Trauma

Do Babies and Small Children Feel and Remember Psychic Pain?

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You may find this hard to believe – but up until the 1990’s infants were routinely subjected to medical procedures including surgery without the benefit of anesthesia.

Pain research’s most famous infant, Jeffrey Lawson, was born prematurely in February 1985 and underwent open heart surgery shortly thereafter. (1) What made this particular surgery noteworthy was the fact that Jeffery was awake and conscious throughout the entire procedure. The anesthesiologist had administered only Pavulon, a paralytic that has no effect on pain. Only after Jeffrey died 5 weeks later did his mother, Jill, learn the truth about his surgery. Jeffrey had been too young to tolerate anesthesia, the anesthesiologist said, and anyway, “It had never been demonstrated to her that premature babies feel pain.” 1 This was not the case of a rogue anesthesiologist; textbooks at the time taught that the surgery Jeffrey underwent “could be safely accomplished with only oxygen and a paralytic”. (1)

Not until a research report from Anand and Hickey, “Pain and Its Effects in the Human Neonate and Fetus,” was published in the New England Journal of Medicine in 1987 did this practice finally begin to end.

Similar to the denial of infant physiological pain has been the denial of psychic pain, including the pain of separation from parents in infancy and childhood. Until the 1970s, infants and children who were hospitalized were actually denied visitation by their parents.

The need for parental love and care and the distress that children suffer without this, were considered unimportant in the physical recovery process for babies and children in the hospital – and the attachment needs of the young child went completely unrecognized in medical circles.

And even now, there are those who question whether trauma and/or loss occurring in the early months and years of life can be remembered. Many deny the importance of separations in the first weeks of life and some doubt whether separations or early trauma of other kinds are encoded in memory.

But this is what Susan Coates, a well known psychologist and the author of September 11: Trauma and Human Bonds (among other books) has to say:

It is now well documented that very young children show the same three basic categories of posttraumatic symptoms observed in adults: reexperiencing, numbing, and hyperarousal.(2) These three clusters of symptoms are the means by which posttraumatic disorders in adults are diagnosed. These clusters have consistently been shown to represent independent factors in the traumatic response process, and there are now over fifty published case reports documenting their presence in children under the age of four.(3)

She goes on to say:

Both Lenore Terr (1988) and TJ Gaensbauer (1995) report that children under the age of three, though unable to describe a trauma in words, enact it in play through motor behavior and somatic responses. Doing this requires a preverbal capacity to symbolically represent traumatic events in memory. Posttraumatic play in very young children is readily distinguishable from ordinary play. It is compulsively driven and it includes repetitive reenactment of the trauma. In addition, very young children show symptoms of reexperiencing the trauma that are highly reminiscent of what is seen in older children and adults: repeated nightmares, distress at exposure to reminders of the trauma, and episodes with features of flashbacks or dissociation.

What Coates is saying, in other words, is that babies, toddlers and young children who experience prolonged separations, or traumatic events, including medical procedures and hospital stays are affected by these events.

And if you have not read or heard about Susan Coates’ case of “Betsy”, you need to. This case involves a ten month old girl who was stabbed repeatedly by a psychotic man while sitting in her stroller in a park. Thanks to the fast action of her babysitter, a police officer and a surgical team, she survived. Her parents noticed no post traumatic symptoms, did not think she remembered the event, did not think it necessary to tell her about what happened and, in fact, were counseled not to do so.

One day, when she was three and playing in the kitchen sink with her father, she leaned against the counter and said “my line hurts”. When her father said, “Oh, you mean your special boo boo?” she said, “No” and made slashing motions with her hand. She said, “It was a very bad day”.

Clearly she had a memory of the traumatic event. And it was a somatic memory, that is, it was felt in her body and expressed through her physical action of replaying the stabbing motions of the man who attacked her. Her parents realized that she needed help to understand what had happened – and they took her to see Susan Coates for psychotherapy. Together, Betsy, her parents and Dr. Coates reconstructed what had happened and what it meant to Betsy.

