In this issue, the second segment of “IMPACTS OF SEPARATION FROM PRIMARY CAREGIVER (S) DUE TO SOCIAL AND POLITICAL TURMOIL DURING EARLY CHILDHOOD; UNIVERSALITY VS. CULTURAL RELATIVISM“, developmental domains will be reviewed from a variety of perspectives as impacted by trauma and violence caused by separation from the primary caregiver(s) due to war and geopolitical turmoil. To cover such a significant and wide-range of domains of human development and giving it the attention and scope it deserves, this segment will be covered within two consecutive issues – this and the next month.
It is exciting to know that the Baby Gazette is now read across the globe. I have received some very interesting communications in response to the context of the articles published in the previous issues, as well as the theme of the “Brief Article” of the last issue. For this reason, I decided to include the “Your Corner“ section reflecting your feedbacks, comments, questions and concerns. I hope this generates your interest to become more involved in what is a mean of communication between you all. It is only through your input, comments and suggestions that Baby Gazette can serve our field more effectively.
IMPACTS OF SEPARATION FROM PRIMARY CAREGIVER (S) DUE TO SOCIAL AND POLITICAL TURMOIL DURING EARLY CHILDHOOD; UNIVERSALITY VS. CULTURAL RELATIVISM
2. Impacts of Exposure to Systemic Violence in Developmental Context in Early Childhood
Young children’s exposure to systemic violence disrupts basic preconditions required for their optimal development. Researchers report that severity, as well as cumulating traumatic experiences of children in systemic violence are important in understanding developmental damages and their sufferings (Garbarino, Kostelny, & Dubrow, 1998). Also, we have learned that children’s responses to systemic violence depends on individual variations such as age, developmental stage and maturation, pre-separation trauma and relationships with the significant others in a child’s life, as well as cultural constructs which impacted parenting, the child’s response repertoire, and factors such as a stable, safe and supportive caregivers. However, as Perry (2001) shows us, in spite of heterogeneity among children on these and other factors, one might observe emergence of particular patterns here. The predominant response patterns in the face of a traumatic experience might be hyper-arousal – fight or flight — and or more anxious, dissociative and dysphoric – internalizing reactions, and or combinations of these two (see Perry et al., 1995a).
Chronic traumatic state resulting in one or more of the above noted reactions have been correlated with changes in the brain functioning and response pattern formation (change from state to trait) resulting in involvement with acts of violence and antisocial behavior during the later years of life (Halperin et al., 1995; Hickey, 1991; Koop et al., 1992; and Loeber et al., 1993; Perry & Azad, 1999; Perry & Pollard, 1998), hypervigilance, mood and personality disorders.
It is now known that most of the brain develops during the first three years of life and brain capabilities such as sensory motor, psychosocial, emotional, and cognitive functioning are use dependent (Perry et al., 1995; Perry & Pollard, 1998; Perry, 1999), and experiences of early childhood influence neurobiological structure and behavioral outcome (Schore, 2001).
During this growth period, a normally growing brain is expected to be able to regulate emotions, tolerate frustration and channel impulsive urges. Conversely, a young child with a disorganized and dysregulated emotional brain will react differently to similar stimuli.
In addition, Ratner (1989) states that our emotions and cognitions are not functioning in a segregated fashion through separate brain centers. Ratner considers emotions and cognition “intimately intertwined.” According to him and Roger Sperry (Lazarus (1984), human emotions are integrated into cognitive processes; an indication of whole brain functioning vs. right brain-left brain split operation of emotions vs. cognitions.
As Bruce Perry (2001) stated, chronic repetitive traumatic experiences (neglect, abuse and stressful situations) in early years of life increase brain reactivity level and decreases capacity of the limbic system – the emotional brain. This in turn, results in reactive tendencies (startle response), aggression, impulsivity, immature and socially unacceptable behaviors. Excessive activation of the neural systems in this manner can alter the developing brain (Perry, 1994; Perry et al., 1995b).
Various studies have shown a relationship between brain functioning, cardiovascular system and heart rate of traumatized children. These changes in the neural systems are expressed in emotional, psychosocial, behavioral and intellectual functioning. Thus, a cycle of maladaptive functioning in response to traumatic and violent experiences takes shape (Perry & Azad, 1999).
