psychisch kranke eltern auswirkung auf kinder/...infant outside the home due to inadequate care,...

Psychisch kranke Elternndash Auswirkung auf Kinder

Parents avec des maladies psychiquesndash effets sur les enfants

Daniel S Schechter MD Leiter der Liaisonabteilung Kinder- u Jugend Psychiatrische Dienst und Eltern-Kind Forschungsprojekte Kinderspital Universitaumlt Genf Meacutedecin adjoint agreacutegeacute responsable de lrsquoUniteacute de liaison et de la Recherche parents-enfant SPEA Hocircpital des Enfants HUGUniGe

1

The acquisition of self-regulation of emotion by the age of 4-5 years is

essential for socialization and learning

2

3

The path towards the achievement of self-regulation of emotion begins during infancy with mutual emotion regulation between mother and baby bullThis process occurs in the context of primary attachment (Hofer 1994) bullIt involves a bidirectional system between mother and infant that is asymmetric The infant is hard-wired to seek proximity and emotional responsiveness from mother since birth But the mother an adult has clearly more capacities to understand modulate and respond to her infantrsquos emotional communication and is thus essential

3

Factors that interfere with maternal participation in mutual emotion

regulation bull Stress

bull Trauma

bull Psychopathology

4

A range of parental psychopathology is associated with disturbances in caregiving behavior and participation in mutual emotion and arousal regulation (Schechter amp Willheim 2009

Child amp Adolescent Psychiatry Clinics of N America)

bull Having a schizophrenic mother represents the greatest risk for placing an infant outside the home due to inadequate care followed by bipolar disorder followed by major depressive disorder (Ranning et al 2015)

bull Mothers with affective and schizophrenic disorders are prone to higher risk of child death (Liu Chen amp Loh 2010)

bull Compared with a non-schizophrenia group the speech of mothers with schizophrenia was less infant-focused Additionally mothers with schizophrenia also used significantly fewer songs or rhymes than the comparison group and showed a trend towards fewer negative comments than depressed controls (Wan Penketh Salmon amp Abel 2008)

bull Primiparous mothers with subclinical depression differed significantly from healthy control mothers ie showed poorer mother-to-infant attachment and higher infant-related hostility 6-8 months postpartum (Behrendt 2016)

Beyond Psychotic and Mood Disordershellip

bull Mothers with Obsessive-Compulsive Disorder (OCD) were less confident and were rated as less sensitive in interactions than the comparison group partly attributable to levels of concurrent depression (Challacombe et al 2016)

bull Panic Disordered mothers also displayed less sensitivity toward their infants and reported parenting behaviors concerning infant sleep and discipline that have been associated with child problems (Warren et al 2003)

bull Borderline Personality Disordered mothers were rated as more intrusively insensitive toward their infants (Hobson et al 2005)

bull As predicted a higher proportion (85) of women with borderline personality disorder than women in the comparison groups showed disrupted affective communication with their infants They were also distinguished by the prevalence of frighteneddisoriented behaviour (Hobson et al 2009)

Maternal Posttraumatic Stress Disorder

(PTSD) related to interpersonal violence (IPV) exposure

bull Interpersonal violence (IPV ie child physical and sexual abuse domestic violence physical assault rape combat etc) is among the most traumatogenic of human experiences (Breslau et al 1991)

bull In Switzerland 154 out of 10000 women are involved as victims in cases of domestic violence that are reported to the police (38 of all violent crime reported)ndash many more cases go unreported (Swiss Federal Statistics 2016)

bull With a prevalence of only 6-7 in the general US population PTSD prevalence among victims of IPV can be as high as 60-80 (Gabbay et al 2004 Breslau et al 1991)

bull In the UK showed that rates of IPV-PTSD have tripled among women ages 16-24 between 2007 and 2014 (42 to 127) (NHS Statistics September 2016)

bull PTSD is characterized by ldquointense fear helplessness and horrorrdquo related to life-threatening events the memories of which do not extinguish over time (Rothbaum amp Davis 2003 Wessa amp Flor 2007)

bull PTSD typically involves re-experiencing avoidancenumbing hypervigilance and negative cognitions (APA DSM-5 2013)

7

The number of children exposed to physical abuse and domestic violence who are reported to the Geneva University

Hospitals (HUG) Child Protection Committee (Groupe de protection de lrsquoenfant) increased dramatically in 2 years

(Rapport annuel du GPE HUG 2015)

2013 () 2014 () 2015 ()

Physical violence 35 (208) 52 (28) 63 (319)

- Certain 21 (125) 36 (194) 48 (243)

- Probable 10 (59) 7 (38) 7 (36)

- Possible 4 (24) 9 (48) 8 (4)

Most children are under the age of 6 years

8

First studies of PTSD and parenting

Lyons-Ruth amp Block (1996) found a significant association between maternal IPV-PTSD and atypical maternal behavior that was characterized by hostility and intrusiveness

Multiple studies have since shown that

general maternal psychological functioning in the wake of violence exposure is a strong mediator of the impact of violence exposure on the child (Scheeringa amp Zeanah 2001 2015)

We wondered about the effects of the infant and toddlerrsquos normative emotion dysregulation on the traumatized parent

9

So where is the threat Hypotheses

bull The child becomes a threat to the

traumatized parent ndash parent avoids child

bull And since the child cannot understand the avoidant andor aggressive behavior of his traumatized parent the parent becomes an unpredictable threat to the child ndash

child gets more distressed

bull Both become trapped in a vicious cycle of mutual

dysregulation leading to risk for the child

10

Mother

Father or other

partner

Child

Mother

violence

PTSD

How does this dysregulated parent-child relationship affect child developmental psychopathology

