Reprezentacje traumy w dzieciństwie, T. Gauensbauer.pdf

ARTI CLE

REPRESENTATIONS OF TRAUMA IN INFANCY:

CLINICAL AND THEORETICAL IMPLICATIONS

FOR THE UNDERSTANDING OF EARLY MEMORY

THEODORE J. GAENSBAUER

University of Colorado Health Sciences Center

ABSTRACT: Understanding the nature of the infant’s internal experience is a crucial prerequisite for de-

lineating the developmental effects of an early trauma. In addition, to the extent that internal represen-

tations of a trauma can be traced over time, traumatic experiences present unique opportunities for the

study of early memory. This article will describe case vignettes of children who experienced a trauma in

the preverbal period and who evidenced forms of memory of their trauma at subsequent points in time.

In conjunction with the clinical material, developmental research bearing on the types of early memories

described will be discussed. The clinical data, reinforced by research ﬁndings, indicate that preverbal

children, even in the ﬁrst year of life, can establish and retain some form of internal representation of a

traumatic event over signiﬁcant periods of time. The speciﬁcity and enduring nature of the internal

representations suggest that speciﬁc therapeutic interventions over and above general comforting will be

required if an infant is to maximally recover from a trauma. The clinical ﬁndings have relevance for a

number of issues currently under debate in the area of infant memory, including the role of reminders in

memory retention, the nature of early memory systems, and the development of autobiographical memory.

RESUMEN: Comprender la naturaleza de la experiencia interna del infante es un prerequisito crucial para

delinear los efectos del desarrollo sobre un trauma que haya aparecido tempranamente. Adicionalmente,

hasta el punto de que el camino de las representaciones internas de un trauma puede seguirse con el

tiempo, las experiencias traum´ticas presentan oportunidades ´nicas para el estudio de la memoria al

principio. Este estudio describir´ casos de ni˜os que experimentaron un trauma en el per´do preverbal y

que dieron muestra de formas de memoria de su trauma en subsecuentes puntos temporales. Conjunta-

mente con el material cl´nico, se discutir´ tambi´n la investigaci´n sobre el desarrollo que parte de los

tipos de primeras memorias descritos. La informaci´n cl´nica, reforzada por los resultados de la inves-

tigaci´n, indica que los ni˜os en el per´do preverbal, aun en el primer a˜o de vida, pueden establecer y

retener alguna forma de representaci´n interna de un evento traum´tico durante signiﬁcativos per´odos

de tiempo. La especiﬁcidad y la naturaleza de aguante de las representaciones internas sugieren que si

un infante se va a recobrar al m´ximo de su trauma, se requerir´n intervenciones terap´uticas espec´ﬁcas

muy por encima del nivel general de ofrecerle un simple consuelo. Los resultados cl´nicos son relevantes

en cuanto a un n´mero de asuntos que actualmente se encuentra en debate en el ´rea de la memoria

infantil, incluyendo el papel de las advertencias recordatorias en la retenci´n de la memoria, la naturaleza

de los primeros sistemas de memoria, as´ como el desarrollo de la memoria autobiogr´ﬁca.

Direct correspondence to: Theodore J. Gaensbauer, Infant, Child, Adolescent, & Adult Psychiatry, 3955 East Expo-

sition Avenue, Suite 402D, Denver, CO 80209; phone: 303-777-8731; fax: 303-777-5857.

INFANT MENTAL HEALTH JOURNAL, Vol. 23(3), 259– 277 (2002)

2002 Michigan Association for Infant Mental Health

Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/imhj.10020

259

260 ● T.J. Gaensbauer

R ´ SUM ´ : Comprendre la nature de l’exp´rience interne du nourrison est crucial pour d´limiter les effets

d’un traumatisme pr´coce sur le d´veloppement. De plus, dans la mesure o` les repr´sentations internes

d’un traumatisme peuvent ˆtre trac´es au ﬁl du temps, les exp´riences traumatiques pr´sentent des op-

portunit´s uniques pour l’´tude de la m´moire pr´coce. Cette ´tude d´crit des vignettes de cas d’enfants

qui ont v´cu un traumatisme durant la p´riode pr´verbale et qui, ult´rieurement, ont pr´sent´ des ´vidences

de formes de souvenirs de leur traumatisme. Conjointement avec la documentation clinique, les recherches

en mati`re de d´veloppement portant sur les sortes de souvenirs pr´coces d´crits seront discut´s. Les

