Rrepresentations of trauma in infancy: Clinical and theoretical implications for the understanding of early memory

MDMA-assisted psychotherapy for PTSD: Growing evidence for memory effects mediating treatment efficacy

The application of MDMA in conjunction with psychotherapy has in recent years seen a resurgence of clinical, scientific, and public interest in the treatment of posttraumatic stress disorder (PTSD). Clinical trials have shown promising safety and efficacy, but the mechanisms underlying this treatment form remain largely unestablished. This article explores recent preclinical and clinical evidence suggesting that the treatment's efficacy may be influenced by the mnemonic effects of MDMA. We review data on the effects of MDMA on fear extinction and fear reconsolidation and the utility of these processes for PTSD treatment. We corroborate our findings by incorporating research from cognitive psychology and psychopharmacology and offer recommendations for future research.

Understanding the Experiences of Living With an Artificial Eye in Children With Retinoblastoma-Perspectives of Children and Their Parents

Background: Retinoblastoma is a rare form of pediatric eye cancer for which enucleation is a common treatment modality. There is an increasing focus upon the impact of enucleation on children and families. This study aimed to explore the experiences of children and their families following enucleation to consider the barriers that may be encountered when adjusting to living with an artificial eye and identifying the support services and strategies used to address these barriers. Methods: Using a descriptive qualitative approach, interviews were conducted with 12 parents and seven children and thematic analysis was used to identify four themes representing the perspective of parents and children. Results: Parent themes identified were (a) entry into the world of retinoblastoma; (b) the importance of specialist support; (c) a family learning to cope; and (d) navigating school. The perspectives of children were (a) the importance of preparation and play; (b) positive reinforcement and hospital support; (c) support and openness at home; and (d) the importance of good school planning. Two overarching themes related to parent and child adaptation were also identified. Discussion: The study findings reveal that the process of adapting to living with an artificial eye extended to influencing decisions around parenting, learning to advocate for their child, and supporting children through school and peer relationships. For children, the importance of ongoing support and information was vital to enhance understanding, adaptation, and development of independence. Overall, the study suggests that children and families undergoing enucleation need continuing, individualized, and specialist support.

When the Good Object is also a Thief: A Memoir of Adoption

This contemporary Kleinian memoir explores the possible existence of an intrapsychic, adoption-specific preoedipal triad including child, birth mother, and adoptive mother that can shape the emerging mind. As an intrapsychic construct, the adoption triad comes to exist in the infantile mind, requiring that adoptees contend with four additional part-object maternal representations: a villain (bad birth mother), a victim (good birth mother), a rescuer (good adoptive other), and a thief (bad adoptive mother). The psychic complexities of this possible adoption triad are explored, with an eye to how it might illuminate the psychosocial challenges experienced by some adoptees, including dysregulated behavior, rage, dissociation, and shame. To this end, Bion's ideas regarding presymbolic, nondefensive communication and Winnicott's understanding of use of the object are invoked. Expanding the preoedipal paradigm of adoption to include the possibility of an intrapsychic, adoption-specific maternal triad can enhance our understanding of the psychology of adoption, as well as highlight the need to consider the ways in which internal objects can exist simultaneously in both dyadic and triadic paradigms.

The Boy Who Was Hit in the Face: Somatic Regulation and Processing of Preverbal Complex Trauma

Examination of novel treatment for complexly traumatized youth, in particular, those exposed to preverbal trauma, is necessary given challenges associated with effective intervention for this population. Therapies that facilitate somatic regulation have demonstrated benefit for some trauma survivors. The current article briefly reviews the emerging literature on symptoms of and treatments for complex and preverbal child trauma and describes Sensory Motor Arousal Regulation Therapy (SMART), an intervention for child and adolescent trauma with preliminary empirical support. SMART aims to enhance sensory motor engagement and promote affective, behavioral and physiological regulation using somatic regulation and sensory integration techniques. Utilizing case study methodology, the article illustrates application of SMART in treatment of a latency-aged child with history of exposure to complex and preverbal traumatic experiences. Case analysis suggests the potential contribution of enhanced somatic regulation in traumatized children toward increased relational engagement, behavioral and emotional regulation, and trauma processing.