So, not only do infants experience pain—and severe stress—when they are subjected to prolonged separation from parents or when they experience physical trauma such as catheterizations, lumbar punctures or other medical procedures without the benefit of anesthesia, but they are ALSO capable of forming symbolic representations and somatic – or bodily – memories of these experiences. In addition, we now know that their capacities for other kinds of memory are far more sophisticated than was thought even thirty years ago. And it is also true that these capacities include the rudiments of an episodic memory system even before the onset of language.

These two factors—the experience of pain and its memory—create necessary and sufficient conditions for traumatization and the development of PTSD – whether around trauma – or loss – in infants and children.

So, why is this important for parents to know?

It is important to recognize that early experiences of pain and separation may be important to your child and how she sees herself and the world. It is part of her life story and part of what has shaped her. And here we are not talking about separations of a few hours or a day, we are talking about long separations of weeks and months.

If a child has suffered an early and prolonged separation or a difficult medical experience, parents may be tempted to discount the possibility that this affected them or that they have any memory of what happened.

It is painful for parents to think otherwise. But it is important to acknowledge that these experiences do affect small children. It is important to talk with them about what happened in an age-appropriate way, and to empathize with how hard it may have been for them – even though they were very little at the time. It is important to be open to what the child has to say about it. And it is important to not make this a one-time conversation. It is important to talk about it with them from time to time and try to help them to understand what this experience might have been like for them and what it may have meant to them.

We need to give children credit for being fully feeling individuals – from the moment they are born and throughout their development.

Today, As We Think About the Victims of the Massive Bombing Campaign in Ukraine, a Post on War and Children

~ corinnemasur2331 ~ Leave a comment

Because of the news of a massive bombing campaign including the bombing of a Ukrainian Hospital today, I would like to post on war on children.

This is an excerpt from my book, How Children Grieve: What Adults Miss and What They Can Do to Help:

One psychiatrist said of both the children and the adults in the Ukraine, “(They) aren’t just grieving a person; (they) are grieving (their) entire existence.”[i]

And, as the United Nation International Children’s Fund (UNICEF) says:

            “In war, children suffer the most”.

As I write, children are dying and losing loved ones every single day in multiple locations around the world, including Ukraine, Gaza, Israel, Russia, Sudan, Somalia, Libya, Myanmar, Yemen, Congo and numerous other countries. These children are suffering in ways that are quite simply horrific and completely incompatible with normal development.

In fact, globally, one in four children, or over 400 million children live in a country affected by armed conflict, terrorism, or disaster.[ii] And armed conflict can last throughout a child’s entire life, such as in Liberia where civil war caused widespread trauma from 1989 to 2004.[iii]

The effects of war are innumerable. They extend far beyond the trauma that is experienced by the loss of loved ones and the witnessing and being the victim of violence. In wartime, children, teens and adults may all experience a brutal shattering of parts of their inner worlds. Their minds may become black holes of horror and despair and their mental functioning can be intruded upon and assaulted by destructive forces. [iv]

Moreover, they experience all the secondary losses of war including the loss of home and community due to fighting and bombardment. They include all the losses embedded in the experiences of evacuation and immigration including the loss of contact with friends, and the division of families. They include all the difficulties associated with adapting to one or more new living arrangements. And they include the loss of food security, the loss of the provision of proper public health measures and the loss of general health care including mental health care.

The World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) estimated that approximately 20 million children and adolescents have been displaced from their country of origin as refugees in the year 2023.[v]

And we must remember that the numbers of children living through war and experiencing displacement are even larger than this because there are many kinds of war—including not only armed conflicts between nations – but also drug wars, gang wars, and more localized street fighting caused by conditions of poverty and social inequality – and these too cause people to suffer and to flee.

In the Ukraine alone, as of March 2022, half of all Ukrainian refugees were children.[vi] And this number does not even include all of the children who have been kidnapped and forced to adapt to life in Russia.  Again, this is a LOT of children who have lost their homes, friends, neighborhoods, schools and so much more.