donn´es cliniques, renforc´es par les r´sultats de recherche, indiquent que les enfants pr´verbaux, mˆme

durant leur premi`re ann´e, peuvent ´tablir et retenir une forme de repr´sentation interne d’un ´v´nement

traumatique, et ceci pendant de grandes p´riodes. La sp´ciﬁcit´ et la nature durable des repr´sentations

internes sugg`rent que des interventions th´rapeutiques sp´ciﬁques allant bien au del` d’un simple r´-

confort seront n´cessaires a`lar´cup´ration maximale du nourrisson apr`s un traumatisme. Les r´sultats

cliniques sont importants pour certains probl`mes faisant actuellement l’objet d’un d´bat dans le domaine

de la m´moire du nourrisson, dont par exemple le rˆle des rappels dans la r´tention de la m´moire, la

nature des syst`mes de la m´moire pr´coce, et le d´veloppement de la m´moire autobiographique.

ZUSAMMENFASSUNG: Um die entwicklungspsychologischen Effekte eines fr¨hen Traumas beschreiben zu

k¨nnen, ist es unerl¨ßlich die inneren Erlebnisse des Kleinkinds zu kennen. Zus¨tzlich bieten traumatische

Erlebnisse eine einmalige Gelegenheit, um die fr¨he Erinnerungsf¨higkeit, jedenfalls so weit, als Spuren

der inneren Repr¨sentationen eines Traumas gefunden werden k¨nnen, zu studieren. Diese Arbeit be-

schreibt Falldarstellungen von Kindern, die ein Trauma in der pr¨verbalen Periode ihres Lebens erlebt

haben und die Zeichen von Erinnerung an ihr Trauma an mehreren sp¨teren Zeitpunkten zeigten. Ent-

wicklungspsychologische Forschung zu den Typen der fr¨hen Erinnerung wird gemeinsam mit dem

klinischen Material diskutiert. Unsere klinischen Beobachtungen, unterst¨tzt durch die Forschungsergeb-

nisse weisen darauf hin, dass vorsprachliche Kinder – sogar im ersten Lebensjahr – einige Formen von

innerer Repr¨sentation eines traumatischen Ereignis ¨ber l¨ngere Zeit herstellen und bewahren k¨nnen.

Die Speziﬁt¨t und die lange Dauer der inneren Repr¨sentationen weisen darauf hin, dass speziﬁsche

therapeutische Interventionen mehr und bedeutender, als allgemeine W¨rme n¨tig sind, wenn ein Klein-

kind sich von einem Trauma erholen soll. Diese klinischen Beobachtungen haben eine Bedeutung bei

einer grossen Anzahl von Themen, die derzeit debattiert werden: kindliche Erinnerung, unter Einschluß

der Rolle von Menschen, die die Erinnerung hervorrufen, die Natur des fr¨hen Erinnerungssystems und

die Entwicklung der autobiographischen Erinnerung.

***

When exposed to a traumatic event, what does the infant understand about what is hap-

pening? Does he or she form an internal representation of the experience? Is the experience

Representations of Trauma in Infancy ● 261

retained in memory? If so, for how long and in what forms? Such questions have distinct

clinical importance, because understanding the nature of the infant’s internal experience is a

crucial prerequisite for delineating the effects of an early trauma on children’s subsequent

development and for designing effective treatment approaches. They also have a larger devel-

opmental signiﬁcance in that questions about infants’capacity for the registration and retention

of experienced events apply not only to traumatic experiences but to environmental stimuli in

general; they speak to the nature of the infant’s inner world. Thus, clinical observations ad-

dressing these questions can contribute not only to issues of treatment, but to the advancement

of understanding of infant memory functioning as well. To the extent that traumas can be

represented internally, and to the extent that these representations can be traced over time,

traumatic experiences represent a unique opportunity for the study of early memory.

This article brings together clinical observations of infants who experienced a trauma in

the preverbal period and who evidenced forms of memory of their trauma at subsequent points

of time. The clinical data, particularly when evaluated in light of burgeoning developmental

research, indicate that preverbal children, even in the ﬁrst year of life, can establish and retain

some form of internal representation of a traumatic event over signiﬁcant periods of time. The

speciﬁcity and enduring nature of the internal representations and their inﬂuence on the child’s

affective responses to subsequent events suggest that speciﬁc therapeutic interventions over

and above general comforting will be required if an infant is to maximally recover from a

trauma. The clinical ﬁndings have relevance for a number of issues currently under debate in

the area of infant memory, including the role of reminders in memory retention, the nature of

early memory systems, and the development of autobiographical memory.