Psychopathological sequelae of female genital mutilation and their neuroendocrinological associations

BACKGROUND

Anecdotal evidence suggests the frequently traumatic nature of female genital mutilation (FGM). At present, systematic research on the psychological sequelae of this tradition has remained limited. The study provides preliminary, high-quality psychodiagnostic data on potential psychopathological consequences of FGM, with a focus on posttraumatic stress disorder (PTSD), shutdown dissociation and other stress-related variables.

METHODS

We investigated a convenience sample of N = 167 women, supported by the women's affairs headquarters in Jijiga (capital of the Ethiopian Somali Region) and a local Ethiopian non-governmental organization. Our main outcome measures were PTSD (PSS-I) and shutdown dissociation (ShuD). We also assessed depression and anxiety (HSCL-25), major depression, substance abuse and dependence, suicidality and psychotic disorders (M.I.N.I.; sub-scales A., B., K., and L.). In addition, we collected hair samples to assess hair cortisol concentrations (HCC) as a neuroendocrinological measure.

RESULTS

The majority of women endured FGM (FGM I: 36%, FGM II/III: 52%) and, regardless of the level of the physical invasiveness, almost all women reported having felt intense fear and/or helplessness. FGM II/III, the more invasive form, was associated with a greater vulnerability to PTSD symptoms (p < .001) and shutdown dissociation (p < .001). Symptoms of depression (p < .05) and anxiety (p < .01) were also elevated. Random forest regression with conditional inference trees revealed evidence of an alteration of the cortisol levels in relation to the age when FGM was experienced (< 1 year) and the invasiveness of the procedure.

CONCLUSION

More extensive forms of FGM are associated with more severe psychopathological symptoms - particularly with an increased vulnerability to PTSD. Higher hair cortisol levels in women who experienced FGM before their first year of age or had more severe forms of FGM indicate long-term neuroendocrinological consequences of FGM and trauma in general on the stress system.

MOMENTS OF MEETING: THE RELEVANCE OF LOU SANDER'S AND DAN STERN'S CONCEPTUAL FRAMEWORK FOR UNDERSTANDING THE DEVELOPMENT OF PATHOLOGICAL SOCIAL RELATEDNESS

Lou Sander and Dan Stern made seminal contributions to our understanding of early child development, particularly in regard to the moment-to-moment intersubjective exchanges and mutual sensitivity that are at the core of the caregiver-infant relationship. Although their own studies focused primarily on the ways in which children's intersubjective experiences of mutual attunement lead to adaptive social relatedness and validate a healthy sense of self, this article focuses on the applicability of their theoretical conceptions to the development of pathological social relations. It explores the premise that the emotional validation derived from recurrent intersubjective experiences of mutual attunement involving negative affects can be as emotionally compelling from the child's standpoint as that derived from positive exchanges. Children's needs to recreate unhealthy, but affectively meaningful, moments with their caregivers can lead to ingrained, automatically operating pathological patterns of social behavior and affective expression that can take on a life of their own and strongly shape the child's subsequent socioemotional functioning. Following an overview of Sander's and Stern's conceptual thinking, developmental research and clinical case material will be utilized to illustrate how their work can enrich our understanding of developmental processes that can contribute to a number of emotion-specific, early relational disturbances.

The Amsterdam Sexual Abuse Case (ASAC)-study in day care centers: longitudinal effects of sexual abuse on infants and very young children and their parents, and the consequences of the persistence of abusive images on the internet

BACKGROUND

Little research has been done on the signs of child sexual abuse (CSA) in infants and very young children, or on the consequences that such abuse - including the persistence of the abusive pornographic images on the internet - might have for the children and their parents. The effects of CSA can be severe, and a variety of risk- and protective factors, may influence those effects. CSA may affect the psychosocial-, emotional-, cognitive-, and physical development of children, their relationships with their parent(s), and the relations between parents. In the so called 'the Amsterdam sexual abuse case' (ASAC), infants and very young children were victimized by a day-care employee and most of the victims were boys. Research involving the children and their parents would enable recognition of the signs of CSA in very young children and understanding the consequences the abuse might have on the long term.

