Many if not most children in institutionalized care in developing countries have experienced trauma.
Last weekend I traveled to New York City, where I participated in a conference on trauma in infancy, “Do Babies Remember Trauma? The Psychology and Neurobiology of Early Trauma” sponsored by The Margaret Mahler Foundation and The Columbia Center for Psychoanalytic Training and Research. My colleagues, Susan Coates and Susan Vaughan and I co-directed the conference, and my friend, Maria Sauzier (“10 points for how to handle sexual abuse allegations” in this blog) and I discussed papers in the conference. It was a powerful conference. The subjects that were addressed included medical trauma, trauma in the home, and trauma on the street – experienced by infants – how it occurs, what are the effects on the mind and the body, and how to treat it. The main speakers were Susan Coates and Lenore Terr – both of whom gave detailed case presentations of children traumatized before the age of 1-year old – and Sunny Anand and Ted Gaensbauer, who talked about the neurobiology of pain and trauma in infancy. A 22-year old young woman, Mia, whom Dr. Terr treated for severe trauma suffered in the home of her biological parents before the age of 1-year, also spoke at the conference, with her adoptive mother.
What was remarkable about the cases was the inescapable awareness that children under the age of 1-year can “remember” trauma, although they usually at least at first remember it in their bodies instead of in their minds. Often the perceptual memory of the trauma is experienced in response to a visual perception, a noise, or a smell. In one case the child was revolted by the smell of oven cleaner and became terrified by the sight of a car the color and make of a car she had not seen since her infancy, in another the child became highly stressed by the color red (the blood in the violent attack), and in another the child felt his neck getting hot and cold and told his therapist that the only way to make it better was to put his hands around his neck, mimicking the way his mother had grabbed him around the neck during his infancy. In these presentations, the therapists first concentrated on two factors – making the child feel safe and involving the parents (or caregivers).
After this, they focused on helping the child construct an acceptable narrative of the traumatic event. In an ongoing psychotherapy, they would try to make the space for the child to take the lead in creating the narrative. For example, the child might create a play in which there was a bad guy that did something that resembled the original traumatic event(s) to another character in the play. That would give the therapist, for example, (not a literal example from the conference) the chance to help the child extend and elaborate the narrative such as by asking why the bad guy did what he was described as doing and what happened to the person he did it to. The therapists made an effort to conclude the narrative with an emphasis on keeping the child safe in the future.
The next part of the program centered on the neurodevelopmental aspects of trauma. Especially with my experiences as a pediatric intern in mind, it was extremely distressing to consider that until the mid-1980’s surgery on infants was routinely conducted without anesthesia. The prevailing wisdom was that infants could not process pain because they did not yet have a functional cerebral cortex, they “did not remember” the pain afterwards, and also that deep anesthesia was dangerous to infants.
Dr. Sunny Anand did not accept this view and conducted studies published in Lancet and in the New England Journal of Medicine that proved infants experienced metabolic and endocrine shock during some serious surgical procedures. His results were persuasive enough to cause the American Academy of Pediatrics and the American Society of Anesthesiologists to change their position and recommend anesthesia for infants undergoing surgery. Unfortunately, even as late as 2005, further studies indicated that many surgical procedures were being performed on unanesthetized infants. One of Dr. Anand’s important articles, KJS Anand & RR Hickey, “Pain and its effects in the human neonate and fetus”, The New England Journal of Medicine, Volume 317, Number 21: Pages 1321-1329,19 November 1987, is available online. In the conference, Dr. Anand talked about pain and consciousness in prenatal and neonatal life. Then Dr. Gaensbauer gave a thoughtful and comprehensive summary of the science involved in the experience of pain and trauma.
In my discussion, I made reference to new research from the lab of Rosario Montirosso in association with Ed Tronick, offering evidence that four month old infants “remember” the social stress of the mother’s sudden unresponsiveness (the still face) if it is repeated two weeks after the first exposure. Perhaps what is most fascinating about these findings is that the change in the tests measuring stress – such as salivary cortisol – depends on individual characteristics of the infant. Does this suggest that the four month old makes his own particular meaning of the stressful event of his mother’s unresponsiveness? I also related the information in Dr. Anand’s talk to a clinical case of mine in which an infant experienced medical trauma in the first weeks of life. When she was later brought to a major teaching hospital for the evaluation of her fearfulness, severe tantrums, and sensory hypersensitivity, a provisional diagnosis of pediatric bipolar disorder was given. In my second opinion, the medical trauma in infancy played an important role not only in the child’s subsequent neurodevelopment but also in the distortion of the family developmental trajectory, as the – also traumatized – parents struggled to set limits on the demanding behavior of a child who when stressed could quickly dissolve into panic and dissociation.
In my reflection after the conference, I thought about how to identify the impact of trauma in infancy in the children who are brought to me with psychological problems. Many of the children that I see have had what I now recognize as medical trauma. I think of the children who may never be able to “put into words” what troubles them because it is locked in their body experience. Can play allow these terrible experiences to find symbolic representation in an adaptive form? Sometimes. I also think about how parents who themselves have been traumatized by their infants’ illness and painful medical procedures need to be helped to make sense of what they have gone through and the effect it might have had on their efforts to parent their sometimes fragile child. Finally, I ask myself how we ever could have believed that infants did not experience pain, what kind of denial did we use to protect ourselves against the awareness of the effects of our actions on these tiny children.