CAROLYN FLYNN, MA, LAC, NCC, CD
DECEMBER 6, 2019
PROPRIETARY AND CONFIDENTIAL INFORMATION
THE IMPACT OF TRAUMA ON ATTACHMENT DURING GESTATION, BIRTH, AND POSTPARTUM: UNDERSTANDING THE ROOT OF PSYCHOSOCIAL WELLBEING AND MENTAL HEALTH
Objectives
2PROPRIETARY AND CONFIDENTIAL INFORMATION
• Explain the impact of trauma during the prenatal period on brain structure, psychosocial development, and mental health across the lifespan
• Understand how modern medicalized childbirth systems promote traumatic birth, maternal mental health disorders, and postpartum experiences that hinder attachment
• Understand how an integrated community doula/parent infant mental health model can be utilized to create positive outcomes for pregnant people with current or past trauma
• Generate interventions to promote attachment during pregnancy and the postpartum period
Roots of Mental HealthBrain Development for Survival or Higher Functioning?The prenate is a sentient being, aware of the environment as sensed through the mother’s experiences
Brain development happens in adaptive response to the mother’s inner and outer world: reactive amygdala or responsive cerebral cortex
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Intergenerational Effect of Adverse Childhood Experiences• Adverse Childhood Experiences (ACEs) Study linked childhood maltreatment to a variety of changes in brain structure, function, and stress‐responsive neurobiological systems
• Higher numbers of ACEs related to adverse adult outcomes
• Offspring of mothers with early adverse childhood experiences show increased risk for poor physical, behavioral, and cognitive outcomes
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Intergenerational Effect of ACEs• Infants whose mothers witnessed IPV in childhood exhibited alterations in baseline cortisol and cortisol reactivity at 1 month
• Children born to mothers with a history of child abuse increased risk of asthma and allergy
• Adult offspring of Holocaust survivors are at greater risk for depression and anxiety disorders
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Theories on Transmission of ACEsPrevailing theory:
Transmission happens postnatal though low quality caregiving, low parental sensitivity and responsiveness
New studies:
ACEs cause changes in the HPA Axis: mechanism for transmission of ACEs to the prenate
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The Role of Cortisol• Cortisol: Stress Hormone vital to many aspects of fetal development
• Abnormal levels may induce neurotoxicity and reduced fetal brain growth
• Placenta secretes CRH (corticotropin releasing hormone) stimulates maternal HPA to secrete more cortisol
• Fetal exposure to cortisol is regulated by placental enzyme 11β‐HSD2
• 11β‐HSD2 changes cortisol to its inactive form: cortisone•Many adverse intrauterine conditions are associated with downregulation of 11β‐HSD2
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Fetal Programming Theory•Biological systems undergoing rapid developmental changes are particularly vulnerable
• Human brain development begins early in gestation, occurs over a protracted period and follows a rapid chain of events
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Prenatal Maternal Stress• Mothers who experienced famine twice as likely to give birth to offspring with schizophrenia
• Mothers in second month of pregnancy during Arab‐Israeli 6 day war were more likely to birth offspring with schizophrenia as young adults
• 18 year olds exposed to earthquake during gestation had significantly lower nonverbal IQ scores than those born a year later.
• PNMS associated with autistic traits in preschool age boys
• PNMS associated with ADHD in preschool‐age boys and preschool age school‐age children
• The number of stressful life events associated with severity of ADHD
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Fetal Response to Maternal Emotions
•Pregnant others watched movie clips to Induce emotions of happiness/sadness
• Fetal movements watched via ultrasound
• Acute emotional changes in pregnant women influences behavior of the prenate
•Sad clip group no return to baseline
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Effect of Trauma on Amygdala• Amygdala develops during early embryonic stage‐ by 15 weeks gestation
• Particularly sensitive during development to elevated levels of cortisol
• One SD deviation in maternal cortisol in early gestation linked with 6.4% increase in size of right amygdala in girls
• Right amygdala: processing negative emotions (fear) processing memory, decision–making, emotional response
• Findings support role of amygdala in affective disorders
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Effect of Anxiety, Depression and Anger on Prenate• Anxiety: preterm birth, low birth‐weight, low APGAR scores, infant cries more frequently
• Induced stress tests created changes in FHR only for prenatesgestating in anxious mothers
• Depression: obstetric complications, shorter gestation, preterm labor, excessive crying/difficult to soothe
• High‐Anger: disorganized sleep patterns, lower scores on Brazleton Neonatal Behavioral Assessment
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Effect of Substance Use on Neonate Experience of prenatal substance use in the uterine milieu has not been examined
Impact of substance use affects elements crucial to development of secure attachment:
• Separation of infant and mother for newborn exam and NICU
• Infant displays more negative affect, greater distancing, and difficult‐to‐distinguish cues
• Lack of attunement or misattunement of parent to child
• Removal of child from parent(s) care by Child Welfare System
• Disruption in the parent‐infant regulatory system
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Attachment: Our Blueprint
• Attachment forms our blueprint for how we relate to ourselves, other people, and the world.