Understanding mechanisms that underlie intergenerational transmission

Violent

Anxious

past violence

RF

RF

(Schechter Suardi in preparation)

11 laquo RF raquo = laquo Reflective functioning raquo a marker for secure attachment as protective factor

Reflective Functioning (RF) an operationalization of mentalization

(Fonagy et al 1998 Slade 2005) bull Fonagy Target Steele amp Steele (1998) created a manual based on their research

by which one could assess adult reflective functioning (RF) by coding narrative responses on the Adult Attachment Interview (AAI)

bull RF in this context refers to an individualrsquos capacity to attribute mental states (thoughts amp feelings) to her own parents and to herself in an interpersonal context in an effort to understand motivatons for behavior (ldquoholding others and oneself in mindrdquo)

bull Parental Reflective Functioning (PRF) (Slade 2005) refers rather to an individual parentrsquos capacity to attribute mental states to her child and in herself in an interpersonal context (ldquoholding onersquos child and oneself in mindrdquo see Coates SW 1998)

+

Clinician-assisted Video-feedback

Exposure Session (CAVES)

Parent-Child Interaction 1-2 wks

Screening

Maternal Assessment

OVERALL PROTOCOL Children Ages 1-35 years

MRI

2-4 wks

Observed and Maternal Report

Child Behavior Ages 5-9 years

Phase I Phase 2

Maternal Report Child

Behavior Ages 2-45 years

Geneva Early Childhood Stress Project within the NCCR-SYNAPSY

(Schechter amp Rusconi Serpa 2013) 13

Sampling

bull Flyers in community hospitals and domestic violence agencies for over-sampling of violence-exposed mothers

bull Adult French-speaking mothers who were not actively substance abusing psychotic pregnant and who could participate in study tasks

bull Biological children ages 12-42 months living with mother who could participate in study tasks

bull Fathers not interviewed for ethical reasons bull Recruited 123 dyads out of which 99 adult mothers with

children mean age 269 months (SD 88) had complete data 64 mothers with PTSD out of which 49 had IPV-PTSD and 35 mothers without PTSD (controls)

bull No significant maternal amp child age and gender group differences (pgt3) (Schechter et al 2015)

14

Maternal exposure to trauma (Schechter et al 2015 CHUD)

0

10

20

30

40

50

60

70

80

90

100

Physical abuseas a child

Sexual abuse asa child

Exposed todomestic

violence as achild

Non-violencerelated trauma

Sexual orphysical assaultas an adult bynon-partner

Sexual orphysical assaultas an adult by

partner

Any type ofphysical or

sexual assault asan adult

35

9 22 28 32

8

41

69

29

64 59

85 89

100

Types of trauma suffered by group

Controls

PTSD

N=84 out of 99 subjects with complete data (excludes 15 mothers who had PTSD due to non-IPV events) 15

16

15-month-old girl and traumatized mother during separation

Can the young child trigger traumatic memory traces in mothers with IPV-PTSD

Mother laquoI canrsquot stand it when babies cryhellip it means putting up with being helplessraquo

17

2015 Oct48179-89 doi 101016jchiabu201505023 Epub 2015 Jul 2 Impact of a maternal history of childhood abuse on the development of mother-infant interaction during the first year of life Fuchs A1 Moumlhler E1 Resch F1 Kaess M1 Abstract hellipWomen who reported moderate or severe sexual andor physical abuse were included in the maltreatment group (n=58 MG) and compared with a non-maltreated comparison group (n=61

CG) Emotional availability (EA) was investigated under experimental conditions when the children were 5 and 12 months of age using the Emotional Availability Scales While mother-child dyads in the MG showed only very discrete interactional alterations at an infant age of 5 months their EA differed significantly from the CG at 12 months due to the lack of an increase in EA observed in the MG Exploratory analyses showed an additional effect of emotional abuse on EA at 12 months These data indicate that the period when child locomotion develops might represent a critical time window for mothers with a history of abusehellip (See also Muzik et al 2016 J Affective Disorders)

There is likely a developmental window (ie sensitive period) specific to the effects of certain forms of parental psychopathology on children

MAIN RESULTS 3 TYPES OF PSYCHOBIOLOGICAL DYSREGULATION BEHAVIORALEMOTIONAL PHYSIOLOGIC NEURAL ACTIVITY

18

Behavioral and emotional dysregulation (Schechter et al 2015 CHUD)

bull Maternal IPV-PTSD severity is associated with difficulty in identifying emotions in self and others (ie alexithymia) (plt01)

bull Both are associated with increased parenting stress (plt005) and decreased maternal sensitivity (plt01) (ie increased controlling and unresponsive behavior) on the CARE-Index

HC

PTSD

Level of stress

HC n= 9 PTSD n=11

Schechter et al 2012 SCAN

19

Physiological Dysregulation of the HPA-Axis among Mothers with IPV-PTSD

Salivary cortisol reactivity to separation stress and circadian rhythms (N=45) (Cordero et al in revision)

Consistent with methylation results

for glucocorticoid receptor NR3c1 (Schechter et al 2015 Frontiers)

20

Cortico-limbic dysregulation when mothers see toddlers (own and unfamiliar) in separation vs play

(Schechter et al 2015 Frontiers)

Blue areas show negative correlations of neural activity and IPV-PTSD severity

Medial Prefrontal Cortex

Posterior Cingulate Cortex

n = 55 p lt 005 k gt 27 21

0102030405060708090

100

43

5 5

38

5 0

55 53

18

94

35 45

control

PTSD

Violence Exposure among the Children of Mothers with versus without IPV-PTSD (N=59)