The past two decades have marked increasing interest in the psychological impact of war on children. Many researchers have studied this subject, it is well documented that exposure to adverse childhood events (including violence and war trauma) leads to a higher-than-average incidence of acute stress disorder, posttraumatic stress disorder (PTSD) and physiological and mental illness).

The most important thing we know about the effect of war on children is that even above and beyond the exposure to risk and violence, the most traumatizing event for children is the threat of separation from one or both parents or actual separation from them. Given the intense attachment of children to their parents, this is the worst consequence of war for children and leads to the most suffering. [vii]

We also know that the most common mental health effects of exposure to war for children are elevated symptoms traumatic stress, depressive disorders, anxiety disorders and post-traumatic stress disorder (PTSD).

There is so much more to say about the effect of war on children. See this site for more in the coming weeks.

[i] Fleming, LaKeisha, How the War in the Ukraine is Affecting the Mental Health of Survivors.

https://www.verywellmind.com/ukrainian-mental-health-during-the-war-5225389

[ii] Gudrun Østby, Siri Aas Rustad, and Andreas Forø Tollefsen, “Children Affected by Armed Conflict, 1990–2019,” Conflict Trends 6.

[iii] Betancourt. T. S., et al., “The Intergenerational Impact of War on Mental Health and Psychosocial Wellbeing: Lessons from the Longitudinal Study of War-Affected Youth in Sierra Leone,” Conflict and Health 14, no. 62 (2020), https://doi.org/10.1186/s13031-020-00308-7.

[iv] Roth, Merav, Ten simple guidelines on initial therapeutic intervention with acute trauma following October 7, 2023. In Psychoanalysis in a Holy Land, Abramovitch, Cusin, Leo, Roth, Alaltiello and Volkan. Pgs. 135 – 162. Frenis Zero Press: Italy.

[v][v]

[vi] United Nations Children’s Fund (UNICEF). Two Million

Refugee Children Flee War in Ukraine in Search of Safety

Across Borders. UNICEF. Available from: https://www.unicef.

org/press‐releases/two‐million-refugee-children-flee‐war‐ukraine‐

search‐safety‐across‐borders.

[vii] Masten AS, Best KM, Garmezy N (1990). Resilience and development: Contributions from the study of children who overcome adversity. Dev Psychopathol 2: 425–444.

Can Children Grow From Loss?

~ corinnemasur2331 ~ Leave a comment

In our 4 part series on loss, I talked about the little losses of everyday life, how children understand death, how to introduce the topic of death to children and what a child may feel when they lose a loved one. But something I did not talk about is the fact that, as hard as losing a loved one is for a child, they can also grow as a result of the experience.

This may come as a surprise.

But many people, including children and teens, not only manage to survive difficult losses, but they also grow as the result of their experience with loss.

Scientists who study trauma and loss have found that there can be a variety of positive psychological changes for some people following challenging life experiences.

Lawrence Calhoun and Richard Tedeschi called this “posttraumatic growth.” They mentioned the following positive changes as being prominent for many people:

·    Greater appreciation of life

·    Greater appreciation and strengthening of close relationships

·    Increased compassion and altruism

·    The identification of new possibilities or a purpose in life

·    Greater awareness and utilization of personal strengths

·    Enhanced spiritual development

·    Creative growth

And, as it turns out, one crucial factor that allows people to turn a difficult event into one that promotes growth is the extent to which they explore their thoughts and feelings around that event.

Many people prefer “to look on the bright side” and to not focus on the difficult things that happen to them. In fact, one young woman who sees me in therapy told me that when she hurt herself as a child, her mother used to say, “pretend that didn’t happen”.

However, Calhoun and Tedeschi found that the ability to acknowledge that the event has happened and to think about and process the painful feelings associated with the event are what allow some people to grow from their difficult experiences.[i]

Two other researchers, Todd Kashdan and Jennifer Kane, also studied this subject. Using a group of college students, they looked at how much people tend to avoid difficult and painful thoughts and feelings versus how much they are willing to allow them. In their study, the most frequently reported traumas amongst their subjects included the sudden death of a loved one, motor vehicle accidents, witnessing violence in the home, and natural disasters.

