Presentation on theme: "POST-TRAUMATIC STRESS IN THE NICU PARENT MARK BERGERON, MD, MPH ASSOCIATES IN NEWBORN MEDICINE, PA CHILDREN’S HOSPITALS AND CLINICS OF MINNESOTA ASSISTANT."— Presentation transcript:
1 POST-TRAUMATIC STRESS IN THE NICU PARENT MARK BERGERON, MD, MPH ASSOCIATES IN NEWBORN MEDICINE, PA CHILDREN’S HOSPITALS AND CLINICS OF MINNESOTA ASSISTANT PROFESSOR, PEDIATRICS UNIVERSITY OF MINNESOTA MEDICAL SCHOOL36TH ANNUAL MINNESOTA PERINATAL ORGANIZATION CONFERENCESEPTEMBER 23, 2010
2 DisclosuresI will not be discussing any experimental or off- label uses for any therapies during this presentation.I have no relevant financial relationships to disclose.
3 ObjectivesDescribe features by which parents in the NICU with post-traumatic stress may be recognized.Describe effective and supportive communication strategies when encountering NICU families in crisis.Identify three resources available to NICU families suffering from emotional trauma.
4 FormatReview what’s known about NICU parents and post- traumatic stressDiscuss future areas of potential research in this areaReview supportive communication strategiesDiscuss resources available to NICU parents and former NICU parents (especially local resources)Open discussion of personal experiences (poignant examples, successes, community needs, etc.)All slides are available on our website (
5 One last disclaimer…I am by no means an expert on mental health or psychological trauma.I am a neonatologist who bears witness to the stress the NICU environment exerts on babies, their parents, and families.
10 Trauma“Experience of a threatening situation that goes beyond the bounds of the individual coping strategies and is accompanied by a sense of helplessness and defenseless abandonment.” (Yehuda, 2002).
11 Post-traumatic Stress Disorder (PTSD) (DSM-IV-TR) A: Exposure to a traumatic event(a) loss of "physical integrity", or risk of serious injury or death, to self or others, and(b) an intense negative emotional response.B: Persistent re-experiencingOne or more of these must be present in the victim:Flashback memories, recurring distressing dreams, subjective re-experiencing of the traumatic event(s), or intense negative psychological or physiological response to any objective or subjective reminder of the traumatic event(s).C: Persistent avoidance and emotional numbingThis involves a sufficient level of:avoidance of stimuli associated with the trauma (thoughts, feelings, or talking about the event(s);avoidance of behaviors, places, or people that could lead to distressing memories;inability to recall major parts of the trauma(s), or decreased involvement in significant life activities;decreased capacity to feel certain feelings;an expectation that one's future will be somehow constrained in ways not normal to other people.D: Persistent symptoms of increased arousal not present beforeThese are all physiological response issues, such as difficulty falling or staying asleep, or problems with anger, concentration, or hypervigilence.E: Duration of symptoms for more than 1 monthIf all other criteria are present, but 30 days have not elapsed, the individual is diagnosed with Acute Stress Disorder.F. Significant impairmentThe symptoms reported must lead to "clinically significant distress or impairment" of major domains of life activity, such as social relations, occupational activities, or other "important areas of functioning”
12 Fundamental question #1 Are all criteria necessary for the traumatic event(s) to be important to a parent’s ability to cope and function?