22

Child symptoms as predicted and mediated by maternal neural activity in reponse to seeing

separation vs play scenes (Schechter Moser et al in revision)

23

Maternal IPV-PTSD is associated with

Attachment Disorder (Secure Base Distortion) at 12-24 months (T1) plt005

Child PTSD at 24-54 months (T2) plt01

(N-T1=59 N-T2=48)

Towards identification of risk for an aggressive endophenotype

(Schechter et al 2016 Behavioural Brain Research)

24

Methylation of the serotonin HTR3A receptor at a specific CpG site (CpG 2_III) in promoter region adjacent to functional SNP both associated with physical abuseviolence in prior studies (Jajodia et al 2015 Perroud et al 2016)

Less methylation of maternal HTR3A at CpG2_III is correlated with

bull greater lifetime maternal violence exposure

bull greater maternal aggression

bull greater child self-endangering behavior impulsivity and aggression

bull less activation of the dorsal medial prefrontal cortex dorsal lateral prefrontal cortex and left medial temporal gyrus in response to film scenes of menacing versus neutral and prosocial adult

M-F interactions

25

Implications for treatment (Schechter amp Rusconi Serpa 2013 Schechter et al 2015)

bull Top-down cortico-limbic regulation dysfunctions when IPV-PTSD mothers are exposed to child helpless states (ie distress separation anxiety tantrums) and thus tend to avoid rather than approach their toddler leading to mutual dysregulation during sensitive periods for the development of emotional regulation (Schechter amp Rusconi Serpa 2013 Moser Schechter et al 2015)

bull We have developed a brief manualized psychotherapy Clinician Assisted Videofeedback Exposure-Approach Therapy or laquo CAVEAT raquo to target this empirically supported mechanism (Schechter Rusconi Serpa Horst Willheim amp Suardi in preparation)

bull Having developed a therapeutic alliance with the traumatized mother we expose mothers to filmed interactions that they might otherwise avoid in joint attention with a co-regulating reflective therapist (Schechter amp Rusconi Serpa 2013)

26

Addressing Maternal Alexithymic Errors and Parenting Distress Clinician Assisted Videofeedback Exposure Sessions or ldquoCAVESrdquo

(Schechter et al 2006 2015)

FOCUS OF INTERVENTION bull Reflective clinician supports the motherrsquos ability to tolerate and integrate

the negative trauma-associate emotions stirred up by routine stresses such as separation and tantrums

TECHNIQUE OF INTERVENTION

bull The clinician states that we are going to focus on what happened during the mother-child interactions that were filmed during the previous visit

bull The clinician asks what the mother remembers most from those interactions what she remembers as the most fun moment and as the most difficult moment for her and for her child

bull The clinician then proposes four 30-second excerpts from Visit 2 for joint parent-clinician review in the following order

an optimal moment (joy joint attentionmutualityetc)

a moment of separation (when mother is not in the playroom)

a moment of reunion (when mother returns)

novel stimuli (clown and scary toys)

CAVES Technique to support and model parental curiosity (PRF) laquo The Mantra raquo

hellipdeliberately repetitive

bull Following each excerpt the clinician poses to the mother a series of questions and probes in order to stimulate maternal RF

Examples of probes (ldquoMantrardquo) Tell me what happened here What do you think was going in your child mind In your mind What were you feeling then Does the moment we watched remind you of any other moments

in your own life If so tell me about that What are you feeling as you are watching that moment with me Why do you think I chose this moment for us to watch

Copyright 2016 Daniel S Schechter MD

CAVES in the Continuum of Video Feedback Interventions

bull The CAVES integrates aspects of four evidence-based interventions Prolonged Exposure Therapy for PTSD (Foa) Interaction Guidance (McDonough) Minding the Baby and MIO (Mentalization-based parent-infant treatment) (Slade Suchman) Infant-Parent Psychotherapy (Lieberman)

bull See review by Rusconi-Serpa Sancho-Rossignol et McDonough on Video Feedback in Parent-Infant Treatment (2009)

bull Specificity of the intervention ndash joint attention to video feedback of mother-child interaction that

involves mother and supportive clinician

ndash exposure to child distress during separation

ndash clinicians modelling of RF during the intervention


Maternal Attributions Rating Scale (MARS) Yields Continuous Ratings of Maternal

Descriptors bull Took content item of WMCI ldquoName 5 words

(adjectives) that describe your childrsquos personalityrdquo and had words rated independently with a 5-point scale

bull Rated by 4 post-doc infancy specialists given age of child only

bull Inter-rater reliability high Negativity ICC=76


Significant Decrease in Negativity of Attributions on MARS after CAVES in a Referred Sample (n=32)

Paired t-tests comparing degree of negativity of maternal attributions from the post-play paradigm condition (wseparation-reunions) to post-CAVES corr sig means SD

n=3241 pV2 1430 276 31 0082 pV3 1235 259 mean SD t (df) sig Paired diffs 195 314 350 (31) 0001 95 CI (081 308) 11 variance of change accounted for by baseline maternal RF Copyright 2016 Daniel S Schechter MD