Kashdan and Kane found that the greater the distress the person experienced, the greater the posttraumatic growth that resulted from it—but only in those people who did not avoid their feelings, or who did so infrequently.

 These findings support the benefits of encouraging children to experience and talk about their feelings following loss. It also supports the importance of having children and teens who are having difficulty experiencing or expressing their feelings get involved in some form of expressive psychotherapy, whether that be individual, group, or family therapy.

Another researcher, Jessica Koblenz specifically studied children who had lost a parent to find out what helps and what hinders them in their grief process. And she also found that there is growth from loss. One child in her study said they had a heightened sense of life and didn’t want to waste time or have regrets. Another said he had become more independent. Some mentioned that they learned to seek help from those who were able to provide it. Some found that exercise was a good method for coping with painful feelings, and others found humor helpful.

Teigan, a young woman I met through Winston’s Wish, told me that what happened to her after she lost her mother shaped what she wanted to do with her life. She described how one of her teachers at school called her every week after her mother died and provided her with much needed attention, support, and guidance. This teacher was an inspiration for Teigan, and she decided to become a grief counselor for children and teens so that she could help other students, just as her teacher had helped her. In the meantime, she was training to lead grief groups just like the one she had participated in herself.

For years, Calhoun and Tedeschi, studied the positive effects of trauma—including loss. They also found that some individuals who had suffered significant trauma experienced positive changes. These changes include improved relationships, new possibilities for life, a greater appreciation for life, a greater sense of personal strength, and increased spiritual development.

They also found some interesting contradictions. People they interviewed said things like “I am more vulnerable, yet stronger.” Individuals who experienced traumatic events tended to talk about their increased sense of vulnerability; however, these same people also reported an increased sense of their own capacities to survive and prevail.

Another experience often reported by trauma survivors was a need to talk with other people about the traumatic events, which tended to deepen some of their personal relationships. Some also found themselves becoming more comfortable with intimacy and having a greater sense of compassion for others who experienced life difficulties.[i]

In my clinical practice, a teenager whose father had died at the beginning of Covid said to me, “My dad’s death gave me a different perspective. I used to think that if a friendship ended or someone died, all the time you put into that relationship was wasted. Now I think that it was valuable. I would rather have had my dad for the time I had him rather than some other dad who was around longer.”

This young woman gained a new perspective and came to a new appreciation of the relationships in her life. She came to understand the importance of the person that her father was despite her lifelong frustration with having had an older dad. And she also recognized that relationships are important in their own right, even if they end prematurely.

Calhoun and Tedeschi also found that some people who faced trauma were more likely to become engaged with fundamental existential questions about death and the purpose of life. A commonly reported change was for the individual to value the smaller things in life more and to also consider the religious, spiritual, and existential components of life. A common theme for many people in this study was that after a traumatic event, philosophies of life can became more fully developed, satisfying, and meaningful.[ii]

Researchers such as Calhoun and Tedeschi have found that growth can occur not despite adversity but because of it.

It is true that they looked predominantly at adults, but interestingly, very similar findings have been found in research on bereaved children.

In a study of what helps and hinders children and adolescents who lose a parent, Jessica Koblenz found multiple areas of growth in many of the children she interviewed.[iii]

Seventy-three percent of the participants in her study felt that navigating and understanding death at an early age made them grow up faster.

And it is interesting to think about whether “growing up faster” is a form of growth or a toll that is paid by children who have experienced early loss. I suspect that some children might consider it a form or growth, some might feel it was a toll they paid, and some might feel that it is both. 

Some children in Koblenz’s study said they responded to loss by embracing life. One said, “I have a heightened sense of life, not wasting time, and not having regrets.” According to some grief theorists, this renewed sense of life is an adaptive form of meaning-making following loss.[iv]

Many of the children Koblenz interviewed said that support helped them to get through their loss. This finding is important because traditional psychological and psychiatric views of bereavement have minimized the role of relationships and support from others in coping with loss. However, more recently, evidence has shown that relational support plays a crucial role in a child’s ability to cope after a loss and may actually improve and intensify some existing relationships.

