Monthly Archives: October 2015

Day 2 of Joy Osofsky at IPMH


The following day Joy Osofsky talked about trauma. She outlined ways in which children can be traumatized by adverse childhood experiences as noted in the “ACE” study, in the 1990’s, . She talked about how trauma affects children’s cognition, behaviors, emotions, and brain architecture. Finally, she described several ways traumatic sequelae can be healed. I would like to think of these issues in terms of a spectrum from normative stress, which can be positive, to trauma, with “tolerable” and “toxic stress” in the middle. I will explain more about this spectrum later on, but I want to introduce the idea of a spectrum of stress at this point, because I believe that much of what Joy was talking about in terms of trauma can also be true in situations of high stress – especially when it is prolonged – that do not reach the level of actual trauma.

Children are traumatized by child maltreatment; exposure to community violence in their neighborhoods and in their schools; exposure to domestic violence in their homes; exposure to or hearing about unusual traumatic events such as accidents, terrorist attacks, or hurricanes; military children when their parents are deployed; and exposure to violence in media (usually the effects of an earlier trauma will be exacerbated by subsequent exposure to media).

Joy and her husband were leaders in the psychological response to Katrina in New Orleans. She notes that the psychosocial impact of natural disasters can be similar to that of trauma. The impact is related to the disruption of family structures, changes in the ways people and communities relate to each other, and the taxing effect on the individual, family, school, and community infrastructure. The psychological referral rate for students was very high after Katrina and then declined, but subsequent smaller spikes seem to reflect retraumatization from other hurricanes, oil spills, etc. A child in my hospital clinic began waking up with nightmares after hearing Donald Trump on television saying that all Mexican immigrants should be deported, because she feared that she would lose her parents.

Interestingly, in New Orleans, the children who were integrated into East Baton Rouge schools had higher depression rates than the children who were able to return to their New Orleans schools. This seems to relate to the importance of a “sense of place”. Another window into trauma is the child welfare system, where children have experienced family violence, substance abuse, sexual abuse, removal from primary caregiver, subsequent placement in foster care, and physical abuse.

Trauma alters the developmental trajectory of the child. Joy referred to the children’s book, The Little Engine That Could. She said that trauma pushes the train off the track, and our job as mental health professionals is to help put the little train back on the track. Joy noted the continuum from stress to trauma, starting with normative, developmentally appropriate stress, then emotionally costly stress, sometimes called “toxic stress”, and finally trauma. Positive stress is necessary to healthy development. It occurs in the context of stable, supportive relationships and results in brief increases in heart rate and mild changes in stress hormone levels. Tolerable stress includes stress responses that could disrupt brain architecture but are buffered by supportive relationships that make it possible for the brain to heal. Toxic stress involves a strong, prolonged activation of the body’s stress response system in the absence of the buffering protection of adult support. Toxic stress can damage the developing brain architecture and create a short fuse for the body’s stress response systems, leading to lifelong problems in learning, behavior, and both physical and mental health.

IPMH Joy Osofsky Weekend

I am catching up on my infant parent postings by writing about a wonderful weekend with Joy Osofsky last month. In her first day of her teaching Joy began by introducing us to three evidence based interventions for very young children – Attachment and Bio-behavioral Catch-up (ABC),  Parent Child Interaction Therapy (PCIT), and Child-Parent Psychotherapy (CPP),  Although not exclusively used for this purpose, these interventions were designed to treat traumatized young children and their parents.

ABC is an intervention for parents of young children who have experienced adversity that helps parents recognize their children’s problematic coping strategies and recognize their own problematic parenting behaviors, so that they can create a caregiving environment that promotes their children’s bio-behavioral regulation. The intervention takes place in 10 sessions that target key issues for traumatized children and is manualized, though the relationship between the clinician and the parent is crucial to the success of the treatment. This intervention is particularly useful for foster parents of infants of toddlers 1-3-years old, high risk birth parents of infants and toddlers, and parents adopting internationally.