Mothers with PTSD have a significantly higher degree of negativity at baseline towards child self and

maternal primary attachment figure (M-PAF) Means (SD) by ANOVA PTSD (Case ) Subthreshold Control F-test (df 256) Towards child V1 1453 (431) 1215 (349) 1084 (305) 677 V3 1128 (404) 1046 (318) 1017 (239) 056 Towards self V1 1483 (356) 1064 (291) 1089 (260) 886 V3 1426 (362) 1164 (276) 1061 (347) 567 Towards M-PAF V1 1612 (499) 1368 (496) 1224 (396) 441 V3 1558 (537) 1296 (429) 1179 (510) 276+ Significance (p) + lt1 ldquordquo= lt05 ldquordquo= lt01 ldquordquo= lt005

Schechter et al (2015) Child Psychiatry and Human Development


Example of change of traumatized motherrsquos attributions towards a 27-month-old boy mother was abused by her

laquo disorganized unstable mother raquo and mother was victim of domestic violence by boyrsquos laquo possessive controlling raquo dad

disorganizedhellip messy worries worries

worries affectionate affectionate

talkative disorganized intelligent

possessive intelligent talkativehellip too much

unstable sometimes selfish awake

MARS score=20 MARS score=155 MARS score=1325

V1 V2 V3 post-CAVES

Negative Distorted Positive Age-Appropriate

Mother stated that she underestimated her importance to son and interpreted his efforts to connect as controlling possessive

(Schechter et al Child Psychiatry amp Human Development in press)


Total Child

Behavior

Problems

Parenting

Stress

Negative

Attributions

PTSD Total

Symptoms

plt05 plt01 plt 001

07 (03) 199 (74)

42 (11)

58 (16)

163 (69)

RMSEA = 07 CFI = 99 SRMSR = 003

Negativity of Attributions Predicts Disrupted Communication in the P-C Relationships (Basu Willheim et al in prep)

Another case example that shows why the CAVES may offer an advantage to

some traumatized mothers and children in an opening phase of

treatment over infant-parent psychotherapy that does not use videofeedback hellip by stimulating

maternal curiosity and wonderment Copyright 2016 Daniel S Schechter MD

Clinical illustration from Geneva (Merminod Kreis Rusconi Serpa)

Mme A and her son Flavio (age 14-months) Flavio was first seen by our consult-liaison team when he was

hospitalized for failure to thrive at age 6-months He was treated discharged but returned as weight not maintained When by 9-10 months of age it became clear that Flavio had a severe

feeding disorder Mme A amp Flavio joined our research study when Flavio reached 12

months and participated over the next 6 weeks Mother completed the CAVES and said that she had not imagined that

her reactions to her child were as she had seen them in the video Subsequent dyadic psychotherapy included videofeedback in the form

of Modified Interaction Guidance (Rusconi Serpa amp McDonough)

36 Copyright 2016 Daniel S Schechter MD

37

Clinical illustration from Geneva Mme Arsquos Story Mother age 22 at time of our study unemployed and on public

assistance She had just begun training to become a home health-aide when she

found out she was pregnant with Flavio and stopped attending History of extreme and chronic domestic violence between her parents

and her alcoholic fatherrsquos otherwise erratic often physically and verbally abusive behavior with the children

Mme A left her parentsrsquo home for Flaviorsquos father at age 18 He became increasingly irritable on verge of violence in peripartum

period Diagnosis of IPV- PTSD (CAPS score of 100 and PCL-S of 43)


Flavio as large and dangerous at 13 months

Whom does Flavio remind you of

Wellhellip my father because my father hit my mother a lot but even morehellipThat makes me think of my boyfriend and at the same time my father Because my father is in fact also someone with a strong personality imposing and my boyfriend the same the father of Flavio therefore reminds me of these two personalities because Flavio is a strong kid It makes me think a little bit of both indeed He is veryhellipeveryone tells me that also in fact from his face (he looks like both men)hellip


laquo CAVES raquo with Mme A

bull With the kind permission of Mme A we will now see several film excerpts from the CAVES when Flavio was 13-months-old (with naso-gastric tube) The therapist is Sandra Rusconi Serpa


CAVES Excerpts with Mme A (Clinician

Sandra Rusconi Serpa)


Towards CAVE-T Modified Interaction Guidance with Mme A following CAVES (Flavio is 14 months-old)

bull With the kind permission of Mme A we will now see several film excerpts from the continuation of infant-parent psychotherapy that incorporated modified interaction guidance with videofeedback after the CAVES and after both therapists saw the DVD of the CAVES The therapists are Gaeumllle Merminod and Axelle Kreis

bull Note laquo ball in the tube raquo game and how Flavio in excitement throws a fast-ball

bull Mother startles

bull Mother lifts tube to protect herself Makes game harder for F


Outcome of this experimental extended treatment

bull Reduction in maternal symptoms and significant improvement in childrsquos feeding and affect regulation observed and quantified in this test-case

bull Parent-infant psychotherapists have become more sensitized to subtle exchanges between traumatized mother and child

bull Motherrsquos startle response at child play gesture opened up the representation first described in the CAVES research visit that took place mid-way through an ongoing psychotherapy


Treatment or Adjunct Intervention

bull This intervention may for some families by choice or by necessity be the only treatment the dyad will receive

bull But we envision this intervention more often as a catalyst transition or first step that precedes a longer-term child-parent psychotherapy andor adult treatment of the parent of a more traditional nature

bull WARNING Cannot learn a CAVES intervention in one 2 hour workshophellip This is meant as a laquo taster raquo


Maintenance

sessions

12 treatement sessions (6x 2 Modules)

