Present and discuss recent psychological research on childrens trauma reactions in western and nonwe

1
Present and discuss recent psychological research
on childrens trauma reactions in western- and
non-western cultures
UNIVERSITY OF BERGEN, NORWAY

• DAG Ø. NORDANGER
• Research Centre for Health Promotion
• Department of Education and Health Promotion
• Faculty of Psychology

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What is trauma?

• objective - subjective
• event - experience
• single - complex

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What are trauma reactions?

• Psychobiology
• Psychiatric diagnosis
• Subjective experience
• Acute - short term - long term
• Development and life course

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Posttraumatic Stress Disorder (PTSD)
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Expansion of PTSD

• Vietnam trauma ? Civilians trauma
• Adults ? Children
• Clinic ? Humanitarian aid
• West ? Non-West

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PTSD Trauma

• An EVENT
• that the person experienced, witnessed, or was
  confronted with, that involved actual or
  threatened death or serious injury, or a threat
  to physical integrity of self or others,
  
• the response to the event involved intense fear,
  helplessness, or horror.
• (DSM-IV-TR APA, 2000)

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PTSD Reactions

• (B) Intrusion symptoms
• Re-experiencing of the traumatic event
• (C) Avoidance symptoms
• Avoidance of reminders of the traumatic event
• (D) Hyper-arousal symptoms
• Symptoms of persistent arousal
• (More than 1 month)

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PTSD in pre-school children

• Dependent on caregiver reactions
• Undifferentiated fear and avoidance
• Separation anxiety, clinging
• Regression - bedwetting
• Repetitive trauma play
• Magical thinking guilt

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PTSD in elementary school children

• Classical PTSD pattern without flashbacks
• Time skew
• Omen formation
• Repetitive trauma play and drawing
• Magical thinking - guilt

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PTSD in adolescent

• Classical PTSD pattern
• More aggression and impulsivity

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War and political violence
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Cambodian children of Pol Pot murdering

• Kinzie, J. D., Boehnlein, J., Sack,
• W. H. (1998). The effects of massive
• trauma on Cambodian parents and
• children. In Y. Danieli (Ed.), International
• handbook of multigenerational legacies
• of trauma (pp. 211-221). New York, US
• Plenum Press.

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Palestinian Children of the Intifadas

• Khamis, V. (2005). Post-traumatic
• stress disorder among school age
• Palestinian children. Child-Abuse-
• and-Neglect, 29(1), 81-95.

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Kurd children of Iraqi genocide, 1988

• Amad, A., Sofi, M., Sundelin-Wahlsten,
• V., von Knorring, A. (2000) Postraumatic
• stress disorder in children after the
• military operation Anfal in Iraqi
• Kurdistan. European Child Adolescent
• Psychiatry, 9, 235-243

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Iraqi children of the Gulf War, 1991

• Dyregrov, A., Gjestad, R., Raundalen,
• M. (2000). Children exposed to warfare
• A longitudinal study. Journal of
• Traumatic Stress, 13(1), 3-21.

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Rwandan children of the massacre, 1994

• Dyregrov, A., Gupta, L., Gjestad, R.,
• Mukanoheli, E. (2000). Trauma exposure
• and psychological reactions to genocide
• among Rwandan children. Journal of
• Traumatic Stress, 13(1), 3-21.

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Bosnian children of ex. Yugoslavia war, 1995

• Goldstein, R.D., Wampler, N.S. (1997).
• War experiences and distress
• symptoms of Bosnian children.
• Pediatrics, 100, 873-878

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American children of 9/11 2000

• Hoven, C. W., Duarte, C. S., et al.
• (2005). Psychopathology among New
• York public school children 6 months
• after September 11. Arch Gen
• Psychiatry, 62 545-552.

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Afghan children of War against terror, 2002

• Mghir, R., Freed, W., Raskin, A.,
• Katon, W. (1995). Depression and
• posttraumatic stress disorder among
• a community sample of adolescent
• and young adult Afghan refugees.
• Journal-of-Nervous-and-Mental-
• Disease, 183(1), 24-30.

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General findings

• Transcends cultures
• Prevalence 20 50
• More PTSD in non-West
• Closeness to event worse
• Life threat worse
• Human design worse
• Girls more vulnerable
• Youngest less vulnerable

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Do we know what is measured?
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Cambodian children and adolescent
Among Cambodian child refugees in US, who were
diagnosed with a full scale PTSD, there were few
impairments in functioning.

• Sack, W. H., McSharry, S., Clarke, G. N., Kinney,
  R., Seeley, J., Lewinsohn, P. (1994). The Khmer
  Adolescent Project .1. Epidemiologic Findings in
  2 Generations of Cambodian Refugees. Journal of
  Nervous and Mental Disease, 182(7), 387.