METHODS/DESIGN

The proposed research project consists of three components: (I) An initial assessment to identify physical- or psychological signs of CSA in infants and very young children who are thought to have been sexually abused (n = 130); (II) A cross-sequential longitudinal study of children who have experienced sexual abuse, or for whom there are strong suspicions; (III) A qualitative study in which interviews are conducted with parents (n = 25) and with therapists treating children from the ASAC. Parents will be interviewed on the perceived condition of their child and family situation, their experiences with the service responses to the abuse, the effects of legal proceedings and media attention, and the impact of knowing that pornographic material has been disseminated on the internet. Therapists will be interviewed on their clinical experiences in treating children and parents. The assessments will extend over a period of several years. The outcome measures will be symptoms of posttraumatic stress disorder (PTSD), dissociative symptoms, age-inappropriate sexual behaviors and knowledge, behavioral problems, attachment disturbances, the quality of parent-child interaction, parental PTSD, parental partner relation, and biological outcomes (BMI and DNA).

DISCUSSION

The ASAC-project would facilitate early detection of symptoms and prompt therapeutic intervention when CSA is suspected in very young children.

Whose memories are they and where do they go? Problems surrounding internalization in children on the autistic spectrum

Recent work in neuroscience has highlighted the contrast between 'procedural' memory for bodily experiences and skills, which is unconscious though unrepressed, and verbalizable, 'declarative' memory, which includes autobiographical memory. Autobiographical memory is weak in people with autistic spectrum disorder, who frequently turn to self-generated sensations for reassurance that they continue to exist. The author suggests that, instead of internalizing shared experiences leading to growth, children with autism can feel that they add to themselves by taking over the qualities of others through the 'annexation' of physical properties that leads to a damaged object and can trigger a particular sort of negative therapeutic reaction. Clinical illustrations drawn from the treatment of two children on the autistic spectrum illustrate some ramifications of these processes in relation to the sense of a separate identity and the capacity to access memories.

Children's memories for events relating to treatment for eye cancer: Influence of age at loss of eye

Treatment for retinoblastoma frequently involves removal of at least one eye in the first 5 years. Variation in age of treatment leads to the assumption that children's later verbal accessibility of early traumatic memories may vary, with some children having less opportunity to make sense of their condition. Video recordings were made of 17 children who had undergone enucleation either before 24 months (n = 8) or after 24 months (n = 9) involved in "hospital play'' using props designed to elicit talk about "eyes." The hypothesis that a larger number of verbalizations about medical procedures would occur in children enucleated after 24 months than before 24 months was supported. Children enucleated after 24 months engaged in significantly more talk about enucleation and/or examination under anesthetic whereas none of the children enucleated in infancy talked about these medical events. The outcome supports the view that there is a transition around 24 months in the extent to which children can have verbal access to previous traumatic memories. The design of interventions needs to take into account that children enucleated in infancy have less opportunity for later verbal access to early memories of traumatic events than those treated later, leading to possible misconceptions about their own condition.

Infant trauma

Trauma forms the second largest cause of death in children under 1 year of age. Infants form a difficult cohort of patients; their range of development, differing physiology and inability to communicate or understand treatment makes them a challenge for any healthcare worker. Several factors compound this problem including a general lack of familiarity within non-specialised trauma services and the difficulty in studying infants as a cohort in academic research. This article aims to summarise the common problems encountered in dealing with infants in a trauma setting and specific differences in their management compared to other children or adults. Where possible it details current evidence most appropriate to the age group.

