Child refugees and the psychological impacts of early childhood trauma

Lessons learnt from child protection

Dr David Everett and Dr Deepa Jeyaseelan

Department of Paediatrics, Flinders Medical Centre

Outline

• The importance of the Early Years

• Lessons from the 1st World experience of child trauma from mal-treatment may apply to young refugee children from disadvantaged countries

Child development

• Physical– Body size, proportions, motor function, health

• Emotional and social– self understanding, interpersonal skills, theory

of mind, friendship, moral reasoning, behaviour

• Cognitive– Intellectual abilities– Executive functions– Imagination– Knowledge– Language

Periods of development• Prenatal

– Conception to birth - most rapid change

• Infancy to toddler (birth to 2 years)– motor, perceptual, intellectual capacity– Language begins– Intimate ties to others and autonomy

• Early childhood (2-6 years)– Refining of motor skills– Self-sufficiency and self control– Language - increased complexity– Play and peers– Morality

Periods of development• Middle childhood (6-11 years)

– Master responsibilities– Group participation, friendships– Morality– Logical thought– Literacy, numeracy

• Adolescence (11-18 yrs)– Autonomy– Transition to adult world– Adult size; sexual maturity– Abstract thinking– Define personal goals and values

Theories of child development• ‘Nature vs nurture’

– Heredity• Person is born with own set of characteristics• e.g. verbal ability, sociability, anxiety

– Impact of environment• Early experiences (-ve or +ve) shape and

establish lifelong patterns of behaviour.

• Maturation – Genetically determined ‘unfolding course’

of growth.– Stepwise; discontinuous

Theories of child development• 20th century

– Psychoanalytic models• Freud psychosexual stages• Erikson’s psychosocial stages of

development

– Behaviourism and social learning theories

• Pavlov - classical conditioning• Skinner - operant conditioning

– Cognitive developmental theory• Piaget - children actively construct

knowledge– i.e. they ACTIVELY learn and ADAPT

Recent developmental concepts

• Critical periods– Limited time during with a child is

biologically prepared to acquire certain adaptive behaviours.

– Needs the support of an appropriately stimulating environment.

• Emotional control, vision and social attachment 0-2 years

• Vocabulary 0-3 years; Second language 0-10 years

• Walking by 4 years• Maths/Logic 1-4 years• Music 3-10 years.

– If opportunity missed • difficult/?impossible to learn.

Ethological theory of attachment• Bowlby 1969• Quality of attachment of child to

caregiver has profound impact on child’s sense of security and capacity to form trusting relationships.– Preattachment - birth to 6w– ‘Attachment in the making’ - 6-8w– Clear-cut attachment - 6m-2yrs– Formation of reciprocal relationship ->18m.

• Need sensitive caregiver– Responsive, consistent, appropriate care.

Recent developmental concepts

• Ecological systems theory

Community

Scouts

School

Sports Club

Art Class

Family

Child

Outcomes of development• All of a child’s early experiences

are educational– If these experiences are consistent,

developmentally sound, emotionally supportive and attachment is secure• positive effects on child and family.

• If children enter school ready to learn

• Better academic outcomes • Linked to improved social,

economic and health outcomes in adulthood.

Outcomes of development• Detection and amelioration of

developmental problems in PRESCHOOL period– increases likelihood of entering school

ready to learn and succeed.

• If DD undetected and untreated– Increased rates of school failure– Behaviour problems– Low self esteem– Loss of potential– Significant economic and social impact on

society once child reaches adulthood.

Early deprivation and enrichment

• Eastern Europe orphanages– Infants placed in adoptive families at

various ages.– The later the child was removed from

deprived rearing condition --> less favourable developmental outcome.

– Unstimulating environment• > 6 months - Cognitive impairments

noted.• > 2 years - Severe and persistent

impairments in all domains of development.

Outcomes of development• Children exposed to significant

neglect or maltreatment• Fail to develop capacity to attach to

others.• Have poor emotional regulation.• Seek control rather than closeness in

relationships.• Have higher rates of aggressive

behaviours and conduct disorders in later life.