Also using principles of Interaction Guidance

and Trauma-focused cognitive therapy

1 session

Intervention plan

3 Evaluation sessions

+ Mother-child relationship and trauma

+ videofeedback

caves

CAVEAT INTERVENTION 16 sessions


laquo If there is one theme that runs throughout the pages of our case

records it is lsquoI want something better for my baby than what I had

myselfrsquo raquo

Fraiberg S (1980) Clinical Studies in Infant Mental Health New York

Basic Books Inc p 28


Thanks Merci pour votre attention Danke fuumlr Ihre Aufmerksamkeit Geneva Early Childhood Stress Project Team

Sandra Rusconi Serpa (co-PI) Sonia Junod Virginie Pointet Raffaella Torrisi Aurelia Manini Florence Caccia Dominik Moser

Francesca Suardi Marylegravene Vital-Benour

46

Thanks to our funders

In Geneva National Center for Competence in Research ldquoSYNAPSYrdquo Swiss National Science Foundation Fondation Gertrude von Meissner UNIGE Research Fund Medical Directorship HUG Fondations PrimrsquoEnfance Oak

UniGe-Princeton Fund

In New York NIH K23-MH68405 to DS Schechter Maternal PTSD and Interactive Behavior IPA Research Advisory Board Grants AACAP Pilot Research Award Sackler Institute for Developmental Psychobiology at Columbia U Ruane Scholarship Award Bender-Fishbein Fund NIH M01 RR000645-34 to DS Schechter Mother-Child Interaction Project MRI Lab New York State Psychiatric Institute

47

The acquisition of self-regulation of emotion by the age of 4-5 years is

essential for socialization and learning

2

3


3



bull Trauma


4




















7




2013 () 2014 () 2015 ()


- Certain 21 (125) 36 (194) 48 (243)

- Probable 10 (59) 7 (38) 7 (36)

- Possible 4 (24) 9 (48) 8 (4)


8






9








10

Mother

Father or other

partner

Child

Mother

violence

PTSD



Violent

Anxious

past violence

RF

RF








+




Screening

Maternal Assessment


MRI

2-4 wks



Phase I Phase 2





Sampling







14


0

10

20

30

40

50

60

70

80

90

100



Exposed todomestic

violence as achild




partner



35

9 22 28 32

8

41

69

29

64 59

85 89

100


Controls

PTSD


16




17





18




HC

PTSD

Level of stress

HC n= 9 PTSD n=11


19





20






n = 55 p lt 005 k gt 27 21

0102030405060708090

100

43

5 5

38

5 0

55 53

18

94

35 45

control

PTSD


22



23




(N-T1=59 N-T2=48)



24







M-F interactions

25





26
















































V1 V2 V3 post-CAVES





Total Child

Behavior

Problems

Parenting

Stress

Negative

Attributions

PTSD Total

Symptoms

plt05 plt01 plt 001

07 (03) 199 (74)

42 (11)

58 (16)

163 (69)















37


































Maintenance

sessions




1 session

Intervention plan



+ videofeedback

caves





myselfrsquo raquo







46





47

3


3



bull Trauma


4




















7




2013 () 2014 () 2015 ()


- Certain 21 (125) 36 (194) 48 (243)

- Probable 10 (59) 7 (38) 7 (36)

- Possible 4 (24) 9 (48) 8 (4)


8






9








10

Mother

Father or other

partner

Child

Mother

violence

PTSD



Violent

Anxious

past violence

RF

RF








+




Screening

Maternal Assessment


MRI

2-4 wks



Phase I Phase 2





Sampling







14


0

10

20

30

40

50

60

70

80

90

100



Exposed todomestic

violence as achild




partner



35

9 22 28 32

8

41

69

29

64 59

85 89

100


Controls

PTSD


16




17





18




HC

PTSD

Level of stress

HC n= 9 PTSD n=11


19





20






n = 55 p lt 005 k gt 27 21

0102030405060708090

100

43

5 5

38

5 0

55 53

18

94

35 45

control

PTSD


22



23




(N-T1=59 N-T2=48)



24







M-F interactions

25





26
















































V1 V2 V3 post-CAVES





Total Child

Behavior

Problems

Parenting

Stress

Negative

Attributions

PTSD Total

Symptoms

plt05 plt01 plt 001

07 (03) 199 (74)

42 (11)

58 (16)

163 (69)















37


































Maintenance

sessions




1 session

Intervention plan



+ videofeedback

caves





myselfrsquo raquo







46





47



bull Trauma


4




















7




2013 () 2014 () 2015 ()


- Certain 21 (125) 36 (194) 48 (243)

- Probable 10 (59) 7 (38) 7 (36)

- Possible 4 (24) 9 (48) 8 (4)


8






9








10

Mother

Father or other

partner

Child

Mother

violence

PTSD



Violent

Anxious

past violence

RF

RF








+




Screening

Maternal Assessment


MRI

2-4 wks



Phase I Phase 2





Sampling







14


0

10

20

30

40

50

60

70

80

90

100



Exposed todomestic

violence as achild




partner



35

9 22 28 32

8

41

69

29

64 59

85 89

100


Controls

PTSD


16




17





18




HC

PTSD

Level of stress

HC n= 9 PTSD n=11


19





20






n = 55 p lt 005 k gt 27 21

0102030405060708090

100

43

5 5

38

5 0

55 53

18

94

35 45

control

PTSD


22



23




(N-T1=59 N-T2=48)



24







M-F interactions

25





26
















































V1 V2 V3 post-CAVES





Total Child

Behavior

Problems

Parenting

Stress

Negative

Attributions

PTSD Total

Symptoms

plt05 plt01 plt 001

07 (03) 199 (74)

42 (11)

58 (16)

163 (69)















