Institute of Community and Family Psychiatry Sir Mortimer B. Davis Jewish General Hospital McGill University CAFT 601 Diversity in Couple and Family Therapy 16 May 2019 Title: Working with Traumatized Children and Families across Culture Presenter: Vincenzo Di Nicola, MPhil, MD, FRCPC, DFAPA Professor of Psychiatry, University of Montreal and The George Washington University Abstract: This presentation outlines a model of working with traumatized children and families across culture. When it comes to trauma in children, we need to address three basic questions: (1) why development matters, (2) why family matters, and (3) why culture matters (Di Nicola, 1992, 1996, 1997, 1998, 2012a, 2012b, 2012c, 2018; Di Nicola & Song, forthcoming). These three aspects of children’s lives are reviewed as key critical contexts to understand the “sequential traumatizing” (Keilson, 1992) of young people as highlighted in two clinical vignettes. In the first vignette, “A Train of Traumas,” the layers of the trauma history of an immigrant child and his family from the Maghreb are teased out as an imbricated series of triggers across developmental, cultural and family predicaments that arise from the “exile situation” (Wenk-Anshohn, 2007). “The Memory Clinic,” the second vignette, revisits the story of an adolescent refugee from a war-torn country in the Middle East whose quest was to forget her trauma. Exposed first to civil war and the loss of her family, then arriving in Montreal as a refugee with her extended family where she was abused, this vignette presents issues about how to create the conditions for listening to the “trauma story” (Mollica, 2009) as enlightened witnesses and the emerging understanding of traumatic memory through identity narratives (Novac, et al, 2017). Together, these vignettes highlight the conditions required for the practice of “trauma-informed care” with children and families across culture. Keywords: Sequential traumatisation, cultural family therapy, transcultural child psychiatry, trauma-informed care, identity narrative

1. Working with Traumatized
Children and Families
across Culture

2. Working with Traumatized
Children and Families
across Culture
Vincenzo Di Nicola, MPhil, MD, PhD
CAFT 601 Diversity in Couple and Family
Therapy
McGill University
Centre for Child Development & Mental Health
4335 Cote St. Catherine Rd.
Montreal, QC
Thursday, May 16, 2019
1:00 – 4:00 pm

3. Vincenzo Di Nicola
vincenzodinicola@gmail.com
Professor of Psychiatry, University of Montreal & GWU
Professor Honoris Causa, FADOM, Brazil
Academician, Bulgarian Academy of Sciences & Arts
Chief, Child & Adolescent Psychiatry,
Montreal University Mental Health Institute, UdeM
Founder & Co-director, Psychiatry and Humanities
Course, UdeM
President, Canadian Association of Social Psychiatry
Co-founder & Past Chair, APA GMH & Psychiatry Caucus
APA Council on International Psychiatry

5. Conflicts of Interest
The presenter has no financial conflicts of
interest to declare

6. Dedication
Trauma
Leslie Solyom, MD – AMI, Thesis supervisor
John Sigal, PhD – JGH, Research supervisor
Family Therapy
Shirley Braverman, MSW – MCH & JGH, Family
Therapy Supervisor
Ron Feldman, MD – JGH, Marital & Family Therapy
Fellowship Supervisor

7. Educational Objectives
The presentation will sensitize participants to appreciate basic
questions about working with traumatized children and their
families across culture to create trauma-informed care:
•Why development matters – and how it changes the clinical
presentation of trauma at different ages;
•Why family matters – and how it creates models for the
experience of trauma that attenuate or amplify both
developmental neurobiology and sociocultural influences;
•Why culture matters – and how it offers or limits the range of
socially privileged perceptions and culturally sanctioned
solutions.

8. Keywords
Sequential traumatisation
Cultural family therapy
Transcultural child psychiatry
Trauma-informed care
Identity narrative
Ref: Williams, Raymond (2015). Keywords: A Vocabulary of
Culture and Society, New Edition. Oxford University Press.

9. Presentation Overview
• This presentation presents a model of working
with traumatized children and families across
culture.
• When it comes to trauma in children, we need
to address three basic questions:
– Why development matters
– Why family matters
– Why culture matters

10. Presentation Overview
• Development – family – culture
• These three aspects of children’s lives are reviewed
as key critical contexts to understand the “sequential
traumatizing” (Keilson, 1992) of young people as
highlighted in two clinical vignettes:
– “A Train of Traumas”
– “The Memory Clinic”
• These vignettes highlight the conditions required for
the practice of “trauma-informed care” with children
and families across culture.