The case examples are drawn primarily from my own practice, with additional cases com-

ing from discussions with colleagues and from the clinical literature. For reasons of space, the

cases cannot be described in great detail. As is common with clinical data, the available infor-

mation is variable and many questions about possible sources of contamination and alternative

explanations for the children’s memory manifestations will naturally arise. Further detail about

the nature of the memories and the manner in which they emerged may be obtained by re-

viewing the cases that have been previously published. Given the rapid developmental changes

occurring in the ﬁrst two years, the case presentations will be grouped by age according to

when the trauma occurred and organized around three periods of major developmental reor-

ganization during infancy — two to three months, six to eight months, and 18 to 24 months

(Emde, Gaensbauer, & Harmon, 1976). In each section, relevant developmental research will

be cited to place the clinical vignettes in the context of what is currently known about infant

memory functioning.

CLINICAL MATERIAL

Zero to Two Months

Given the large number of newborns who experience painful medical procedures, the question

of whether a newborn infant can internally register a traumatic experience is an important one.

Unfortunately, systematic research addressing this question is very sparse. Based on the data

that is available, however, there is reason to believe that a newborn would be capable of such

registration, albeit extremely rudimentary in nature. Newborn infants manifest all of the cardinal

physiologic stress responses to pain (Anand & Hickey, 1987; Marshall, 1989). They are also

capable of both instrumental and classical conditioning (Blass, Ganchrow, & Steiner, 1984;

DeCasper & Fifer, 1980; Little, Lipsitt, & Rovee-Collier, 1984). Such capacities suggest that

262 ● T.J. Gaensbauer

in the ﬁrst weeks of life an infant would have the ability to both experience a stress response

and conditionally pair it with an accompanying stimulus such that subsequent behavior could

be inﬂuenced. Sander’s pioneering work demonstrated that newborns develop expectations, or

“experiential-perceptual gestalts” (Sander, 1995), based on previous interactive encounters, and

show affective and behavioral disturbances when these expectations are violated (see also

Slater, 1995). Sander’s study of the effects of mothers donning a ski mask when their infants

were seven days of age offers a compelling example. As the infants were brought to the breast

and looked into their mother’s face, they startled and hesitated to begin feeding. In the transition

to sleep following the feeding they showed increased restlessness, spitting up, and fussiness

(Sander, 1991, cited in Nahum, 2000).

Even more relevant to the issue of the registration of traumatic experience, Gunther (1961)

observed that newborn infants who experienced an anoxic airway obstruction during feeding

would subsequently resist being put to the breast. When forced, they would cry and ﬁght even

more. In cases where such struggles persisted for even two or three feedings, merely positioning

the infants in preparation for the feeding would cause them to “start crying from the expectation

that they [would] be put on the breast” (p. 38). An anecdote reported to me by a mother was

consistent with Gunther’s observations. When her three-day-old infant was having difﬁculty

nursing, a very aggressive nurse held the infant’s head, forced open his jaw, and shoved the

mother’s breast into his mouth. The infant became upset, gagged, and arched his back away

from the breast. At this moment, the nurse, who happened to be wearing a distinctive pink

scrub suit with “neon pink” hearts, was paged and left the room. When the nurse returned 10

minutes later, the mother reported that the infant “saw who it was” and immediately arched

his back and pushed against his mother’s body with his legs with such force that he rolled over

on the bed.

Although we do not know whether or in what form such “experiential-perceptual gestalts”

from this early period might be retained in the form of internal schemas, there is evidence for

the persistence of somatic memories. For example, Fitzgerald, Millard, and McIntosh (1989)

demonstrated persisting cutaneous hypersensitivity to pain following repeated heel pricks,

while Liley (1972) reported that infants who experienced as few as 10 heel pricks in the ﬁrst

three days of life could show distress for many weeks thereafter when their heels were grasped.

Consistent with these reports I have had two instances reported to me of persisting hypersen-

sitivity in the heel region following repeated heel pricks in infancy. In one case, a young adult,

unaware that he had experienced repeated heel pricks to the point of tissue maceration as a

newborn, reported to his parents with puzzlement that whenever he was under stress his heels

hurt. In a second instance, the parents of a four-year old girl with a similar newborn experience

reported that she repeatedly pounded her heels against the mattress while in bed to relieve an

irritable sensation. Interestingly, a recent research study with rats has provided parallel support

for the hypothesis that somatic sensations from the newborn period can endure. Ruda, Ling,

Hohmann, Peng, and Tachibana (2000) found that rat pups exposed to a painful stimulus to

the paws in the ﬁrst weeks of life showed hypersensitivity to pain as adults. The adult rats also

showed excessive sprouting of nerve endings in the afferent sensory regions of the spinal cord

that corresponded to the affected limb.