Psychological and Emotional Development
Children differ from adults in their ability to predict, make sense of and respond to, defend themselves or avoid any tragic event (Reshma Samuel, 2004).
Reshma Samuel (2004) in his report on the children’s reaction to trauma lists the following:
“1) Violence and Coerciveness
2) Criminal perpetration
3) Sense of revenge and bitterness leading to maladjustments, fragmented relationships
4) Suicidal Tendencies
5) Arson and damage to property
6) Withdrawn Behavior, Avoidance, Helplessness
7) Bullying and Teasing
8) Inability to fully use one’s resources to contribute towards society
9) Sense of meaninglessness and aimlessness
10) Fright or Fight
11) Confusion, Dependence, Bewilderment, Disorganized Thinking, Impulsiveness, Desperation, Apathy, Constantly unsettled
12) Excessively Cautious or Negligent
13) Manipulation of others, Opportunism,
14) Irrational fears and phobias
15) Flashbacks or Nightmares
16) Physiological Weakening”
Traumatic events can have serious short and long-term implications on the future outcome of children. These events can play a significant negative role in increasing the risk of:
(a) Psychiatric disorders in children (Rutter & Yule, 2002);
(b) General health related problems (Friedman and Chase-Lansdale, 2002);
(c) Revictimization of children in the hands of adults through variety of abuses and neglect;
(d) Economic deprivation resulting in vulnerability to exploitations as slave for sex and forced labour.
War affected and victims of geopolitical violence may become forced refugees. Frequently, refugee families are kept in detention centers for a long time until their – cases’ are processed. Young children of these families suffer tremendously because of these detentions. Sensory deprivation in these centers show speech and language delays, retardation in emotional expressions and age appropriate developmental milestones. The environmental restrictions and restraints, and lack of access to resources in these centers impact Physio-biological and psychological developmental aspects of the young children.
When refugee families of young children are placed in detention centers, children’s physical and developmental needs are not being adequately met. The baby is at risk for delays in gross motor and speech development for lack of safe stimulation and places to explore. The nutritional and educational needs of these children are not met either. Nutritional and educational deprivations result in poor growth and development in all biological, physiological, and psychosocial domains.
Discrimination and Racism
Although geopolitical conflicts resulting in hate crimes represent only a segment of all crimes against young children, their impacts are significant in many ways. For one, prejudice breeds prejudice, racism and discrimination.
Lack of age appropriate resources, equipment, toys, and stimuli, and lack of educational facilities and resources — human and otherwise – is endemic in refugee centers. These deprivations may act as instruments of racial oppression and result in a sense of hopelessness. I have frequently observed that immigrant children with enthusiasm and high expectation for, and positive attitude toward excellence in education, becoming disillusioned and developing negative attitudes in a few years. Then, feelings of hopelessness and alienation takes place, and then becomes a leading force toward antisocial activities, such as school drop outs, gang memberships and violence.
Mother-Child Relational Development
Maternal (in this writing, mother is a term implied to the child’s primary caregiver; biological or otherwise) impression and representation during and after systemic violence is a significant factor in a child’s developmental outcome. Most influential early experiences are known to be through communications between the child/caregiver dyad, which are sensory driven, emotionally loaded and mostly nonverbal (Schore, 1994). A preponderance of evidence suggests that sensory emotional deprivation has detrimental impact on the psychosocial and developmental well being of children.
Traumatic experiences shatter the basis of a child’s belief in safety and trust in the caregivers and their ability to protect and support them. Any of optimal development and on-going rupture without repair in communication between the child/caregiver dyad as prevalent in systemic violence, may result in relational trauma, negatively impacting the experience-dependent maturation of the brain’s coping systems and the trajectory of developmental processes.
Recent research presents a link between the infant’s relational problems representing disorganized attachment behavior, and caregiver’s expression of withdrawal, dissociation, trancelike and fright (Schuengel, Bakersmans-Kranenburg, & Van Ijzendoorn, 1999) and depression – emotional representations that are prevalent among gender specific victims of war-geopolitical conflicts and traumatized caregivers.