• Working model of self, other, and world• Relationship with parent sets the
expectation for how others will relate to self
Do Attachment Styles form Prenatally?Attachment Style Relationship with
CaregiverPrental Environment
Secure Internalized Connection
Pregnancy is welcomed, mother communicates intentionally with infant through thought, touch, and words. Mother’s physical and emotional needs are met.
Avoidant/Dismissive Internalized Abandonment
Unintended pregnancy, partner rejection, hyperemesis gravidarum, pain during pregnancy
Anxious/Preoccupied Internalized Oppression
Environmental Stress, Fear of infant’s wellbeing, basic needs not met
Disorganized Internalized Fear Violence toward mother/infant, toxic levels of cortisol
Peace on Earth Begins with Birth
Guerilla Midwife Video
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Robin Lim, Founder Bumi Sehat, Indonesia
CNN Hero of the Year 2011
Modern Medicalized Childbirth• Understanding Childbirth as a pathological process in need of medical monitoring and treatment rather than a normal, physiologic process
• Economics and fear of malpractice
•High Tech, Low‐Touch” Birth
• Patriarchal views have devalued process of labor as rite of passage
• Authoritative Knowledge
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Intervention Rates2018 CDC Data on Cesarean Rates
• US Cesarean Rate 31.9% • 25.9% C/S rate for low‐risk
•WHO recommendation: 10 and 15%• Healthy People 2020 Target: 23.9%
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2017 Data on Intervention Rates
• 3.1% forceps/vacuum• 73.5% epidural• 24.5% induction• 21% augmentation• 24.7% antibiotics during labor
• 98.4% births occurred in hospital
Obstetric ViolenceLegal term adopted in Venezuela, 2007 to protect against appropriation of the body and reproductive processes of women by health personnel
• Dehumanized treatment
•Abuse of medication
• Conversion of natural processes into pathological ones
• Loss of autonomy and the ability to decide freely about their bodies and sexuality
• Negatively impacting the quality of life of women.
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Obstetric Violence: Examples • Procedures performed without informed consent/refusal •Withholding or misuse of information • Sexual violation: sexualizing of procedures: “husband stitch”• Use of body for teaching: vaginal exams • Medically unnecessary procedures or restraint for physician convenience or fear of malpractice
• Refusal of medical care • Disrespectful language • Instituting blanket policies restricting forms of care (VBAC, Eating and drinking, walking)
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Prevalence of Obstetric Violence2013 Study:
• 59% of women with episiotomy did not consent to procedure
•25% of women with induction felt pressure to consent to treatment
•20% of women who were induced felt provider had “final decision”
•38% women with c/s reported provider had “final decision”
2014 study:
• Doulas, birth educators, and nurses: Half witnessed a physician conduct procedures over woman’s explicit objections
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Maternal Mental Health• Postpartum Anxiety 17.1%
• Postpartum PTSD 9% full criteria, 18% symptomatic
• Postpartum Depression: 4.8%
• Postpartum Psychosis: .5%
Maternal mental health and ability to regulate emotional states correlated to secure attachment, parenting capacities and child outcomes
Experiences of Post‐Partum PTSD
• Flashbacks and nightmares
• Avoidance of reminders, including baby
• Feelings of numbness and dissociation
• Intense need to know the details of birth• Anger, anxiety and depression> Rage, panic attacks, suicidality• Isolation from other mothers
• Effect on relationship with partner
Risk for Childbirth‐Related PTSD: Client Factors
Client Factors
•Previous history of trauma
• History of psychological problems
• Unplanned pregnancy
• Not breastfeeding for as long as planned
Care Factors
•Perceived lack of control
• Pressure for induction
• Pressure for epidural
• High level of obstetric intervention
• Dissatisfaction with intrapartum care
Effect of Birth Trauma on Breastfeeding• Two themes: driven, perseverance in breastfeeding or early termination of breastfeeding
• Feeling detached from the experience
•Needing to atone for the trauma experienced by the child
• Flashbacks to birth trauma
• Delayed or perceived diminished milk supply
• Feeling violated or stripped of dignity while breastfeeding
Effect of Birth Trauma on Infant• Physical harm: hypoxia, injury to scalp, nose, cut with scalpel
• Association between schizophrenia and premature rupture of membranes, gestational age shorter than 37 weeks, use of resuscitation or incubator
•Maternal pain, medical procedures, dissociation disrupts bonding during “golden hour”
• Disruption of co‐regulation of temperature, heartrate, and brainwave states. Traumatized mother offers infant states of stress dysregulation
Effect of Birth Trauma on Attachment
• Feelings of inadequacy lead to diminished responsiveness
• Mother may blame infant for the traumatic event.