Interestingly, participants in Koblenz’s study stated that their most helpful source of support were other mourning children who could relate with their exact position.

Koblenz also found that becoming self-reliant was a coping strategy that some of the participants in her study utilized. In her study, kids said that they began to rely more on themselves once they decided that they could no longer depend on others. For some, it was easier to express they “were strong” and “could handle it alone” than to acknowledge their loneliness.[v]

Koblenz says that the sentiment of “needing to be strong” was expressed by many participants and reflected their inability to convey vulnerability. As one participant said of her childhood loss, “Everyone always said, ‘You’re so strong.’ No one ever said, ‘It’s okay if you’re not.’” From this Koblenz concluded that applauding children’s ability to handle their grief alone may make it difficult for them to feel they can be completely open and show their vulnerable selves. But some participants were able to find a balance of healthy independence while still reaching out to others in times when they needed help.[vi]

[i] Lawrence G. Calhoun and Richard G. Tedeschi, “The Foundations of Posttraumatic Growth: An Expanded Framework,” in Handbook of Posttraumatic Growth: Research and Practice, ed. Calhoun and Tedeschi (New Jersey: Lawrence Erlbaum, 2006), 3–23.

[ii] Richard G. Tedeschi and Lawrence G. Calhoun, “Posttraumatic Growth: A New Perspective on Psychotraumatology,” Psychiatric Times 21, no. 4 (April 1, 2004).

[iii] Jessica Koblenz, “Growing from Grief: Qualitative Experiences of Parental Loss,” Omega 73, no. 3 (March 2015): 203–230.

Talking To Your Children About the War in Israel and Gaza – Part I

~ Thoughtful Parenting ~ Leave a comment

By Dr. Corinne Masur

Mohammed Abed/AFP via Getty Images

Our world feels particularly frightening right now – two major wars, several smaller armed conflicts (Sudan, Ethiopia, The Sahel, the Mexican and Central American drug and gang wars) and so many natural disasters.

Do we talk with our children about these things?

And if so, how?

And more specifically, for those of us personally affected by the latest war in Israel and Gaza, how do we handle our own feelings and those of our children simultaneously?

I cannot pretend to have definitive answers. 

The attack on Israel came as a shock to all of us. 

The war there is just days old. And we are all trying to absorb and process the magnitude of the horror.

We may be filled with anxiety – or sadness – or anger. We may be feeling all of these emotions in succession and combination. 

When we hear what’s happening and see the images of beautiful young people who have been kidnapped or killed or the videos of devastation, we may feel physically ill. 

So how do we deal with our own emotions? And then how do we address the situation with our children?

I have some suggestions.

For those of us who are directly affected because we have family and friends in Israel or Gaza, the situation is the hardest. We have the competing interests of trying to track our loved ones while also wanting to protect our children from being overwhelmed by the events in Israel and by our own fear and horror.

We need to be free to experience our own feelings – while also needing to be in control for our children. Because we know that in order for our children to feel cared for and safe, they need to know that we are still able to be in control and in charge.

This is an extremely difficult dillemma.

And for others of us, not so directly affected, we are still full of emotion – outrage, fear, terrible sadness.

It is tempting for many of us to keep the news on all day, to check our newsfeeds on our phones and computers constantly, to read the newspaper and to talk about the war at home, on the phone and together with friends and family.

But is this the best thing to be doing – for ourselves? Or for our children?

Let me share my thoughts on this.

If you have children under the age of eight, for their sake, and for your own, try the following:

– Turn off the TV news and keep it off. Repeated exposure to violence, even on the television or phone, can be traumatizing – for adults as well as children.

– Even when the terrible events we see are not happening directly to us, we can be traumatized just by the act of seeing them or hearlng about them. This is called vicarious traumatization. 

– If you must check the news on your phone, do so in private – if you have to take a bathroom break to do so, then do that – and do so only a few times per day, if possible.

– Talk to friends and relatives about the war out of earshot of your children.