- Action for Rights of Children (ARC), (September 2002). Save the Children Fund. ARC is an inter-agency initiative, initiated by UNHCR and the International Save the Children Alliance in the Office of the High Commissioner for Human Rights. www.savethechildren.net/arc/.
- Friedman RJ, Chase-Lansdale PL. (2002). Chronic adversities. In: Rutter M, Taylor E, editors. Child and Adolescent Psychiatry. 4th ed. Blackwell Publishing: Oxford; 261-276.
- Garbarino, J., Kostelny, K., & Dubrow, N. (1998). No place to be a child: Growing up in a war zone. Jossey-Bass.
- Halperin JM, Newcorn JH, Matier K (1995). Impulsivity and the initiation of fights in children with disruptive behavioral disorders. J Child Psychol Psychiatry 36(7):1199-1211.
- Hickey, E. (1991). Serial Murderers and Their Victims. Belmont, CA: Wadsworth Publishing.
- Koop, C.E., Lundberg G. (1992). Violence in America: a public health emergency. Journal of the American Medical Association. 22:3075-3076.
- Lazarus, R. (1984). On the primacy of cognition. American Psychologist, 39, 124-129.
- Loeber, R., Wung, P., Keenan, K., et al. (1993). Developmental pathways in disruptive child behavior. Development and Psychopathology. 5:103-133.
- Perry, B.D. (1994). Neurobiological sequelae of childhood trauma: post-traumatic stress disorders in children. In M. Murberg (Ed.), Catecholamines in Post-traumatic Stress Disorder: Emerging Concepts. Washington, D.C. American Psychiatric Press, pp 253-276.
- Perry, B.D., Pollard, R.A., Baker, W.L., et al (1995a). Continuous heart rate monitoring in maltreated children [Abstract]. Annual Meeting of the American Academy of Child and Adolescent Psychiatry, New Research.
- Perry, B.D., Pollard, R., Blakely, T., et al (1995b). Childhood trauma, the neurobiology of adaptation and ‘use-dependent’ development of the brain: how “states” become “traits'”. Infant Mental Health Journal.16(4):271-291.
- Perry, B.D., & Pollard, R. (1998). Homeostasis, stress, trauma, and adaptation: a neurodevelopmental view of childhood trauma. Child and Adolescent Psychiatric Clinics of North America. 7(1):33-51.
- Perry, B.D. (1999). Memories of fear: how the brain stores and retrieves physiologic states, feelings, behaviors and thoughts from traumatic events: In JM Goodwin and R. Attias, (Eds.), Splintered Reflections: Images of the Body in Trauma. Basic Books, 26-47.
- Perry, B.D., & Azad, I. (1999). Post-traumatic stress disorders in children and adolescents. Current Opinion in Pediatrics. 11:121-132.
- Perry, B.D. (2001). The neurodevelopmental impacts of violence in childhood. In Schetky D & Benedek, E. (Eds.) Textbook of child and adolescent forensic psychiatry. Washington, D.C.: American Psychiatric Press, Inc. 221-238.
- Ratner, C. (1989). A Social Constructionist Critique of Naturalistic Theories of Emotion. Journal of Mind and Behavior, 10, 211-230.
- Reshma Samuel (2004). Children affected by Trauma can manifest the following tendencies: Asia Cutting Edge, 23-27, Malaysia Workshop Dealing with Traumatized Children, 4
- Rutter, M., and Yule, W. (2002). Applied scientific thinking in clinical assessment. In: Rutter M, Taylor E, editors. Child and Adolescent Psychiatry. 4th ed. Blackwell Publishing: Oxford. 03-116.
- Schore, A.N. (1994). Affect regulation and the origin of the self: The neurobiology of emotional development. Mahwah, NJ: Erlbaum.
- Schore, A. (2001). The effects of early relational trauma on right-brain development, affect, regulation and infant mental health. Infant Mental Health Journal. Vol. 22 (1-2), 201-269.