37


































Maintenance

sessions




1 session

Intervention plan



+ videofeedback

caves





myselfrsquo raquo







46





47




















7




2013 () 2014 () 2015 ()


- Certain 21 (125) 36 (194) 48 (243)

- Probable 10 (59) 7 (38) 7 (36)

- Possible 4 (24) 9 (48) 8 (4)


8






9








10

Mother

Father or other

partner

Child

Mother

violence

PTSD



Violent

Anxious

past violence

RF

RF








+




Screening

Maternal Assessment


MRI

2-4 wks



Phase I Phase 2





Sampling







14


0

10

20

30

40

50

60

70

80

90

100



Exposed todomestic

violence as achild




partner



35

9 22 28 32

8

41

69

29

64 59

85 89

100


Controls

PTSD


16




17





18




HC

PTSD

Level of stress

HC n= 9 PTSD n=11


19





20






n = 55 p lt 005 k gt 27 21

0102030405060708090

100

43

5 5

38

5 0

55 53

18

94

35 45

control

PTSD


22



23




(N-T1=59 N-T2=48)



24







M-F interactions

25





26
















































V1 V2 V3 post-CAVES





Total Child

Behavior

Problems

Parenting

Stress

Negative

Attributions

PTSD Total

Symptoms

plt05 plt01 plt 001

07 (03) 199 (74)

42 (11)

58 (16)

163 (69)















37


































Maintenance

sessions




1 session

Intervention plan



+ videofeedback

caves





myselfrsquo raquo







46





47




2013 () 2014 () 2015 ()


- Certain 21 (125) 36 (194) 48 (243)

- Probable 10 (59) 7 (38) 7 (36)

- Possible 4 (24) 9 (48) 8 (4)


8






9








10

Mother

Father or other

partner

Child

Mother

violence

PTSD



Violent

Anxious

past violence

RF

RF








+




Screening

Maternal Assessment


MRI

2-4 wks



Phase I Phase 2





Sampling







14


0

10

20

30

40

50

60

70

80

90

100



Exposed todomestic

violence as achild




partner



35

9 22 28 32

8

41

69

29

64 59

85 89

100


Controls

PTSD


16




17





18




HC

PTSD

Level of stress

HC n= 9 PTSD n=11


19





20






n = 55 p lt 005 k gt 27 21

0102030405060708090

100

43

5 5

38

5 0

55 53

18

94

35 45

control

PTSD


22



23




(N-T1=59 N-T2=48)



24







M-F interactions

25





26
















































V1 V2 V3 post-CAVES





Total Child

Behavior

Problems

Parenting

Stress

Negative

Attributions

PTSD Total

Symptoms

plt05 plt01 plt 001

07 (03) 199 (74)

42 (11)

58 (16)

163 (69)















37


































Maintenance

sessions




1 session

Intervention plan



+ videofeedback

caves





myselfrsquo raquo







46





47






9








10

Mother

Father or other

partner

Child

Mother

violence

PTSD



Violent

Anxious

past violence

RF

RF








+




Screening

Maternal Assessment


MRI

2-4 wks



Phase I Phase 2





Sampling







14


0

10

20

30

40

50

60

70

80

90

100



Exposed todomestic

violence as achild




partner



35

9 22 28 32

8

41

69

29

64 59

85 89

100


Controls

PTSD


16




17





18




HC

PTSD

Level of stress

HC n= 9 PTSD n=11


19





20






n = 55 p lt 005 k gt 27 21

0102030405060708090

100

43

5 5

38

5 0

55 53

18

94

35 45

control

PTSD


22



23




(N-T1=59 N-T2=48)



24







M-F interactions

25





26
















































V1 V2 V3 post-CAVES





Total Child

Behavior

Problems

Parenting

Stress

Negative

Attributions

PTSD Total

Symptoms

plt05 plt01 plt 001

07 (03) 199 (74)

42 (11)

58 (16)

163 (69)















37


































Maintenance

sessions




1 session

Intervention plan



+ videofeedback

caves





myselfrsquo raquo







46





47








10

Mother

Father or other

partner

Child

Mother

violence

PTSD



Violent

Anxious

past violence

RF

RF








+




Screening

Maternal Assessment


MRI

2-4 wks



Phase I Phase 2





Sampling







14


0

10

20

30

40

50

60

70

80

90

100



Exposed todomestic

violence as achild




partner



35

9 22 28 32

8

41

69

29

64 59

85 89

100


Controls

PTSD


16




17





18




HC

PTSD

Level of stress

HC n= 9 PTSD n=11


19





20






n = 55 p lt 005 k gt 27 21

0102030405060708090

100

43

5 5

38

5 0

55 53

18

94

35 45

control

PTSD


22



23




(N-T1=59 N-T2=48)



24







M-F interactions

25





26
















































V1 V2 V3 post-CAVES





Total Child

Behavior

Problems

Parenting

Stress

Negative

Attributions

PTSD Total

Symptoms

plt05 plt01 plt 001

07 (03) 199 (74)

42 (11)

58 (16)

163 (69)















37


































Maintenance

sessions




1 session

Intervention plan



+ videofeedback

caves





myselfrsquo raquo







46





47

Mother

Father or other

partner

Child

Mother

violence

PTSD



Violent

Anxious

past violence

RF

RF








+




Screening

Maternal Assessment


MRI

2-4 wks



Phase I Phase 2





Sampling







14


0

10

20

30

40

50

60

70

80

90

100



Exposed todomestic

violence as achild




partner



35

9 22 28 32

8

41

69

29

64 59

85 89

100


Controls

PTSD


16




17





18




HC

PTSD

Level of stress

HC n= 9 PTSD n=11


19





20






n = 55 p lt 005 k gt 27 21

0102030405060708090

100

43

5 5

38

5 0

55 53

18

94

35 45

control

PTSD


22



23




(N-T1=59 N-T2=48)



