Daniel S. Schechter

Distorted Maternal Mental Representations and Atypical Behavior in a Clinical Sample of Violence-Exposed Mothers and Their Toddlers

ABSTRACT Objective: To determine whether maternal violence-related posttraumatic stress disorder (PTSD), reflective functioning (RF), and/or quality of mental representations of her child predicts maternal behavior within a referred sample of mothers exposed to interpersonal violence and their children (aged 8–50 months). Method: A total of 41 dyads completed 2 videotaped visits including measures of maternal mental representations and behavior. Results: Negative and distorted maternal mental representations predicted atypical behavior (Cohens d > 1.0). Although maternal PTSD and RF impacted mental representations, no significant relationships were found between PTSD, RF, and overall atypical caregiving behavior. Severity of maternal PTSD was, however, positively correlated with the avoidant caregiving behavior subscale. Conclusions: Maternal mental representations of her child are useful risk indicators that mark dysregulation of trauma-associated emotions in the caregiver.

Disturbances of attachment and parental psychopathology in early childhood.

As the field of attachment has expanded over the past four decades, the perturbations in the relational context which give rise to disturbances of attachment are increasingly, though by no means conclusively, understood. In Part I, this article reviews the historical and current state of research regarding normative attachment classification, the diagnosis of Reactive Attachment Disorder, and the proposed categories of Secure Base Distortions and Disrupted Attachment Disorder. In Part II, the article explores the role of parental psychopathology and the manner in which disturbed caregiver self-regulation leads to disturbances in the mutual regulation between caregiver and infant. The question of the relationship between particular types of maternal pathology and particular forms of attachment disturbance is examined through recent research on the association between maternal posttraumatic stress disorder (PTSD), Atypical Maternal Behavior, and child scores on the Disturbances of Attachment Interview (DAI). The authors present original research findings to support that the presence and severity of maternal violence-related PTSD were significantly associated with secure base distortion in a community pediatrics sample of 76 mothers and preschool-age children. Clinical implications and recommendations for treatment of attachment disturbances conclude the article.

Ataque de nervios and history of childhood trauma

Objective: Ataque de nervios is a common, self-labeled Hispanic folk diagnosis. It typically describes episodic, dramatic outbursts of negative emotion in response to a stressor, sometimes involving destructive behavior. Dissociation and affective dysregulation during such episodes suggested a link to childhood trauma. We therefore assessed psychiatric diagnoses, history of ataque, and childhood trauma in treatment-seeking Hispanic outpatients (N = 70). Significantly more subjects with an anxiety or affective disorder plus ataque reported a history of physical abuse, sexual abuse, and/or or a substance-abusing caretaker than those with psychiatric disorder but no ataque. In some Hispanic individuals, ataque may represent a culturally sanctioned expression of extreme affect dysregulation associated with childhood trauma. Patients with ataque de nervios should receive a thorough traumatic history assessment.

Methylation of NR3C1 is related to maternal PTSD, parenting stress and maternal medial prefrontal cortical activity in response to child separation among mothers with histories of violence exposure.

Prior research has shown that mothers with Interpersonal violence-related posttraumatic stress disorder (IPV-PTSD) report greater difficulty in parenting their toddlers. Relative to their frequent early exposure to violence and maltreatment, these mothers display dysregulation of their hypothalamic pituitary adrenal axis (HPA-axis), characterized by hypocortisolism. Considering methylation of the promoter region of the glucocorticoid receptor gene NR3C1 as a marker for HPA-axis functioning, with less methylation likely being associated with less circulating cortisol, the present study tested the hypothesis that the degree of methylation of this gene would be negatively correlated with maternal IPV-PTSD severity and parenting stress, and positively correlated with medial prefrontal cortical (mPFC) activity in response to video-stimuli of stressful versus non-stressful mother–child interactions. Following a mental health assessment, 45 mothers and their children (ages 12–42 months) participated in a behavioral protocol involving free-play and laboratory stressors such as mother–child separation. Maternal DNA was extracted from saliva. Interactive behavior was rated on the CARE-Index. During subsequent fMRI scanning, mothers were shown films of free-play and separation drawn from this protocol. Maternal PTSD severity and parenting stress were negatively correlated with the mean percentage of methylation of NR3C1. Maternal mPFC activity in response to video-stimuli of mother–child separation versus play correlated positively to NR3C1 methylation, and negatively to maternal IPV-PTSD and parenting stress. Among interactive behavior variables, child cooperativeness in play was positively correlated with NR3C1 methylation. Thus, the present study is the first published report to our knowledge, suggesting convergence of behavioral, epigenetic, and neuroimaging data that form a psychobiological signature of parenting-risk in the context of early life stress and PTSD.