• Dissociative states lead to risk for unresponsiveness and misattunement
• Pitocin interferes with oxytocin receptors
• C‐Section recovery and/or NICU>delayed skin‐to‐skin contact
Optimal Attachment in the Hours After Birth• First Hour: Breast Crawl
• Skin‐to‐skin for first 6 hours/through first sleep cycle “wires” baby’s brain and mother’s brain
• First 24 hours are critical for wiring mother for caretaking behaviors
• Mother doesn’t nurse infant, infant nurses mother
• Early Skin‐to‐Skin contact improves newborn temperature regulation, reduces newborn crying, and increases maternal affection
• 2 day gap before milk comes in: acts on amygdala and ensures soothing from mother
• Breastmilk promotes myelin production
•* First Hours are optimal, but not necessary for secure attachment
Call to Action• Ecological‐Transactional Model: Consider bidirectional relationships between individuals, their relationships, and their environments
• View prenate as a sentient being whose formation is adaptive in response to the uterine milieu
• Understand medicalized birth as a social justice issue
•Meet basic physical, emotional, and social needs of pregnant women as a preventative intervention
• Treat mother and child as a system impacted by trauma: relational models of treatment
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Relational Treatment Models: FBR• Began as a collaboration between DCF, the Yale Child Study Center and Johns Hopkins University in 2007
• Serves families who are pregnant or parenting
• In‐home services overcome barriers to treatment
• Built on premise that parenting is a strong motivator for recovery and children can safely remain with parents with SUD when given appropriate clinical support
• Based on attachment theory and insight‐oriented psychotherapy
• Therapist is a secure base from which clients can explore ways their past experience influence their current parenting. Client can then become secure base for child to explore the world.
• 3 hours of in‐home therapeutic services: 2 hours focus substance use, one hour dyadic PIMH with
• Currently focused on moving from promising to evidence‐based program
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Relational Treatment Models: S.T.A.R.T.• Based on FBR Model
•Funded by DOH Integrated Opioid Treatment/Substance Exposed Infant Grant
• Supportive Trauma‐attuned Attachment‐based Recovery & Treatment
• Free in‐home 18 month program for pregnant and parenting people up to 14 weeks postpartum at the time of intake
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Relational Treatment Models: S.T.A.R.T.
• Trauma, Attachment, Substance Use Therapist
Works at intersection of trauma, attachment, and substance use
•Integrated Doula/Case ManagerSupports basic physical, emotional, and relational needs
•Peer Recovery SpecialistSupportive approach, lived experience in recovery
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Interventions: Parent‐Infant Mental HealthA dyadic approach addressing effect of trauma on the parent‐child system
• The client is the relationship between parent and child
• A relational approach to changing intergenerational transmission of ACEs patterns of abuse, neglect, and substance use
• Focus creating secure attachment and repair of attachment ruptures: Relationship between therapist and caregiver is the mechanism for change
• Outcomes include:
co‐regulation in parent‐child dyad
increased parental reflective functioning
increased caregiver attunement responsiveness
decreased parental stress
Interventions: Parent‐Infant Mental Health in the HPA Axis Paradigm
• Impaired caregiving due to trauma and substance use is only part of the intergenerational transmission of ACEs•Early Intervention during pregnancy to aid in prevention of transmission through changes in HPA Axis functioning •Prevention of role reversal and reliance of parent on child for emotional needs: Inclusion of doula and peer recovery specialist• Focus on reduction of maternal stress and basic physical and relational needs•Support early attachment and mothering behaviors
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Interventions: Doulas as Maternal Mental Health Professionals• Building parenting capacities: Mothering the
Mother
• Prevention of role reversal
• Prevention of birth trauma
• Lower intervention rates
• Increase satisfaction with birth experience
• Support initiation and maintenance of breastfeeding
• Support early attachment and mothering behaviors
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Interventions: Birth Experience Survey
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Screening tool developed by Dr. Emily Bosk and staff of START program to screen for events correlated with Postpartum PTSD
Not a validated measure but consistent with research on P‐PTSD risk factors
Interventions: Child Parent Psychotherapy
• A dyadic intervention that uses play within the context of parenting relationship to heal child trauma
•What happens in relationship is healed in relationship
• Child and parent co‐construct a narrative of traumatic experience and understand the perspective of the other
•Therapist holds perspective of child and parent simultaneously
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InterventionsMindfulness and body‐based stress reduction
Massage during pregnancy: reduces depression and improves neonatal outcomes
Psychoeducation regarding evidence‐based interventions
Advocacy for informed consent and refusal
Delayed cord clamping: Increases Myleanation
Opportunities for social connection: Increase oxytocin receptors
Early skin‐to‐skin contact
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Intervention: Connection to Resources• Evidencebasedbirth.com• Improvingbirth.org
• Ican‐online.org•Nationalpartnership.org: The Rights of Childbearing Women
• #Breakthesilence
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Interventions
One change in thoughtTwo changes in heartThree changes in practice
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