• Higher rates of DD and learning difficulties (30-40%).

What factors impact on developmental outcomes?• Social and behavioural determinants of health

– Environmental factors– Psychosocial factors– Behavioural / Lifestyle factors– Physiological factors– Global forces – Government policies/ health care system

• These factors interact with child’s genetic and temperamental predisposition– Results in biological changes– Determines coping, resilience and health outcomes

for adult life.

Risk factors for child health outcomes

More likely to have mother with less than high school education; be from single parent household or ESL household.

Backgrounds of prenatal stressors, maternal mental health or substance abuse issues, poor family organisation.

Lower SES – outcomes for children

• Poorer behavioural scores• Higher drop out rates from school• Higher criminality• Higher rates of smoking/substance

abuse.• Increased marginalisation

– Less use of health services

• Poorer SES and (mental)health as adult• Risks for poorer outcomes are

cumulative

JUST AS …..• Disease research leads to healthy-living

knowledge and recommendations

• Vehicle accident research leads to improved road safety

SO …..• Observation and research from early childhood

adversity and trauma has led to ideas for advantaging children. And its all to do with the Brain.

THE BRAIN

•It is the organ responsible for

everything we do – love, laugh,

walk, talk, create or hate

•It has one hundred billion nerve

cells organized into a complex net

of continuous activity

•Its function is a reflection of our

experiences

Prime evolutionary directives of the brain

•Stay alive!

•Affiliate and mate

•Protect and nurture dependents

Brain development is sequential and hierarchical.Like most hierarchies, it is fairly rigid in function, and has a large ‘executive function’ department which is dependant on progressively smaller ‘primitive

function’ departments!

Sequential neurodevelopment

•The brain is undeveloped at birth

•It organizes from the bottom up (brain stem to cortex) and from the inside out

•Experiences do not have equal impact throughout development (generally greater impact the earlier the age)

Translating experience (sensory input) into function (patterned neuronal activity).

• All neurons change their molecular functioning in a use-dependent fashion

• Therefore, patterned sensory input leads to patterned changes in neuronal systems

• Patterned neuronal changes allow the brain to make internal representations of the ‘external’ world

• The more a neural system is activated, the more that system changes to reflect that activation pattern – this is the basis for development, memory and learning.

Experience matters, because experience Experience matters, because experience changes the brain (good and bad)changes the brain (good and bad)

States become Traits

Especially if repeated, unpredictable, physically or verbally violent

Memory

Cognitive

Emotional

Motor

State

Complexity

Plasticity

Mal-treatment, trauma and fear – impact on learning

Traumatized children have a typical set of observable problems at school. Includes difficulties with attention, processing and storing information, and problems acting on their experiences in an age-appropriate manner

• Physical and sexual mal-treatment of children is almost always accompanied by psychological and emotional mal-treatment

• Vast majority of mal-treatment is perpetrated by somebody in a carer role.

That is, it is a breach of Healthy Attachment

Healthy attachment

• “Optimal” caregiving in the early years – is positive, harmonious, responsive and predictable

• Involves the Somatosensory Bath (B. Perry)

– Touch, taste, sight, smell, sound and movement in the caregiver-infant interaction

– These primary sensations play a major role in providing the patterned, repetitivepatterned, repetitive sensory stimulation and experiences that help organise organise the child’s developing brainthe child’s developing brain

Poor attachment

NEGLECT – effects of early intervention on brain growth are enhanced the earlier the

intervention starts

0

5

10

15

20

25

30

1 yr 2 yrs 3yrs 4yrs

Head circumferemcepercentile - beforeintervention

Head circumferencepercentile - afterintervention

social disadvantage perpetuates itself if intervention does not occur early

Source: Inequality in the early cognitive development of British children in the 1970 cohort by Leon Feinstein, Economica, February 2003