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Cultural biases
PTSD symptoms do not mean the same to children
all over the world merely because they can be
found in children all over the world. Cate
gory fallacy, confer Kleinman, 1987
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Cambodian folk psychology

• Culturally normal and acknowledged symptoms of
  bereavement
• Being haunted by images of the past
• Visits of supernatural forces during sleep
• Visits of spirits from the homeland

Eisenbruch, M. (1991). From Posttraumatic stress
disorder to Cultural bereavement Diagnosis of
Southeast Asian refugees. Social Science and
Medicine, 33(6), 673-680.
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Test items measuring intrusion

• Pictures about it popped into my mind.
• I thought about it when I didnt mean to.
• I had nightmares about it.
• Other things kept making me think about it.
• Impact of Event Scale - Revised (IES-R)

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Tigrayan folk psychology

• Expressing sorrow
• Welcomes evil spirits
• Spoils your eyes
• Makes your knees week
• Bends your backbone
• Irritates God

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Test items measuring avoidance

• I tried not to think about it.
• I tried to remove it from memory.
• I stayed away from reminders of it.
• I tried not to talk about it.
• Impact of Event Scale - Revised (IES-R)

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Disorder or adaptive response?
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East Timor population survey
Silove, D. (2005, Feb 2). Building recilience
hope following armed conflict Culture,
empowernment and peace building. Paper presented
at the 7th International conference on health and
human rights, Feb 2, Vadodara, India.
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Inner city New Yorkers after 9/11
McNally, R., Bryant, R., Ehlers, A. (2003).
Does early psychological intervention promote
recovery from posttraumatic stress. Psychological
Science in the Public Interest, 4(2), 45-79.
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Children of 9/11

• There were no differences between pre- and
  post-September 11 groups on measures on
• parent and child anxiety.
• Henry, D. B., Tolan, P. H., Gorman-Smith, D.
  (2004). Have there been lasting effects
  associated with the September 11, 2001, terrorist
  attacks among inner-city parents and children?
  Professional psychology Research and practice.
  35(5) 543-547.

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Review of trauma literature

• The vast majority of trauma survivors recover
  from initial posttrauma reactions without
  professional help.
• McNally, R., Bryant, R., Ehlers, A. (2003).
  Does early psychological intervention promote
  recovery from posttraumatic stress. Psychological
  Science in the Public Interest, 4(2), 45-79.

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1996 literature review

• Research efforts have failed to describe any
  stressor that is so devastating that it causes
  psychopathology in everyone.
• McFarlane, A., deGirolamo, G. (1996). The
  nature of traumatic stressors and the
  epidemiology of posttraumatic reactions. In B. A.
  van der Kolk, A. C. McFarlane L. Weisaeth
  (Eds.), Traumatic stress The effects of
  overwhelming experience on mind, body and society
  (pp. 129-154). New York, US Guilford Press.

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Resilience
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Palestinian children
Children with high ideological commitment
(identification with the cause), are more
protected from developing PTSD than children with
weak ideological commitment.

• Punamaeki, R. L. (1996). Can ideological
  commitment protect children's psychosocial
  well-being in situations of political violence?
  Child Development, 67(1), 55-69.

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Tamil former child soldiers
High ideological commitment (identification with
the cause), buffers the development of certain
posttraumatic symptoms.

• Kanagaratnam, P., Raundalen, M., Asbjørnsen, A.
  (2005). Ideological commitment and posttraumatic
  stress in former Tamil child soldiers.
  Scandinavian Journal of Psychology, 46,
• 511-520.

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Life quality among young Palestinians
Kanaaneh, M., Netland, M., Raundalen, M.
(1999). From a Wounded Childhood to Disillusioned
Adulthood. Revisiting Intifada children in the
period of fragile peace. Report. NORDPAS, Bergen,
Norway
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Life quality among young Palestinians
Kanaaneh, M., Netland, M., Raundalen, M.
(1999). From a Wounded Childhood to Disillusioned
Adulthood. Revisiting Intifada children in the
period of fragile peace. Report. NORDPAS, Bergen,
Norway.
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Resilience and meaning
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Resilience factors

• Self confidence
• Inner locus of control sense of mastery
• Sense of coherence
• Sharing of emotions
• Sense of continuity predictability
• Belonging and attachment
• Vaaktaar, T. Christie, H. (2000). Styrk sterke
  sider. Oslo, Kommuneforlaget.

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Resilience factors

• Security and safety
• Justice
• Attachment
• Identity and role
• Existential meaning
• Silove, D. (2005, Feb 2). Building recilience
  hope following armed conflict Culture,
  empowernment and peace building. Paper at the 7th
  ISHHR conference on health and human rights, Feb
  2, Vadodara, India.

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Cambodian children and adolescent
Children in foster homes in US, encouraged to
leave their culture behind, had more
post-traumatic complaints than those fostered in
Cambodian groups in Australia, encouraged to take
part in traditional ceremonies.

• Eisenbruch, M. (1991). From Posttraumatic stress
  disorder to Cultural bereavement Diagnosis of
  Southeast Asian refugees. Social Science and
  Medicine, 33(6), 673-680.

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Hardships of war redefined

• The major threats to children are those
  adversities that undermine basic protective
  systems for development.

Masten, A. S. (2001). Ordinary magic Resilience
processes in development. American Psychologist,
56(3) 227-238.
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Correlates of war and political violence

• Poverty and deprivation
• Caregiving
• Love
• Social support
• Education
• Basic health care
• Hunger, malnutrition
• Stigma
• Exploitation/abuse

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Complex PTSD (next DSM?)

• Helplessness
• Shame
• Guilt
• Stigma
• Feeling different
• Aggression
• Search for rescuer

• Loneliness
• Loss of faith
• Hopelessness
• Despair
• Distrust
• Sadness
• Suicidal thoughts

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Psychotherapy cannot cure misery
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Thank you!