– Don’t think you can be in the same room with your children and talk in a low voice about the war – when you do this children often understand that there is something being said that they aren’t supposed to hear – and they will try very hard indeed to hear what it is.

– If you go to a restaurant with your children and they have the news on the TV over the bar, either go to a different restaurant or ask the waiter privately (ie, not in front of your children) if they would be willing to change the channel.

– Over the next few weeks, if your child is going on a play date at a friend’s house, ask the parents of the child your child is going to play with what they do in their home about having the TV on or talking about the war – before you child goes over.

– But also, be proactive. Talk to your children (starting with those around age 3 and up) directly about what is happening. 

– Tell them the facts in simplified form.  For example, “A group called Hamas started a fight with Israel on Saturday. Now Hamas and Israel are fighting and it is very hard for the people there.” You can add a few specific details about your friends and relatives – but not too many, and none that are graphic. And you can say, “Daddy and I are very worried about this”.

– Answer your children’s questions – and they will have many. 

– But keep it simple – and leave out the disturbing details.

-Use very simple language. Children this age do not know where the Middle East is or what a terrorist is. Leave out the facts about children and families being killed or taken hostage. These details are too frightening for young children.

– When they ask if your friends or relatives will be safe, again, answer honestly. 

You can say, “They are doing everything they can to stay safe” or “They are trying hard to stay safe, but right now we don’t know what will happen. War is scary for everybody”.

– If they ask, reassure your children that the war is far away and that they are safe in your home.

And if you have children over the age of eight, you can try these:

– Turn the TV news off and keep it off – again, for your own sake and for theirs.

– Keep adult conversations about the war either out of earshot of your children or limited to what you feel they can hear without becoming overwhelmed with fear.

– Address the situation directly with your children.

– Ask your children what they know about the war.

– Ask them what they think about the war.

– Ask them what their friends are saying about the war.

– Ask them what their friends have seen on social media about the war (sometimes it’s better to ask what friends are doing rather than asking your shile what he/she/they are doing).

– And If they ask, tell them what you think about the war. But try to stay as steady as you can during these conversations. This may be very hard. But, again, the most frightening thing for children of all ages is seeing their parents feeling overwhelmed or out of control.

– This can lead to a wider discussion about war in general. Or about the history of the relationship between Israel and the Palestinians. Or about the development of Hamas. These discussions can add much needed context for what is happening right now.

– If you are sad about the war, do not be afraid to share this. Even crying in front of your children is fine. It shows them one way to express the scared and upset feelings both you and they may have.

-If your children have their own cell phones, suggest that they check the news infrequently, if at all. 

– If they are teenagers and/or if they are particularly interested in what is going on in Israel and Gaza, encourage them to look at the reliable news sites and to stay away from the sensationalized news – including stories and images on social media – and tell them why you don’t think it will be helpful for them to look at these sites. You can tell them openly that you feel these images are just too horrific and too upsetting for anyone of any age to look at. You can also say, that looking at the images plays into the terrorist’s desire to terrorize people. However, be prepared for the possibility that you will have limited influence with your teenagers’ viewing decisions.

– Check for signs of your older children overwhelming themselves with painful media. Try to be aware of whether they seem particularly anxious or overwhelmed. And if they do, sit down and talk about what they – and you – are feeling. Try not to argue over social media use and this sort of thing at this time. 

– And try to take care of yourself. Try not to overwhelm yourself with information or with constant vigilance and discussion – if this is at all possible for you.

Sending fervent wishes for peace to all –

Corinne Masur

For more on this topic:

https://www.npr.org/2023/10/11/1205017249/how-to-talk-to-children-violence-israeli-palestinian-gaza-hamas

Further Resources:

How to Talk to Kids About What’s Happening in Israel Right Now:
(An overview of how to address age groups developmentally)
 
Helping Children Cope After a Traumatic Event: A recovery guide for parents, teachers, and community leaders

(From the Child Mind Institute)
 
Israel at War- Guidelines for Families and Individuals

(A guide from Ohel, a social service agency serving children and families in Brooklyn. )
 
Helping Children with Tragic Events in the News

(From PBS Kids)