Psychoanalytic perspectives on early trauma: interviews with thirty analysts who treated an adult victim of a circumscribed trauma in early childhood

Information on the long-term effects of early trauma and how such effects are manifested in treatment was obtained through interviews with thirty analysts who had treated an adult patient with a circumscribed trauma in the first four years of life. Childhood traumas fell into four categories: medical/accidental; separation/loss; witnessing a traumatic event; and physical/sexual abuse. Traumatic carryover was recorded in terms of explicit memories, implicit memories (somatic reliving, traumatic dreams, affective memories, behavioral reenactments, and transference phenomena), and global carryover effects (generalized traumatic affective states, defensive styles, patterns of object relating, and developmental disruptions). Linkages between the early trauma and adult symptomatology could be posited in almost every case, yet the clinical data supporting such linkages was often fragmented and ambiguous. Elements of patients' traumas appeared to be dispersed along variable avenues of expression and did not appear amenable to holistic, regressive reworking in treatment. The data did not support linear models of traumatic carryover or the idea that early traumatic experiences will be directly accessible in the course of an analysis. Factors that we believe help explain why traumatic aftereffects in our sample were so heterogeneous and difficult to track over the long term are discussed.

Event trauma in early childhood: symptoms, assessment, intervention

Expanding research over the last two decades has documented that very young children's responses to an event trauma will involve the same three basic categories of posttraumatic symptomatology observed in older children and adults that is, reexperiencing, numbing/avoidance, and hyperarousal. The ways in which these three symptom clusters will be manifested in very young children and recent progress in the establishment of developmentally sensitive and reliable criteria for the diagnosis of posttraumatic stress disorder (PTSD) in this age group are described. In addition to PTSD symptomatology, three additional factors that differentiate young children's responses to a trauma from those of older children and adults-their cognitive immaturity, their developmental vulnerability, and the relational context of early trauma given young children's dependence on caregivers-also are discussed. Principles of assessment and treatment are then described. These discussions emphasize the importance of normalizing traumatic responses, supporting the parent-child relationship and restoring trust, desensitizing the child's distress to traumatic reminders, helping the child and parents to process and develop a meaningful narrative of the traumatic event through expressive therapeutic techniques, and promoting effective strategies of restoration and repair.

Mental health in infants with esophageal atresia

Chronic somatic illness in infancy may challenge the development of mental health and impinge the infant's capability to form close interpersonal relationships. Esophageal atresia (EA) is a congenital anomaly requiring neonatal surgery, medical aftertreatment, and extended hospitalization. The aim of the study was to assess mental health and to find prognostic factors for mental health among infants with EA. Thirty-nine infants treated consecutively during 2000 to 2003 and their mothers were included. Infant mental health was assessed by Diagnostic Classification: 0-3 (Zero to Three, 1994). Medical and environmental data were collected from medical records and semistructured interview with the mothers. Child development was assessed with the Bayley scales, second edition (N. Bayley, 1993). Maternal psychological distress, anxiety, and child temperament were assessed by self-report questionnaires: the General Health Questionnaire, 30-item version (D. Goldberg & P. Williams, 1988); the State Trait Anxiety Inventory (C.D. Spielberger, R. Gorsuch, & R. Lushene, 1970); and the Infant Behaviour Questionnaire (M.K. Rothbart, 1981). Thirty-one percent of the infants with EA showed mental health disorders by 1 year of age. Prognostic factors predicting mental health were posttraumatic symptoms reported by mother, more than one operation, mechanical ventilation beyond 1 day, and moderate/severe chronic family strain. Relational trauma, vulnerable attachment, and impaired self-development are highlighted as possible pathways for psychopathology. Children with EA are vulnerable to mental health disorders, and this study may help clinicians to identify children at risk.

The long-term consequences of early childhood trauma: a case study and discussion

There is a great need to better understand the impact of traumatic events very early in life on the course of children's future development. This report focuses on the intriguing case of a girl who witnessed the murder of her mother by her father at the age of 19 months and seemed to have no recollection of this incident until the age of 11, when she began to exhibit severe symptoms of posttraumatic stress disorder (PTSD) in response to a traumatic reminder. The case presentation serves as the basis for a discussion regarding pertinent issues involved in early childhood trauma. This case and accompanying discussion were originally presented at the 19th Annual Meeting of the International Society for Traumatic Stress Studies and were transcribed and revised for use in this article. Specific topics include early childhood memory and trauma, learning and the appraisal of danger, and PTSD and traumatic grief in early childhood. Clinical and public health implications are also discussed. This case illustrates the dramatic impact that "preverbal" traumatic memories can have on children's later functioning and speaks to the importance of assisting very young children in the immediate aftermath of traumatic events.