- Schuengel, C., Bakermans-Kranenburg, M.J., & Van IJzendoorn, M.H. (1999). Attachment and loss: frightening maternal behavior linking unresolved loss and disorganized infant attachment. Journal of Consulting and Clinical Psychology, 67, 54-63.
The World Medical Association (WMA) announced the publication of the online version of its Medical Ethics Manual.
The WMA is very interested in hearing the reactions of readers to the Manual: “Whether you are a practicing physician, a medical student or a teacher of medical ethics, please let us know by email, regular mail or fax whether the Manual in its present form meets your needs and how you think it can be improved in future editions. In addition, we would like to know whether you see a need for additional ethics resources from the WMA, and if so, on what topics.” “Up to 10 copies of this document may be made for your non-commercial personal use, provided that credit is given to the original source. You must have prior written permission for any other reproduction, storage in a retrieval system or transmission, in any form or by any means.”
Requests for permission should be directed to The World Medical Association, B.P. 63, 01212 Ferney-Voltaire Cedex, France; email: email@example.com, fax (+33) 450 40 59 37.
Below, there is a segment of the content on page 44 and 46 of the manual for your review with all rights reserved for the World Medical Association.
“Evidence of consent can be explicit or implicit (implied). Explicit consent is given orally or in writing. Consent is implied when the patient indicates a willingness to undergo a certain procedure or treatment by his or her behaviour. For treatments that entail risk or involve more than mild discomfort, it is preferable to obtain explicit rather than implied consent.
There are two exceptions to the requirement for informed consent by competent patients:
- Situations where patients voluntarily give over their decisionmaking authority to the physician or to a third party. Because of the complexity of the matter or because the patient has complete confidence in the physician’s judgment, the patient may tell the physician, “Do what you think is best.” Physicians should not be eager to act on such requests but should provide patients with basic information about the treatment options and encourage them to make their own decisions. However, if after such encouragement the patient still wants the physician to decide, the physician should do so according to the best interests of the patient.
- Instances where the disclosure of information would cause harm to the patient. The traditional concept of ‘therapeutic privilege’ is invoked in such cases; it allows physicians to withhold medical information if disclosure would be likely to result in serious physical, psychological or emotional harm to the patient, for example, if the patient would be likely to commit suicide if the
Futile and nonbeneficial can be understood as follows. In some situations a physician can determine that a treatment is ‘medically” futile or nonbeneficial because it offers no reasonable hope of recovery or improvement or because the patient is permanently unable to experience any benefit. In other cases the utility and benefit of a treatment can only be determined with reference to the patient’s subjective judgment about his or her overall well-being.”
Just for Your Information
ZERO TO THREE – 20th National Training Institute (NTI)
November 4-6, 2005, Washington DC
Visit the ZTT website, www.zerotothree.org for more information.
Infant Development Association of California (IDA)
Building the Future: Growing Thriving Early Childhood Communities
April 21-23, 2005
Westin Los Angeles Airport Hotel
Visit www.idaofcal.org for more information
Phone: (916) 453-8801
Mail: PO Box 189550, Sacramento, California 95818-9550, USA
The Infancy & Early Childhood Training Course
Assessment, Diagnosis, & Intervention Planning
Stanley Greenspan and Serena Wieder
April 29-30, and May 1-2, 2005
Hilton McLean, Tysons Corner, Virginia
For more information, contact: www.floortime.org
Mail: 4938 Hampden Lane, Suite 229, Bethesda, Maryland 20814
Way to go with Baby Gazette! It’s lovely to hear from you and see that you are still out there making efforts towards change for little people in the world.
I have a couple of questions you may be able to answer and if not, perhaps know who could.
How do you justify medical necessity for an infant (other than purely by diagnosis via DC: 0-3 and crosswalk).
How do you write progress notes that continue to demonstrate medical necessity, for an infant who was drug-exposed?
Do you use any standardized measures for assessment (other than the ICARE assessment which I use)?
Do you know of/use any measures that assess the relationship/attachment between infant/toddler and caregiver?
I am so out at sea here being the only infant specialist here!
I may think of other questions later, but these are good for a start. I am so proud of you for continuing to plug away at this and hope that you get your rewards long before you see heaven!!