Two main emphases of ABC intervention are that (1) some children reject their caregivers even though they need nurturance, and (2) parents can sometimes behave in ways that frighten children, often without realizing it. When traumatized children behave in rejecting ways, their parents must learn to re-interpret their signals so that they can respond to them with effective nurturance. Also, parents who have been traumatized or frightened as young children will sometimes display an angry or frightened face to their child or even “tune out” (“dissociate”) in a way that may frighten a child. Parents with troubled past histories may also misinterpret their children’s expressions of distress and fail to respond in a comforting way. This intervention teaches parents to recognize patterns such as these in their own behavior and in that of their children so that they can learn optimal patterns of parenting behavior. These optimal behaviors include following the child’s lead with delight, attending to the child’s signals, supporting the child’s agency, and the importance of touch.

An interesting feature of this intervention is that of encouraging the parent to provide nurturance even if it doesn’t come naturally – “fake it until you make it”, as I say. We know that practicing a behavior can build new neural circuits in the brain, and ABC attempts to override the parents’ own problematic tendencies by building good nurturing behaviors that are practiced and reinforced in the relationship with the clinician. In this intervention, the parent’s problematic past is directly addressed as it is currently represented in the parent’s behavior towards her child.

PCIT is an intervention in which the clinician behind a two-way mirror coaches the parent through a bug in the parent’s ear. This is a strictly behavioral approach that incudes elements of family systems theory, learning theory, and traditional play therapy. The emphasis is on restructuring parent-child patterns, rather than modifying target behaviors. PCIT is designed to be most effective in treating disruptive behaviors. In this intervention, parents are not blamed but are given responsibility for improving their child’s behavior.

Decisions about family preservation, reunification, or permanency need to be made prior to beginning a course of PCIT, which takes place in 14-21 weekly sessions. Some of the limitations of PCIT are that it focuses on the child’s behavioral problems and parent skills but not on domestic violence, substance abuse, or parent psychopathology.

The third intervention, CPP, focuses on current stress and trauma as well as “ghosts from the nursery” in the past of the parents. This phrase is the title of a famous paper by Selma Fraiberg, a pioneer of parent-infant mental health and refers to traumatic experiences in the parents’ past that haunt them when they become parents themselves (Fraiberg, Adelson, & Shapiro, 1987). This intervention is also manualized and multi-theoretical.
The intervention uses play, physical contact, and language to further the child’s development. Symbolic play is used to create a “trauma narrative”. Games are used to help with emotional and physical regulation – such as blowing, patting, and breathing games. Mazes and other games are used to help a child gain a sense of his body in space, and touch is used to restore trust in physical contact. Another way of describing this intervention is that it is a combination of play and “unstructured developmental guidance”. Important feature of this guidance are to help the parent understand appropriate developmental expectations of their young child and to help both parent and child name and cope with strong feelings. In addition to modeling good parenting behaviors and offering concrete assistance, such as with safe housing, the clinician makes interpretations linking present to past and distant past, “ghosts in the nursery”. These interpretations create the “trauma narrative”.

An interesting and I think important study of the factors disrupting and facilitating emotion regulation is being conducted by a group in New York and Geneva. They suggest that the child’s helplessness, fear, and rage can elicit traumatic memory traces in the mother with PTSD (“ghosts in the nursery”) and propose to help the mother change her behavior in a similar way to the ABC protocol but with videotape feedback. Since I am familiar with videotape feedback and a big believer in its effectiveness, I am awaiting the results of this study with anticipation (Schachter and Rusconi Serpa, 2014).
Fraiberg, S., Adelson, E., & Shapiro, V. (1987). Ghosts in the nursery: A psychoanalytic approach to the problems of impaired infant– mother relationships. In S. Fraiberg (Ed.), Selected writings of Selma Fraiberg (pp. 101–136). Columbus: Ohio State University Press.