High social class, high score at 22 months

High social class, low score at 22 months

Low social class, high score at 22 months

Low social class, low score at 22 months

0

10

20

30

40

50

60

70

80

90

100

22 28 34 40 46 52 58 64 70 76 82 88 94 100 106 112118

Age in months

Av

era

ge

po

sit

ion

in

th

e d

istr

ibu

tio

n

Social background is a more powerful predictor of educational outcomes by age 10 than attainment at 22 months

less able richer children overtake more able poorer children by the age of six

Suggested References

• http://www.rch.org.au/immigranthealth/index.cfm• www.ChildTrauma.org – large resource site• Neuroarcheology of Childhood Maltreatment, B. Perry• Long-term effects of nurse home visitation on children’s

criminal and antisocial behaviour. D. Olds et al, JAMA, 1998• The economic cost of child abuse and neglect in SA, 1998,

Office of Families and Children• Childhood trauma, the neurobiology of adaptation, and “use-

dependent” development of the brain: how states become traits. B. Perry et al, Infant Mental Health Journal, 1995

• Early Years Study, McCain & Mustard.

Experience of child refugees

• Approximately half of the world’s 20 million refugees are children.– Majority are from central Africa (57%).

• Phases of experience– Preflight– Flight– Resettlement

• 4 broad reactions– Anticipation, devastating event, survival

and adjustment.

Preflight

• Onset of political violence/war– Witness or even engage in violence

• Social upheaval and increasing chaos in region

• Limited access to school– Disruption of education and social

development

• Anticipate/Cope with devastating event.

Flight

• Great uncertainty about future• Displacement from home• Transitional placement

– Risks of community violence, rape, abuse, DV exposure, disease, physical injuries.

• Dependence on others from basic needs– Inadequate nutrition, hygiene, medical care

• Separation from parents and caregivers.– This has a greater impact on children than

exposure to war atrocities.

Resettlement

• Coping with new belief systems, values– Challenges their adjustment– Straddle old and new cultures more than

their parents• May be cultural liaison for family.

• Losses– Homeland, family, friends, possessions

• Struggles to establish ‘normalcy’– Parent may be present but emotionally

absent.

• Acculturation – 4 phases– Contact, conflict, crisis and adaptation.

Outcomes for child refugees

• High risk for mental health problems– Exposure to trauma– Superimposed on complex

acculturation and adjustment processes.

• More likely long term poor outcome– Greater number of risk factors– Younger the child

• <11 year old 3x more likely to develop PTSD Sx from experiences.

Protective factors

• Parents – Ability to cope, to maintain sense of calm

and order, avoidance of dangerous situations

• Ideological commitment to cause• Use of multiple coping strategies

– Emotion-inhibiting / focused, wishful thinking.

• Other social supports– Connections to culture of origin– Acculturation expands networks.

Increased vulnerability to psychological symptoms

• Exposure to war and political violence• Individual vulnerability before trauma

exposure• Lower pre-migratory expectations• Resettlement stress

– Father’s long term (>6 mths) unemployment in first year.

– Mother’s emotional well-being– Family’s negativity– Acute chronic health issues

Child response to trauma

• Attention problems• Anxiety• Mood disorders• Hyper/Hypovigilance• Sleep disorders• Behaviour/conduct disorder• Suicidal ideation• PTSD

Clinical presentation

• Withdrawal

• Extremes of aggression and negative emotion

• Fearfulness of benign items /people

• Disrupted sleep

• Somatic symptoms

Clinician’s role in the care of child refugees

• Prior to settlement– Health care focuses on basic survival

• Resettlement– Refugees contend with a myriad of

agencies, organisations, schools, courts, medical facilities and social services.

– Hierarchy of needs and access may determine their agendas of use.

– Minimise ONGOING harm and risks health outcomes.

Clinician’s role in the care of child refugees

• Promote optimal nutrition, growth and physical health.– Includes immunisations

• Developmental screening– Refer to community based services as

needed

• Screen for and act on behavioural and mental health concerns raised– Have awareness of interventions known to

benefit young children and advocate for children’s access to services

• Home visiting; Incredible Years; CAMHS

Clinician’s role in the care of child refugees

• Provide info and surveillance with regards to injury prevention– awareness of protection of children from

injury and abuse.

• Screen for psychosocial risk– DV, maternal depression, isolation.