BDNF methylation and maternal brain activity in a violence-related sample

It is known that increased circulating glucocorticoids in the wake of excessive, chronic, repetitive stress increases anxiety and impairs Brain-Derived Neurotrophic Factor (BDNF) signaling. Recent studies of BDNF gene methylation in relation to maternal care have linked high BDNF methylation levels in the blood of adults to lower quality of received maternal care measured via self-report. Yet the specific mechanisms by which these phenomena occur remain to be established. The present study examines the link between methylation of the BDNF gene promoter region and patterns of neural activity that are associated with maternal response to stressful versus non-stressful child stimuli within a sample that includes mothers with interpersonal violence-related PTSD (IPV-PTSD). 46 mothers underwent fMRI. The contrast of neural activity when watching children—including their own—was then correlated to BDNF methylation. Consistent with the existing literature, the present study found that maternal BDNF methylation was associated with higher levels of maternal anxiety and greater childhood exposure to domestic violence. fMRI results showed a positive correlation of BDNF methylation with maternal brain activity in the anterior cingulate (ACC), and ventromedial prefrontal cortex (vmPFC), regions generally credited with a regulatory function toward brain areas that are generating emotions. Furthermore we found a negative correlation of BDNF methylation with the activity of the right hippocampus. Since our stimuli focus on stressful parenting conditions, these data suggest that the correlation between vmPFC/ACC activity and BDNF methylation may be linked to mothers who are at a disadvantage with respect to emotion regulation when facing stressful parenting situations. Overall, this study provides evidence that epigenetic signatures of stress-related genes can be linked to functional brain regions regulating parenting stress, thus advancing our understanding of mothers at risk for stress-related psychopathology.

The Relationship of Violent Fathers, Posttraumatically Stressed Mothers and Symptomatic Children in a Preschool-Age Inner-City Pediatrics Clinic Sample

This study aims to understand if greater severity of maternal posttraumatic stress symptoms (PTSS), related to maternal report of interpersonal violence, mediates the effects of such violence on (a) child PTSS as well as on (b) child externalizing and internalizing symptoms. Study participants were mothers (N = 77) and children 18 to 48 months recruited from community pediatric clinics. Data were analyzed continuously via bivariate correlations and then multiple linear regression. Post hoc Sobel tests were performed to confirm mediation. Paternal violence accounted for 15% of the variance of child PTSS on the PCIP-OR (β = .39, p ≤ .001). While the child’s father being violent significantly predicts child PTSS related to domestic violence, as mentioned, when maternal PTSS is included in the multiple regression model, father’s being violent becomes less significant, while maternal PTSS remains strongly predictive. Sobel tests confirmed that maternal PTSS severity mediated effects of paternal violence on clinician-assessed child PTSS as well as on maternal report of child externalizing and internalizing symptoms. When presented with a preschool-aged child who is brought to consultation for behavioral difficulties, dysregulated aggression, and/or unexplained fears, clinicians should evaluate maternal psychological functioning as well as assess and treat the effects of interpersonal violence, which otherwise may be avoided during the consultation.

When Parenting Becomes Unthinkable: Intervening With Traumatized Parents and Their Toddlers

Intervention with infants, preschoolers, and their families requires that the child and adolescent psychiatrist shift perspective from a one-person psychology to a multiperson or Brelational[ psychology. Assessment and intervention with children younger than 5 years therefore necessitate that the clinician pay close attention to the unique characteristics of the parentYchild relationship. These characteristics include adaptation to each other’s temperaments, developmental capacities, and biological and psychological needs and desires, and to the demands of the particular environment with which the parentYchild relationship contends. Central to this work is the observation of parentY child interactionVholding, communicating, feeding, grooming/diapering, dressing, and, of course, playing. For those who practice in clinics or private offices, these observations occur during free and unstructured interactions in an environment where age-appropriate toys are available for the child. The content of the child’s spontaneous play; the parent’s affective, behavioral, and verbal responses to the child and their play; the child’s response during play while the parent speaks with the therapist; and the child’s direct response to the parentVall are key sources of information regarding the nature of the interaction. The child and adolescent psychiatrist alternately considers the child’s and parent’s perspectives, while also stepping outside of both individual perspectives to view the childYparent relationship. Thus, in addition to developmental and psychiatric vantage points, a relational vantage point is adopted. In an effort to maximize the potential for adaptive socialYemotional functioning of parent and child, particular attention is paid to both protective and risk factors within the relationship. One such factor, the presence of which is considered a protective element and the absence of which implies risk, is that of Bmentalization.[ Mentalization is the capacity to reflect on, and hold in mind, the mental states (i.e., feelings, thoughts, beliefs) of oneself and others. Empirical research suggests that this capacity is a parental trait that forms in the first years of life within the context of the attachment relationship with the parent’s own caregivers. The parent’s mentalization capacity affects the parent’s caregiving behavior with her own child and, in turn, the child’s attachment behavior with the parent. The processes involved in mentalization have been operationalized as a range of Bself-reflective functioning[ or BRF.[ Reflective functioning was originally developed as a codification of verbal examples of mentalization ranging from examples of low RF to high RF. It was used to code narrative content from the Adult Attachment Interview (C. George et al., unpublished, 1984). High RF was found to correlate significantly with secure adult attachment and subsequently with the Assistant Editors