Circumcision is another commonly experienced painful experience from the newborn pe-

riod worthy of attention in regard to potential carryover effects. Although a number of studies

have shown only transient and mild behavioral effects (Emde, Harmon, Metcalf, Koenig, &

Wagonfeld, 1971; Marshall, Porter, Rogers, Moore, Anderson, & Boxerman, 1982; Marshall,

Stratton, Moore, & Baxerman, 1980), a recent study has raised interesting questions about

longer lasting retention. In a group of four- and six-month-old infants undergoing routine

vaccination, Taddio, Katz, Ilersich, & Koren (1997) found increased distress re-

Representations of Trauma in Infancy ● 263

sponses (assessed by facial expression and duration of crying) in infants who had been circum-

cised as newborns compared to uncircumcised infants. They questioned whether similarities in

the subjective and/or physiological response to the two painful stimuli triggered a more intense

distress response to the vaccination, akin to a posttraumatic stress reaction.

Three to Six Months

The period between two and three months is a period of major developmental change, as infants

develop a new awareness of the world around them (Emde & Robinson, 1979). They begin to

make reliable discriminations between caregivers and respond differentially based on their

previous interactions with that caregiver (Robson & Moss, 1970). They are able to anticipate

stimulus patterns and sequences as shown both by anticipatory gazing (Haith, Wentworth, &

Canﬁeld, 1993), and by negative emotional responses when social expectations are violated,

for example when mothers maintain a “stone face” (Tronik, Als, Adamson, Wise, & Brazelton,

1975). At this age infants also learn to appreciate means-ends relationships involving their own

actions, or what Piaget (1952) termed “procedures to make interesting spectacles last,” and are

capable of remembering these “procedures” for extended periods of time. For example, by two

months of age, infants are capable of retaining a learned action, such as moving their leg to

make a mobile move. By three months they are able to retain that learning for as long as a

week without reminders (Hill, Borovsky, & Rovee-Collier, 1988). By ﬁve months, infants are

able to demonstrate memory for familiar stimuli for periods of weeks when exposed to visual

paired comparisons (Fagan, 1990), a paradigm dependent on brain structures traditionally as-

sociated with declarative memory (McKee & Squire, 1993). An impressive study of memory

retention from this period is that of Perris, Myers, & Clifton (1990). At 6.5 months a group of

infants was exposed to a single laboratory experiment involving reaching in the dark for a

sounding object. The children showed evidence of remembering, as demonstrated by increased

successful reaching and increased tolerance of the experimental situation compared to inex-

perienced controls, when exposed to a similar stimulus situation two years later. Also around

three months, discrete affective states such as pleasure, fear, anger, and sadness begin to emerge

(Izard & Malatesta, 1987). Combined with the infant’s growing capacity to register environ-

mental events, this emerging affect differentiation enables the infant to establish emotionally

meaningful, situation-speciﬁc, internal representations. These “cognitive-affective schemata”

allow the infant to recognize and respond in emotion-speciﬁc ways to ensuing events that have

similar stimulus conﬁgurations (Gaensbauer, 1982).

Three cases that I was involved with have illustrated the capacity of three- to four-month-

old infants to retain such “cognitive-affective schemata” for extended periods. One infant,

repeatedly and severely abused by his biological father between the ages of three and 10 weeks

before being placed in foster care, showed fearful reactions to men for many months. During

his ﬁrst month in foster care, when approached by his foster father or teenage foster brother,

he would cry inconsolably. The foster mother also noted that he would often startle if she

inadvertently made an abrupt gesture in his direction, such as during diaper changes. Although

these reactions diminished within his foster family, at six months, when an adult male bearing

a physical resemblance to the father attempted to pick him up, he immediately startled and

began to scream. At eight months, during a medical exam, when the doctor made an affectionate

gesture with the intention of stroking his head, the child startled so abruptly that the doctor

was taken aback. Except for the occasional startles, none of these types of reactions were seen

in interactions with adult women. I ﬁrst saw him at nine months (a time when stranger distress

is common). As I talked to him from a distance of ﬁve feet he appeared quite frightened. He

had a very fearful expression, a frozen posture, marked hyperventilation, and began to cry

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