform practice, particularly in the field of foster care and adoption. A brief outline of attachment theory and the four main patterns of attachment is followed by a review of attachment-based support services and psychotherapies with fostered and adopted children, including infants, preschoolers, school age children, and caregivers. Particular attention is given to the behaviour, defensive strategies and developmental needs of fostered and adopted children with pre-placement histories of abuse and neglect.

Self-Criticism and Self-Warmth: An Imagery Study Exploring Their Relation to Depression

When things go wrong for people, those who are self-critical, compared to those who self-reassure, are at increased risk of psychopathology. However, little is known of the internal processes involved in self-criticism and self-reassurance, such as the ease of eliciting critical imagery, and the power, emotion and vividness of self-criticalness and self-reassurance. This study used a self-imagery task to investigate trait self-criticism and trait self-reassurance in relation to the ease and clarity of generating self-critical and self-reassuring images, and the felt power and emotion of self-critical and self-reassuring imagery. We also explored these in relation to depressive symptoms in students. Results suggested that trait self-criticism is associated with ease and clarity in generating hostile and powerful self-critical images, while trait self-reassurance is associated with ease and clarity of generating warm and supportive images of the self. Data analysis using structural equation models also suggests that difficulties in generating self-reassurance and compassionate images about the self with self-directed warmth, may also contribute to depressive symptoms. Thus self-critics may not only suffer for elevated negative feelings about the self but may also struggle to be able to generate self-supportive images and feelings for the self, and these difficulties could be a focus of therapeutic interventions.

Hypothèses neurobiologiques concernant les liens entre psychopathie et maltraitance infantile

INTRODUCTION

This article aims to closely link maltreatment subjected in childhood with the psychopathy, which is characterised by 2 factors: factor one: callousness, lack of guilt, emotional shallowness; factor two: antisocial behaviour, violence and impulsivity. If the parental education system seems to have an effect on the development of "factor two", "factor one" is for the authors of unknown aetiology. I will try to theorize that harsh and chronic maltreatment could be responsible for this emotional impairment which characterizes psychopathic individuals.

LITERATURE FINDINGS

There's a wealth of literature on the consequences of maltreatment on the brain's development in childhood, which are considered from a stress point of view, some individuals developing a syndrome called "post-traumatic stress disorder": PTSD (Perry, Shore, Van der Kolk, Teicher, Bremner, Carrion, De Bellis, Lanius, Nutt...). With prolonged chronic stress, the hypothalamic-pituitary-adrenal (HPA) axis is hyper-activated, with the resulting release in adrenocorticotropin and cortisol, which involves structural changes, cell atrophy and neuronal loss. According to the authors, there are 2 responses to harsh or chronic stress: dissociation (numbing) which involves the parasympathetic system, and hyperarousal which involves the sympathetic system. One of the worst neurobiological effects of repeated stress is amygdala kindling. Many laboratory studies on physiological alterations of amygdala in rats show that kindling interferes with the acquisition of fear conditioning.

CONCLUSION

Now, fear conditioning is the model on which the abusive education system is based. If this cannot develop, the child lives in the present, reacting to the unconditioned stimulus (US) like blows (with autonomic reactions), but the emotional association between this and the conditioned stimulus (CS) -- like hostile glances or shouting -- could not be registered in the orbital frontal cortex and the conditioned stimulus would not provoke autonomic responses which enable the anticipation of a danger connected with an interdict. Thus, psychopathic tendencies can develop.

Neurobiology of infant attachment

A strong attachment to the caregiver is critical for survival in altricial species, including humans. While some behavioral aspects of attachment have been characterized, its neurobiology has only recently received attention. Using a mammalian imprinting model, we are assessing the neural circuitry that enables infant rats to attach quickly to a caregiver, thus enhancing survival in the nest. Specifically, the hyper-functioning noradrenergic locus coeruleus (LC) enables pups to learn rapid, robust preference for the caregiver. Conversely, a hypo-functional amygdala appears to prevent the infant from learning aversions to the caregiver. Adult LC and amygdala functional emergence correlates with sensitive period termination. This study suggests the neonatal brain is not an immature version of the adult brain but is uniquely designed to optimize attachment to the caregiver. Although human attachment may not rely on identical circuitry, the work reviewed here suggests a new conceptual framework in which to explore human attachments, particularly attachments to abusive caregivers.