The association of serotonin receptor 3A methylation with maternal violence exposure, neural activity, and child aggression ☆

Background Methylation of the serotonin 3A receptor gene (HTR3A) has been linked to child maltreatment and adult psychopathology. The present study examined whether HTR3A methylation might be associated with mothers’ lifetime exposure to interpersonal violence (IPV), IPV‐related psychopathology, child disturbance of attachment, and maternal neural activity. Methods Number of maternal lifetime IPV exposures and measures of maternal psychopathology including posttraumatic stress disorder (PTSD), major depression and aggressive behavior (AgB), and a measure of child attachment disturbance known as “secure base distortion” (SBD) were assessed in a sample of 35 mothers and children aged 12–42 months. Brain fMRI activation was assessed in mothers using 30‐s silent film excerpts depicting menacing adult male‐female interactions versus prosocial and neutral interactions. Group and continuous analyses were performed to test for associations between clinical and fMRI variables with DNA methylation. Results Maternal IPV exposure‐frequency was associated with maternal PTSD; and maternal IPV‐PTSD was in turn associated with child SBD. Methylation status of several CpG sites in the HTR3A gene was associated with maternal IPV and IPV‐PTSD severity, AgB and child SBD, in particular, self‐endangering behavior. Methylation status at a specific CpG site (CpG2_III) was associated with decreased medial prefrontal cortical (mPFC) activity in response to film‐stimuli of adult male‐female interactions evocative of violence as compared to prosocial and neutral interactions. Conclusions Methylation status of the HTR3A gene in mothers is linked to maternal IPV‐related psychopathology, trauma‐induced brain activation patterns, and child attachment disturbance in the form of SBD during a sensitive period in the development of self‐regulation. HighlightsMaternal severity of interpersonal violence exposure (IPV) was associated with diagnosis of maternal post‐traumatic stress disorder (PTSD).Maternal IPV‐PTSD was in turn associated with disturbed child attachment.HTR3A gene methylation was linked to maternal IPV exposure and aggressive behavior and disturbed child attachment and self‐endangering behavior.HTR3A methylation at the CpG2_III site was linked to decreased medial prefrontal cortical activity in response to menacing relational stimuli.

Negative and Distorted Attributions Towards Child, Self, and Primary Attachment Figure Among Posttraumatically Stressed Mothers: What Changes with Clinician Assisted Videofeedback Exposure Sessions (CAVES)

Abstract This study found that within a non-referred community pediatrics clinic sample, the severity of mothers’ trauma-related psychopathology, in particular, their interpersonal violence-related (IPV) posttraumatic stress, dissociative, and depressive symptoms predicted the degree of negativity of mothers’ attributions towards their preschool age children, themselves, and their own primary attachment figure. Results also showed that mothers with IPV-related posttraumatic stress disorder (PTSD) as compared to non-PTSD controls showed a significantly greater degree of negativity of their attributions toward their child, themselves and their primary attachment figure during childhood. The study finally found a significant reduction in the degree of negativity of mothers’ attributions only towards their child following a three-session evaluation-protocol that included a form of experimental intervention entitled the “Clinician Assisted Videofeedback Exposure Session(s)” (CAVES), for mothers with IPV-PTSD as compared to control-subjects.

The relation of general socio-emotional processing to parenting specific behavior: a study of mothers with and without posttraumatic stress disorder

Socio-emotional information processing during everyday human interactions has been assumed to translate to social-emotional information processing when parenting a child. Yet, few studies have examined whether this is indeed the case. This study aimed to improve on this by connecting the functional neuroimaging data when seeing socio-emotional interactions that are not parenting specific to observed maternal sensitivity. The current study considered 45 mothers of small children (12–42 months of age). It included healthy controls (HC) and mothers with interpersonal violence-related posttraumatic stress disorder (IPV-PTSD), as well as mothers without PTSD, both with and without IPV exposure. We found that anterior cingulate cortex (ACC) and ventromedial prefrontal cortex (vmPFC) activity correlated negatively with observed maternal sensitivity when mothers watched videos of menacing vs. prosocial adult male–female interactions. This relationship was independent of whether mothers were HC or had IPV-PTSD. We also found dorsolateral prefrontal cortex (dlPFC) activity to be correlated negatively with maternal sensitivity when mothers watched any kind of arousing adult interactions. With regards to ACC and vmPFC activity, we interpret our results to mean that the ease of general emotional information integration translates to parenting-specific behavior. Our dlPFC activity findings support the idea that the efficiency of top-down control of socio-emotional processing in non-parenting specific contexts may be predictive of parenting behavior.