Schechter D, Rusconi Serpa S (2014). Understanding how traumatized mothers process their toddlers’ affective communication under stress: towards preventive intervention for families at high risk for intergenerational violence, in R Emde and M Leuzinger-Bohleber, Eds., Early Parenting and Prevention of Disorder, Karnac Press, pp. 90-117.


Bathroom Problems I: Soiling or Encopresis


Many of the children whose parents consult me suffer from a condition called encopresis, or soiling, a distressing problem that is diagnosed in children older than 4-years old.  Encopresis usually starts with constipation. If a child experiences pain when passing a hard or large stool, it is common for the child to tighten up and hold back in response to the urge to defecate.  This of course makes the constipation worse, and often soft stool from higher in the gut leaks around the hard mass in the colon, causing soiling.

The first step in dealing with this problem is to go to the pediatrician. Good medical care is essential to the treatment of these symptoms. If the constipation is not treated the withholding is likely to continue and may cause anatomical changes in the gut such as stretching of the muscular intestinal wall. Children who suffer from chronic constipation may also develop a disturbed coordination of muscle function in the anal sphincter. Medical treatment often involves stool softeners that draw water into the gut and soften the stool, making it easier and less painful to pass. There are other more vigorous and more intrusive interventions that can be used if necessary.

Pediatricians also often recommend behavioral plans. The most effective behavioral plan is for parents to gently but firmly insist that the child sit on the toilet after mealtimes – usually breakfast and supper – twice a day for 5-10 minutes. The natural movements of the intestines after meals aid in defecation. Sometimes small rewards or star charts help motivate children to follow through with this plan.

If this is a typical pediatric problem, why is it a concern for a child psychiatrist? The main reason is that there are three groups of children who might come to me for another reason who are also prone to having encopresis. The first is anxious children, the second is aggressive children, and the third is children with developmental problems such as attention deficit disorder (ADHD) or  autistic spectrum disorders (ASD).

When I describe anxious and aggressive children as belonging to different groups I am only referring to their outward behavior. Most anxious children are afraid of the destructive potential of their own aggression (even if their general behavior is timid and withdrawn). Similarly, children with aggressive behavior usually struggle with the fear that their aggression will get out of control and hurt someone – especially a family member or themselves.  What is a natural response to the fear of something dangerous getting of control? Control it! In other words, hold it in. Since children make meaning with and about their bodies even more than adults do, they “hold it in” concretely and physically. This psychological meaning almost always occurs simultaneously with the biological meaning of the threat of passing a hard stool. In my office practice, it is common for a child who allows himself to freely play an aggressive theme, such as dinosaurs biting each other, to interrupt the play and go into the bathroom to poop.

Children with developmental problems are even more interesting. In addition to all the other reasons mentioned above, they have difficulty picking up their body’s cues such as the urge to defecate. This is because they have trouble paying attention to their body’s signals and also because they sometimes cannot decipher them. Some children with ASD need to be told to put on a coat or mittens when it is cold outside since they don’t notice the cold feeling without help. (Readers may be surprised when I link the diagnoses ADHD and ASD in the general category of developmental problems, but I think that is the most sensible way to understand them.)

Helping children with their fears and helping them learn to pay attention to the signals their bodies send them is very important, but nothing can take the place of a regular bathroom routine of sitting on the toilet for 5-10 minutes after breakfast and supper. So why do parents find this so difficult to do? One reason is that the child who is afraid of passing a painful stool will object, and parents of fearful children often have trouble insisting that they face challenges that frighten them. Another reason is that the child with attentional problems or the child who has trouble reading body cues will often “tune out” while sitting on the toilet (sometimes get lost in a book). While “tuning out” will sometimes not prevent a bowel movement, the child who is not paying attention to his body will not learn how to respond to his body’s signals. That is why I do not recommend letting a child read or play with an iPad while sitting on the toilet. It is difficult, but it is a good exercise for both parent and child to help the child tolerate this routine.