Music therapy with sexually abused children

Music is part of everyday life, and is generally regarded as therapeutic. There is increasing interdisciplinary interest in innate human musicality and the link between music and the emotions. Innate musicality is evident in the dynamic forms of emotional expression that both regulate and cultivate the foundations of meaning in human communication (intersubjectivity). This article discusses music therapy, drawing from interdisciplinary perspectives, and illustrated by case material of individual music therapy with a sexually abused child. Where the growth of mind and meaning is devastated at its core by early relational trauma, music, when used with clinical perception, may reach and work constructively with damaged children in an evolving, musically mediated therapeutic relationship.

Results of psychodynamically oriented trauma–focused inpatient treatment for women with complex posttraumatic stress disorder (PTSD) and borderline personality disorder (BPD)

In a naturalistic outcome study, the authors evaluated the results of a specific psychodynamically oriented trauma-focused inpatient treatment for women with complex posttraumatic stress disorder and concomitant borderline personality disorder, self-mutilating behavior, and depression. At admission, the frequency of self-mutilating behavior and the amount of inpatient treatment (an average of 68 days annually) of the sample was high, characterizing this patient group as "previously therapy resistant." Treatment outcome was assessed both at the end of treatment and in a 1-year follow-up. In comparison with a treatment-as-usual control group, the treatment program brought about significant and stable improvements both in trauma-specific symptoms (e.g. dissociation, intrusion, avoidance) and in general psychiatric symptoms (e.g., general symptom distress, frequency of self-mutilating behavior, number of hospitalizations). The frequency of inpatient treatments (hospitalizations) decreased dramatically (< 10 days annually; effect size: d = 2.88).

Mental health, attachment and breastfeeding: implications for adopted children and their mothers

Breastfeeding an adopted child has previously been discussed as something that is nice to do but without potential for significant benefit. This paper reviews the evidence in physiological and behavioural research, that breastfeeding can play a significant role in developing the attachment relationship between child and mother. As illustrated in the case studies presented, in instances of adoption and particularly where the child has experienced abuse or neglect, the impact of breastfeeding can be considerable. Breastfeeding may assist attachment development via the provision of regular intimate interaction between mother and child; the calming, relaxing and analgesic impact of breastfeeding on children; and the stress relieving and maternal sensitivity promoting influence of breastfeeding on mothers. The impact of breastfeeding as observed in cases of adoption has applicability to all breastfeeding situations, but may be especially relevant to other at risk dyads, such as those families with a history of intergenerational relationship trauma; this deserves further investigation.

The Role of Adult Attachment Styles in Psychopathology and Psychotherapy Outcomes

Attachment theory provides a model for understanding how the attachment styles formed in infancy systematically affect subsequent psychological functioning across the life span. Attachment styles provide the cognitive schemas, or working models, through which individuals perceive and relate to their worlds. In turn, these schemas predispose the development of psychopathologies and influence outcomes when people undergo psychotherapy. After reviewing recent empirical findings, the authors conclude that an understanding of attachment theory facilitates the conceptualization of clients' problems and the selection of appropriate interventions. Accordingly, attachment styles should be assessed as a standard part of treatment planning. Furthermore, the authors propose that attachment styles should be assessed as individual difference variables in psychotherapy outcome research because adult attachment styles dictate how people perceive and respond to their environments and, therefore, how clients respond differentially to various treatments.

Risk for schizophrenia--broadening the concepts, pushing back the boundaries

This paper gives an overview of environmental risk factors for schizophrenia. The presence of certain biological and psychosocial factors at certain points in the lifespan has been linked to later development of schizophrenia. These include prenatal infection, obstetric complications, childhood developmental impairments, early rearing environment, adolescent cannabis use, urban dwelling and membership of a minority population. Some of these risk factors operate on an individual level and some on a societal level but all need to be considered in the context of schizophrenia as a life-long brain disorder. Research interest in schizophrenia, especially neuro-imaging interest, is shifting to ever earlier stages of the disease process and so the journey to discover the causes of schizophrenia is likely to take us right back to the beginning of development.

The future of research on intimate partner violence: person-oriented and variable-oriented perspectives

This article uses the distinction between the person and the variable orientations as a frame for structuring (1) research on IPV, (2) results of this research, and (3) an agenda for future research. The main tenet of this agenda is that causes, processes, and effects of IPV are person and context specific; therefore, results that relate variables to each other are of limited value if it can be shown that the processes that take place, the meaning of the variables, the profile of the transgressors and the women who experience IPV depend on time, environment, and research design. Examples of valuable variable-oriented research are given; examples of the growing contribution made by person-oriented research are given as well. Sample theories are sketched out, for the variable-oriented, the person-oriented, and the theoretical research arenas, the need for future research is derived from inconsistencies and shortcomings in both current research and theory. Sample research questions are proposed. The contributions made by the authors of this Special Section are embedded within the discussion of research and theory of IPV. It is shown that each of the contributions is valuable within a particular segment of the research landscape.