13 Fundamental question #2 How commonly are features of post-traumatic stress experienced by NICU parents?
14 Impact of NICU experience on parents Sense of loss of personal control over eventsEspecially related to infant survivalLoss of role as decision maker and care giverWhen is this regained?discharge or beyond?Appearance of fragile or sickly infantElevated distress leading toDepression and anxietyASD and PTSDEmotional distress correlated withInfant maturity and Complications (DeMeier, RL et al. (1996))
15 Literature Review“Post Traumatic Symptomatology in Parents with Premature Infants: A Systematic Review of the Literature” Karatzias A, et al. Journal of Prenatal and Perinatal Psychology and Health (2007)Analyzed studies quantitative, qualitative, and mixed quantitative qualitative designs
16 Systematic review Search criteria English Published in peer-reviewed journalsParticipants: parents/caregivers of premature infantsRelated toPost-traumatic symptomatology following preterm birthTraumatic experiences of parents with premature infants and/orEffectiveness of interventions/treatment of post-traumatic symptomatology in parents following preterm birth
17 Systematic review Five studies identified All published after 1997 Primary research papersNo reviews or meta-analyses
18 Wereszczak et al. (1997) Objective: Method: Findings: Study vividness of memories primary caregivers recall after 3 years post preterm birthMethod:Qualitative: Semi-structured interviews of 44 mothers or grandmothersFindings:At 3 years post-birth, caregivers report vivid memories related to infant appearance and behavior, pain, procedures, illness severity, and uncertainty of outcomes
19 Pierrhumbert et al. (2003) Objective: Methods: Findings: Examine effects of PTSD reactions of parents on sleeping and eating problems of former preterm infants.Methods:Perinatal PTSD questionnaire (PPQ, by Quinnell and Hynan, 1999) administered to 50 families (mothers and fathers) of former preterm infants and 25 families of full term infants at enrollment and at 6 mos. CGAFindings:67% of mothers of preemies vs. 6% controls exhibited clinical post-traumatic reactions at 6 mos past expected due dateIntensity of those reactions correlated with eating/sleeping problems of infants
20 Holditch-Davis et al. (2003) Objective:Investigate post-traumatic stress responses of mothers with premature infantsMethods:Mixed qualitative-quantitative design w/ semi-structured interview screening for PTS features at enrollment and at 6 months corrected age30 mothers of high-risk preterm infantsFindings:All mothers had at least one PTS symptom12 had two symptoms16 had three symptomsInfant illness severity was significantly associated with PTS symptoms
21 Kersting et al. (2004) Objective: Methods: Findings: Investigate PTS responses of mothers of premature infantsMethods:Prospective longitudinal50 mothers of premature infants assessed with Impact of Events Scale (IES) (Horowitz et al. 1979) at 1-3 days, 14 days, 6 mos. and 14 mos. post-birth vs. 30 mothers of uncomplicated term infant birthsFindings:Higher rates of traumatic symptoms in mothers of preemies at all time points persisting without reduction at 14 mos. (p < .05)
22 Jotzo and Poets (2005) Objective: Methods: Findings: Investigate effectiveness of a trauma-preventative psychological intervention for parents of premature infants during hospitalizationMethods:Sequential control-group designSingle session crisis intervention w/ psychologist w/ additional support throughout hospitalization when needed25 mothers in intervention group/25 in control groupAssessment at discharge w/ IESFindings:19 mothers in control group showed symptoms of clinical trauma post-birth compared to 9 in the intervention group
23 Systematic reviewResearch on the perspectives of NICU parents is limitedStudies had methodological limitationsSmall size, high attrition ratesLittle diversityTime of assessmentMothers vs. fathersLack of control for illness severityNo clinician-administered assessment tool for PTSDIntervention studies are particularly lackingLimited information on effective strategies of support
24 “For Parents in NICU, Trauma May Last” By Laurie Tarkan August 25, 2009
25 Shaw et al. (2009)“The Relationship Between Acute Stress Disorder and Posttraumatic Stress Disorder in the Neonatal Care Unit”
26 Shaw et al. (2009) Objective: Methods: Examine the prevalence of PTSD in parents 4 months after the birth of preterm or sick infantsExamine the relationship between PTSD and ASD symptoms immediately following birthMethods:18 parents completed completed a self-report assessment of ASD at baselineSelf-report assessment for PTSD and depression completed at 4 months.
27 Shaw et al. (2009)Findings:33% of fathers and 9% of mothers met criteria for PTSDASD symptoms highly correlated with development of PTSD and depressionFathers showed a more delayed onset in PTSD symptoms, but were at greater risk by 4 months than mothers
28 Future researchStandardized clinical scales along with open-ended interview schedules to obtain pre-post birth dataMore long-term follow-up data neededMore fathers in sampling, more racial diversityInfant illness severity should be recordedAttempt to correlate PTS symptoms with depressionEnhances bias recall of events?
29 Fundamental question #3 Given a lack of evidence, what strategies of support/intervention should be offered in the NICU and after discharge?