• Support family– Parental mental health, community

supports• Empower caregivers --> increase their

independence

• Culturally appropriate practice.

Clinician’s role in the care of child refugees

• Address social needs early• Learn about culturally familiar people and

supports and develop partnerships.• Faciliate communication

– Culturally trained clinicians, interpreters.

• Account for developmental vulnerabilities and abilities– To determine pace and nature of

psychotherapeutic intervention.– Be aware of stigma associated with seeking

mental health support– Talking about painful events may not be

experienced as valuable by refugees.– Take into account the role of ongoing traumatic

triggers.

Discussion

Vitamin D/Rickets

• http://www.health.sa.gov.au/PPG/Default.aspx?tabid=202

• SA Perinatal Guidelines, Chapter 5c “Vitamin D deficiency”

  Introduction | Vitamin D deficiency in pregnancy | Antenatal screening and treatment | Neonatal management | References | Last reviewed

Rickets - general osteopenia (bone thinning), rib fractures, irregular metaphyses, peri-osteal new bone formation, bowing

Enuresis

Definitions

• International Children’s Continence Society (1997)

• Enuresis– Normal voiding that occurs at an inappropriate or

socially-unacceptable time or place– nocturnal or diurnal– diurnal enuresis vs dysfunctional voiding

• neuropathic & nonneuropathic

• Incontinence– Involuntary loss of urine, objectively demonstrable, and

constituting a social or hygienic problem

Evaluation - History

• Current symptoms and signs– voiding pattern - stream/volume/frequency (diary)

– dysuria/frequency/urgency

– holding manoeuvres

– perineal hygiene - vulvovaginitis/balanitis

– UTI’s

– constipation

• Specific problems in infancy• Age and pattern of toilet training

– primary vs secondary

– longest dry periods

• Family history of urological problems• Social history - think about CSA

Pathogenesis of Bladder Dysfunction

“Bad” bladder behaviours

• Adoption of holding manoeuvres to suppress desire to void

- leads to overactive detrusor with uninhibited bladder contractions

• develop volitional control over contraction of the external sphincter - external sphincter is used as ‘on-off’ switch

for bladder

- difficulty relaxing sphincter when attempting to void voluntarily (detrusor sphincter discoordination)

Holding Maneuvers

Evaluation - Physical Exam

• Exclude structural lesions– Abdominal examination– Genital examination

• labial adhesions/meatal stenosis

• bifid clitoris

• Exclude occult neurological disorders– examine back for signs of occult spina bifida– DTR’s lower limbs– gait– anal wink

Evaluation - Investigations

• Urinalysis - dipstick, M/C/S, (urine osmolality)• Ultrasound (IVP if suspect ectopic ureter)

– estimate functional bladder capacity & residual

• MCU if abnormal USS• Spinal Imaging• Urodynamics

General Principles of Treatment

• Treat constipation• Ensure adequate fluid intake• Bladder retraining

– Timed voiding schedule

– Double voiding if large post-void residual

– Physiotherapy - pelvic floor retraining

– Biofeedback

• Medications– Antibiotic prophylaxis if UTI

– Anticholinergics eg propantheline, oxybutinin

Urge Syndrome Lazy Bladder Diurnal Enuresis

Other names Detrusor instability Dysfunctional voiding

Pathogenesis Uninhibited bladdercontractions during filling

Bladder-sphincterdiscoordination

Unclear

Symptoms ‘Minor’ wettingUrgencyFrequencyHolding manoeuvres

‘Minor’ wettingSometimes urgency

Uncontrolled voidingNo/deny urgeComplete bladder emptying

Voiding Pattern Small volumeFrequent voiding

Large volumesInfrequent voidingLarge post-void residual

Normal voiding

AssociatedProblems

UTIConstipation

UTIConstipation

Behavioural problemsEncoporesis(UTI)

Management Treat constipationIncrease fluid intakeTimed voidingAnticholinergics

Treat constipationTimed voidingDouble voiding

Psychosocial assessmentBehavioural program

Voiding Disorders - Summary