Obsessive compulsive disorder: A review of possible specific internal representations within a broader cognitive theory

Obsessive Compulsive Disorder (OCD) is one of the most incapacitating of anxiety disorders, and is rated as a leading cause of disability by the World Health Organization (1996). Current cognitive models of OCD have focused on beliefs and management strategies involved in the development, maintenance, and exacerbation of OCD. However, despite evidence of their association to psychopathology, few researchers have applied the idea of underlying cognitive-affective structures, such as perceptions about the self and world, as operating in individuals with obsessive-compulsive thoughts and behaviors. This paper critically engages with current cognitive, developmental, and attachment research associated with views about the self and world. It is argued that consideration of such underlying cognitive-affective vulnerabilities may lead to a broader understanding of the development and maintenance of OCD. Consistent with previous theoretical work (e.g. ), we also argue that early experiences of parenting lead to the development of a dysfunctional self-structure and world-view relevant to OCD. Thus, this paper aims to extend the focus of current OCD research by exploring the possible role of a broader range of underlying vulnerability structures in the development and maintenance of OCD-related dysfunctional beliefs and symptoms.

Alexithymia, interhemispheric transfer, and right hemispheric specialization: a critical review

BACKGROUND

One neural model of alexithymia relates the condition to poor interhemispheric transfer, while another model associates it with a disturbance in right hemisphere activity.

METHODS

The available empirical evidence directly relating alexithymia to a deficit in interhemispheric transfer and/or in right hemisphere activity is critically reviewed.

RESULTS

The interhemispheric transfer studies have related alexithymia to a deficit in transfer, but the nature and directionality of the transfer deficit have yet to be determined. Many of the hemispheric specialization studies do not relate alexithymia to a right hemisphere dysfunction. Shortcomings of these studies are reviewed.

CONCLUSIONS

The hypothesis that alexithymia is related to a deficit in the right-to-left transfer of emotional information and to a right hemisphere impairment in emotion processing remains to be tested directly and definitively. Suggestions for future research are made.

A new model for understanding the role of environmental factors in the origins of chronic illness: a case study of type 1 diabetes mellitus

There is a need for a new pathophysiological model explaining and linking the role of numerous non-genetic factors believed to contribute to origins of many chronic physical diseases. This article presents a theoretical model for explaining the confusing and often contradictory findings regarding the role of environmental influences in type 1 diabetes, a disease that has been widely studied, for which clear diagnostic criteria exist, and for which development of effective prevention strategies represents significant challenges. The model is formulated from the large database of research regarding increasing understanding of the interaction between environmental factors, physiology, and autonomic regulatory function. Data is integrated from research in the fields of the experience-dependent maturation of the nervous system and the neurophysiology of traumatic stress to demonstrate how disruptions in early bonding and attachment, including adverse events such as traumatic stress, are capable of causing: (1) long-term imbalances in autonomic regulatory function and (2) relative dominance of sympathetic or parasympathetic activity. The proposed model of autonomic dysfunction suggests that ongoing mechanisms promoting high glucose in the context of decreasing insulin production in type 1 diabetes represent a state of relative sympathetic dominance influenced by environmental factors affecting autonomic, immune and endocrine systems during critical period programming. The model further identifies a link between the many seemingly unrelated non-genetic risk factors, and appears capable of explaining contradictions and enigmas in epidemiological and clinical studies regarding non-genetic origins of type 1 diabetes, including the role of stress, variation in age of onset, and duration of the preclinical phase.

Assessment of early mother-child relation in infants with oesophageal atresia

Fifteen one-year old infants with oesophageal atresia and their parents were used to demonstrate how the Parent-Child Early Relational Assessment (PCERA) can be used to explore the mother-child interaction in a clinical sample of children. The infants and their mothers were videotaped for 5-min episodes during feeding and free play, and the quality of the mother-infant interactions was assessed by PCERA. The results showed areas of strength regarding most of the maternal, infant and dyadic components. There was concern about maternal positive physical contact, maternal quality of verbalizations to or about the child, maternal social initiative, infant's communicative competence and infant's visual contact with mother. This concern of social proximity between infants and their mothers was most prominent in the feeding situation. The present study indicates that oesophageal atresia in infants may constitute stressors impinging on the parent-infant relationship. PCERA was found to be an adequate assessment tool with acceptable reliability to evaluate the mother-infant interaction.