30 Step one: Recognize the feelings TerrorGriefImpotenceDepressionJealousyAnger“Even the most well-adapted appearing couple with an infant in the NICU is undergoing the most stressful crisis of their lives”Rachel, Social Worker
31 Step two: ValidateReassure parents that their emotions are a NORMAL response to severe stressMothers and fathers are more alike than differentBe wary of stereotypingUse communication that focuses on the individual parent’s experience and emotionsEmpathyEncourage verbalization
32 A unique parent perspective “You are going to be disorganized and upset for months—some of us for years. We feel crazy, and we want to return to normal quickly. But that is the worst thing that we can try to do, because we can’t stop or reverse the natural, healing process of our emotional reactions without doing damage to ourselves. The only things that are normal for high- risk parents are terror, grief, impotence, and anger… And experiencing these lousy emotions are signs that we parents are doing well, not poorly.”
33 A unique perspective“… the medical staff can do wonderful things to help angry parents, even though I know that angry parents are one of the most troublesome things for you. It is natural for you to want to avoid angry parents, but please stay with us. When we erupt and explode, don’t go away, even though you have pressing obligations. Stay there, nod your heads, and let our anger blow past you like the desert winds. Then, in the next day or two, when you sense that we might be more rational, come back to us and re-establish communications. Go over what we were mad about, and show us that you believe that our feelings are important to you. This is crucial. Many times, trust is the only good feeling a parent has. If that trust ever disappears, then that is the worst crash on the roller coaster for parents.”Michael Hynan, Ph.D. and parent of ex-preemie
34 Creating a supportive environment Continuity of carei.e. primary nursesFamily-centered care practicesBedside rounding with familiesOn-site social workersParent-to-parent groupAdvisor/leader (paid vs. volunteer)Seamless discharge to home transitionEngage parents in developmental care earlyEncourage parenting competenciesHome nurse visitsMedical Home modelNICU Follow-up clinic
35 Supporting a family: where to refer? Hospital social workerOther resourcesPregnancy and Postpartum Support Minnesota (PPSM)mental health & perinatal practitioners, service organizations, and mother volunteers offering emotional support and treatment to Minnesota families through the perinatal yearsPerinatal Mental Health Resource List, 4th Ed.
37 ConclusionNICU hospitalization generate a traumatic experiences for most, if not all, parentsMany will exert signs of acute and post-traumatic stressManifestations and likely effects vary among individualsFuture research needed to better understand the nature of ASD and PTSD in NICU parents
38 ReferencesHoditch-Davis, D; Bartlet, TR; Blickman, AL; Shandor Miles, M. (2003). Posttraumatic stress symptoms in mothers of premature infants. JOGNN, 32,DeMeier, RL; Hynan, MT; Harris, HB; et al. (1996). Perinatal stressors as predictors of symptoms of posttraumatic stress in mothers of infants at high risk. Journal of Perinatology, 16,Jutzo, M; Poets, CF. (2005). Helping parents cope with the trauma of premature birth: An evaluation of a trauma-preventive psychological intervention. Pediatrics, 115,Kersting, A; Dorsch, M; Wesselmann, U, et al. (2004). Maternal posttraumatic stress response after the birth of a very low-birth-weight infant. Journal of Psychosomatic Research, 57,Pierrhumbert, B; Nicole A; Muller-Nix, C; Forcada-Guex, M; Ansermet, F. (2005). Parental post-traumatic reactions after premature birth: Implications for sleeping and eating problems in the infant. Archives of Disease in Childhood and Fetal and Neonatal Education, 88,Shaw, RJ; Bernard, RS; DeBlois, T; Ikuta, LM; Ginzburg, K; Koopman, C. (2009). The Relationship between acute stress disorder and posttraumatic stress disorder in the neonatal intensive care unit. Psychosomatics, 50,Wereszczak, J; Shandor Miles, M; Holditch-Davis, D. (1997). Maternal recall of the neonatal intensive care unit. Neonatal Network, 16,Yehuda, R. (2002). Clinical relevance of biologic findings in PTSD. Psychiatric Quarterly, 73,
39 ReferencesWith much gratitude to Michael Hynan, Ph.D., University of Wisconsin – Milwaukee for his generous sharing of his insight, personal stories and research. (