24







M-F interactions

25





26
















































V1 V2 V3 post-CAVES





Total Child

Behavior

Problems

Parenting

Stress

Negative

Attributions

PTSD Total

Symptoms

plt05 plt01 plt 001

07 (03) 199 (74)

42 (11)

58 (16)

163 (69)















37


































Maintenance

sessions




1 session

Intervention plan



+ videofeedback

caves





myselfrsquo raquo







46





47






+




Screening

Maternal Assessment


MRI

2-4 wks



Phase I Phase 2





Sampling







14


0

10

20

30

40

50

60

70

80

90

100



Exposed todomestic

violence as achild




partner



35

9 22 28 32

8

41

69

29

64 59

85 89

100


Controls

PTSD


16




17





18




HC

PTSD

Level of stress

HC n= 9 PTSD n=11


19





20






n = 55 p lt 005 k gt 27 21

0102030405060708090

100

43

5 5

38

5 0

55 53

18

94

35 45

control

PTSD


22



23




(N-T1=59 N-T2=48)



24







M-F interactions

25





26
















































V1 V2 V3 post-CAVES





Total Child

Behavior

Problems

Parenting

Stress

Negative

Attributions

PTSD Total

Symptoms

plt05 plt01 plt 001

07 (03) 199 (74)

42 (11)

58 (16)

163 (69)















37


































Maintenance

sessions




1 session

Intervention plan



+ videofeedback

caves





myselfrsquo raquo







46





47

Sampling







14


0

10

20

30

40

50

60

70

80

90

100



Exposed todomestic

violence as achild




partner



35

9 22 28 32

8

41

69

29

64 59

85 89

100


Controls

PTSD


16




17





18




HC

PTSD

Level of stress

HC n= 9 PTSD n=11


19





20






n = 55 p lt 005 k gt 27 21

0102030405060708090

100

43

5 5

38

5 0

55 53

18

94

35 45

control

PTSD


22



23




(N-T1=59 N-T2=48)



24







M-F interactions

25





26
















































V1 V2 V3 post-CAVES





Total Child

Behavior

Problems

Parenting

Stress

Negative

Attributions

PTSD Total

Symptoms

plt05 plt01 plt 001

07 (03) 199 (74)

42 (11)

58 (16)

163 (69)















37


































Maintenance

sessions




1 session

Intervention plan



+ videofeedback

caves





myselfrsquo raquo







46





47


0

10

20

30

40

50

60

70

80

90

100



Exposed todomestic

violence as achild




partner



35

9 22 28 32

8

41

69

29

64 59

85 89

100


Controls

PTSD


16




17





18




HC

PTSD

Level of stress

HC n= 9 PTSD n=11


19





20






n = 55 p lt 005 k gt 27 21

0102030405060708090

100

43

5 5

38

5 0

55 53

18

94

35 45

control

PTSD


22



23




(N-T1=59 N-T2=48)



24







M-F interactions

25





26
















































V1 V2 V3 post-CAVES





Total Child

Behavior

Problems

Parenting

Stress

Negative

Attributions

PTSD Total

Symptoms

plt05 plt01 plt 001

07 (03) 199 (74)

42 (11)

58 (16)

163 (69)















37


































Maintenance

sessions




1 session

Intervention plan



+ videofeedback

caves





myselfrsquo raquo







46





47

16




17





18




HC

PTSD

Level of stress

HC n= 9 PTSD n=11


19





20






n = 55 p lt 005 k gt 27 21

0102030405060708090

100

43

5 5

38

5 0

55 53

18

94

35 45

control

PTSD


22



23




(N-T1=59 N-T2=48)



24







M-F interactions

25





26
















































V1 V2 V3 post-CAVES





Total Child

Behavior

Problems

Parenting

Stress

Negative

Attributions

PTSD Total

Symptoms

plt05 plt01 plt 001

07 (03) 199 (74)

42 (11)

58 (16)

163 (69)















37


































Maintenance

sessions




1 session

Intervention plan



+ videofeedback

caves





myselfrsquo raquo







46





47

17





18




HC

PTSD

Level of stress

HC n= 9 PTSD n=11


19





20






n = 55 p lt 005 k gt 27 21

0102030405060708090

100

43

5 5

38

5 0

55 53

18

94

35 45

control

PTSD


22



23




(N-T1=59 N-T2=48)



24







M-F interactions

25





26
















































V1 V2 V3 post-CAVES





Total Child

Behavior

Problems

Parenting

Stress

Negative

Attributions

PTSD Total

Symptoms

plt05 plt01 plt 001

07 (03) 199 (74)

42 (11)

58 (16)

163 (69)















37


































Maintenance

sessions




1 session

Intervention plan



+ videofeedback

caves





myselfrsquo raquo







46





47


18




HC

PTSD

Level of stress

HC n= 9 PTSD n=11


19





20






n = 55 p lt 005 k gt 27 21

0102030405060708090

100

43

5 5

38

5 0

55 53

18

94

35 45

control

PTSD


22



23




(N-T1=59 N-T2=48)



24







M-F interactions

25





26
















































V1 V2 V3 post-CAVES





Total Child

Behavior

Problems

Parenting

Stress

Negative

Attributions

PTSD Total

Symptoms

plt05 plt01 plt 001

07 (03) 199 (74)