Affects, agency, and self-regulation: complexity theory in the treatment of children with anxiety and disruptive behavior disorders

In an increasingly unsettled and violent world, with swelling numbers of children who are abused, abandoned, or neglected, emotionally if not physically, and an increasing population of aggressive preschool children with anxiety and disruptive behavior disorders who cannot be contained in ordinary settings, psychoanalysts can make a contribution. Early intervention is essential. In very early childhood, new procedural memories for interacting with others and for regulating affects can be formed more easily than they can ever be again. Intervention should aim toward helping the child develop a sense of agency, establish moral standards, assume self-responsibility, and attain the capacity for emotional regulation. The principles of complex dynamic systems can inform psychoanalytic treatment strategies, as demonstrated with five children whose cases are presented.

"Scared stiff": catatonia as an evolutionary-based fear response

Catatonia, long viewed as a motor disorder, may be better understood as a fear response, akin to the animal defense strategy tonic immobility (after G. G. Gallup & J. D. Maser, 1977). This proposal, consistent with K. L. Kahlbaum's (1874/1973) original conception, is based on similarities between catatonia and tonic immobility ("death feint") as well as evidence that catatonia is associated with anxiety and agitated depression and responds dramatically to benzodiazepines. It is argued that catatonia originally derived from ancestral encounters with carnivores whose predatory instincts were triggered by movement but is now inappropriately expressed in very different modern threat situations. Found in a wide range of psychiatric and serious medical conditions, catatonia may represent a common "end state" response to feelings of imminent doom and can serve as a template to understand other psychiatric disorders.

Randomized controlled trial of skin-to-skin contact from birth versus conventional incubator for physiological stabilization in 1200- to 2199-gram newborns

AIM

Conventional care of prematurely born infants involves extended maternal-infant separation and incubator care. Recent research has shown that separation causes adverse effects. Maternal-infant skin-to-skin contact (SSC) provides an alternative habitat to the incubator, with proven benefits for stable prematures; this has not been established for unstable or newborn low-birthweight infants. SSC from birth was therefore compared to incubator care for infants between 1200 and 2199 g at birth.

METHODS

This was a prospective, unblinded, randomized controlled clinical trial; potential subjects were identified before delivery and randomized by computerized minimization technique at 5 min if eligible. Standardized care and observations were maintained for 6 h. Stability was measured in terms of a set of pre-determined physiological parameters, and a composite cardio-respiratory stabilization score (SCRIP).

RESULTS

34 infants were analysed in comparable groups: 3/18 SSC compared to 12/13 incubator babies exceeded the pre-determined parameters (p < 0.001). Stabilization scores were 77.11 for SSC versus 74.23 for incubator (maximum 78), mean difference 2.88 (95% CI: 0.3-5.46, p = 0.031). All 18 SSC subjects were stable in the sixth hour, compared to 6/13 incubator infants. Eight out of 13 incubator subjects experienced hypothermia.

CONCLUSION

Newborn care provided by skin-to-skin contact on the mother's chest results in better physiological outcomes and stability than the same care provided in closed servo-controlled incubators. The cardio-respiratory instability seen in separated infants in the first 6 h is consistent with mammalian "protest-despair" biology, and with "hyper-arousal and dissociation" response patterns described in human infants: newborns should not be separated from their mothers.

Transforming the legacies of childhood trauma in couple and family therapy

A multi-theoretical couple/family therapy clinical social work practice model synthesizes various social, family, trauma, and psychodynamic theories to inform a biopsychosocial assessment that guides clinical interventions. The client population involves adult partners who have negotiated the impact of childhood trauma, i.e., physical, sexual, and emotional abuses, including culturally sanctioned trauma. Couples may also be dealing with the aftermath of acute trauma related to interpersonal violence, political conflict, and/or the dislocations related to refugee or new immigrant status. Clinical examples demonstrate the usefulness of the model as well as contraindications when active physical violence is present. The construct of resilience remains a central focus in assessment and treatment. Specific attention to cultural and racial diversity enriches both assessment and treatment interventions with these high-risk couples and families. This practice model will be explicated in depth in an upcoming publication from Columbia University Press titled Transforming the Legacies of Trauma in Couple Therapy.