42 (11)

58 (16)

163 (69)















37


































Maintenance

sessions




1 session

Intervention plan



+ videofeedback

caves





myselfrsquo raquo







46





47




HC

PTSD

Level of stress

HC n= 9 PTSD n=11


19





20






n = 55 p lt 005 k gt 27 21

0102030405060708090

100

43

5 5

38

5 0

55 53

18

94

35 45

control

PTSD


22



23




(N-T1=59 N-T2=48)



24







M-F interactions

25





26
















































V1 V2 V3 post-CAVES





Total Child

Behavior

Problems

Parenting

Stress

Negative

Attributions

PTSD Total

Symptoms

plt05 plt01 plt 001

07 (03) 199 (74)

42 (11)

58 (16)

163 (69)















37


































Maintenance

sessions




1 session

Intervention plan



+ videofeedback

caves





myselfrsquo raquo







46





47





20






n = 55 p lt 005 k gt 27 21

0102030405060708090

100

43

5 5

38

5 0

55 53

18

94

35 45

control

PTSD


22



23




(N-T1=59 N-T2=48)



24







M-F interactions

25





26
















































V1 V2 V3 post-CAVES





Total Child

Behavior

Problems

Parenting

Stress

Negative

Attributions

PTSD Total

Symptoms

plt05 plt01 plt 001

07 (03) 199 (74)

42 (11)

58 (16)

163 (69)















37


































Maintenance

sessions




1 session

Intervention plan



+ videofeedback

caves





myselfrsquo raquo







46





47






n = 55 p lt 005 k gt 27 21

0102030405060708090

100

43

5 5

38

5 0

55 53

18

94

35 45

control

PTSD


22



23




(N-T1=59 N-T2=48)



24







M-F interactions

25





26
















































V1 V2 V3 post-CAVES





Total Child

Behavior

Problems

Parenting

Stress

Negative

Attributions

PTSD Total

Symptoms

plt05 plt01 plt 001

07 (03) 199 (74)

42 (11)

58 (16)

163 (69)















37


































Maintenance

sessions




1 session

Intervention plan



+ videofeedback

caves





myselfrsquo raquo







46





47

0102030405060708090

100

43

5 5

38

5 0

55 53

18

94

35 45

control

PTSD


22



23




(N-T1=59 N-T2=48)



24







M-F interactions

25





26
















































V1 V2 V3 post-CAVES





Total Child

Behavior

Problems

Parenting

Stress

Negative

Attributions

PTSD Total

Symptoms

plt05 plt01 plt 001

07 (03) 199 (74)

42 (11)

58 (16)

163 (69)















37


































Maintenance

sessions




1 session

Intervention plan



+ videofeedback

caves





myselfrsquo raquo







46





47



23




(N-T1=59 N-T2=48)



24







M-F interactions

25





26
















































V1 V2 V3 post-CAVES





Total Child

Behavior

Problems

Parenting

Stress

Negative

Attributions

PTSD Total

Symptoms

plt05 plt01 plt 001

07 (03) 199 (74)

42 (11)

58 (16)

163 (69)















37


































Maintenance

sessions




1 session

Intervention plan



+ videofeedback

caves





myselfrsquo raquo







46





47



24







M-F interactions

25





26
















































V1 V2 V3 post-CAVES





Total Child

Behavior

Problems

Parenting

Stress

Negative

Attributions

PTSD Total

Symptoms

plt05 plt01 plt 001

07 (03) 199 (74)

42 (11)

58 (16)

163 (69)















37


































Maintenance

sessions




1 session

Intervention plan



+ videofeedback

caves





myselfrsquo raquo







46





47






M-F interactions

25





26
















































V1 V2 V3 post-CAVES





Total Child

Behavior

Problems

Parenting

Stress

Negative

Attributions

PTSD Total

Symptoms

plt05 plt01 plt 001

07 (03) 199 (74)

42 (11)

58 (16)

163 (69)















37


































Maintenance

sessions




1 session

Intervention plan



+ videofeedback

caves





myselfrsquo raquo







46





47





26
















































V1 V2 V3 post-CAVES





Total Child

Behavior

Problems

Parenting

Stress

Negative

Attributions

PTSD Total

Symptoms

plt05 plt01 plt 001

07 (03) 199 (74)

42 (11)

58 (16)

163 (69)















37


































Maintenance

sessions




1 session

Intervention plan



+ videofeedback

caves





myselfrsquo raquo







46





47
















































V1 V2 V3 post-CAVES





Total Child

Behavior

Problems

Parenting

Stress

Negative

Attributions

PTSD Total

Symptoms

plt05 plt01 plt 001

07 (03) 199 (74)

42 (11)

58 (16)

163 (69)















37


































Maintenance

sessions




1 session

Intervention plan



+ videofeedback

caves





myselfrsquo raquo







46





47

Total Child

Behavior

Problems

Parenting

Stress

Negative

Attributions

PTSD Total

Symptoms

plt05 plt01 plt 001

07 (03) 199 (74)

42 (11)

58 (16)

163 (69)















37


































Maintenance

sessions




1 session

Intervention plan



+ videofeedback

caves





myselfrsquo raquo







46





47













37


































Maintenance

sessions




1 session

Intervention plan



+ videofeedback

caves





myselfrsquo raquo







46





47



























Maintenance

sessions




1 session

Intervention plan



+ videofeedback

caves





myselfrsquo raquo







46





47



myselfrsquo raquo







46





47




46





47





47

psychisch kranke eltern auswirkung auf kinder/...infant outside the home due to inadequate care,...

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