11. A Personal Perspective
• Early training experiences with trauma
– OCD clinic – mentor Auschwitz survivor – L Solyom
– GCOS study of Holocaust survivors – JJ Sigal
• Work with migrants and refugees
• Work with disenfranchised Quebec population
– “Narrative resources” – Jerome Bruner
• Work in Haiti and Brazil
• Syrian and other refugees in Montreal

12. Grandchildren of Survivors (GCOS)
• Clinic study of third generation of Holocaust
survivors
• Are the experiences of grandchildren due to
experiences of the first generation, the second
generation, or both?
• Refs: Sigal, J.J., DiNicola, V., & Buonvino, M. (1988). Grandchildren of
survivors: Can negative effects of prolonged stress be observed two
generations later? Canadian Journal of Psychiatry, 33: 207-212.
• Sigal, John J. & Weinfeld, Morton (1989). Trauma and Rebirth:
Intergenerational Effects of the Holocaust. NY: Praeger.

13. Grandchildren of Survivors (GCOS)
• Two GCOS index groups:
– Index 1 – at least 1 survivor grandparent (GP)
– Index 2 – at least 1 survivor GP and one survivor
parent
• Two comparison groups:
– GCOI – 1 GP who immigrated to Canada before WWII
– GCON – All 4 GPs were native born

14. Grandchildren of Survivors (GCOS)
Results
•GCOS are not distinguishable from other clinic
children with respect to mood, personality, or
behavioral items included in the study
•However, GCOS are grossly overrepresented in
our clinic sample – 300% more!
•School-performance-related difficulties in the
Index 2 group (survivor GP + survivor parent)

15. Grandchildren of Survivors (GCOS)
Results
•GCOS may be more vulnerable due to the
cumulative psychological effect of having
grandparents and parents exposed to extreme and
prolonged stress
•Can we generalize from our data to the
community of GCOS?
•Our GCOS community study showed that if
anything, they function better than the GCON!

16. Grandchildren of Survivors (GCOS)
Discussion
•Discrepancy between clinic and community data
for both COS and GCOS!
•How to explain marked overrepresentation of
GCOS in our clinic sample?
•We examined family problems, marital
relationships, and child-rearing practices
– GCOS Index 2 had more school problems
– Fathers work-focused, less attentive as parents

17. Grandchildren of Survivors (GCOS)
Discussion
•Our study not only fails to explain GCOS over-
representation in the clinic, but also why GCOS in the
community show less psychopathology and better social
functioning
•Speculative hypothesis: The superior psychological
functioning of GCOS is related to the parents’ and
grandparents’ psychological investment in them who
represent hope for the rebirth and regeneration of families
truncated by Nazi persecution

18. Vignette #1
“A Train of Traumas”
• In this vignette, the layers of the trauma
history of an immigrant child and his family
from the Maghreb are teased out as an
imbricated series of triggers across
developmental, cultural and family
predicaments.
• Ref: Keilson, Hans (1992). Sequential Traumatisation in Children: A Clinical
and Statistical Follow-up Study on the Fate of the Jewish War Orphans in
the Netherlands. Jerusalem, Israel: The Magnes Press, The Hebrew
University.

19. Family Psychiatry
• Why family matters – and how it creates models for the
experience of trauma that attenuate or amplify both
developmental neurobiology and sociocultural influences

20. What are we missing?

21. Defining Family Studies
La terapia familiare è il punto di partenza
per lo studio di unità sociali sempre più ampie.
Family therapy is the starting point
for the study of ever wider social units.
– Mara Selvini Palazzoli

22. Cultural Psychiatry
• Why culture matters – and how it offers or limits the range of
socially privileged perceptions and culturally sanctioned
solutions

23. Cultural Family Therapy (1997)

24. Immigrant Families
and Transcultural
Psychotherapy
(2004)

25. Child Psychiatry
• Why development matters – and how it changes the clinical
presentation of trauma at different ages

26. Transcultural
Issues in
Child Psychiatry
(1992)

27. Di Nicola, Vincenzo (2012).
Family, psychosocial, and cultural
determinants of health.
In: Sorel, Eliot, ed., 21st
Century
Global Mental Health.
Burlington, MA: Jones & Bartlett
Learning, pp. 119-150.

28. Letters to a
Young Therapist:
Relational Practices for the
Coming Community
(2011)

29. Vignette #2
“The Memory Clinic”
• This vignette revisits the story of an adolescent from a war-
torn country in the Middle East whose quest was to forget her
trauma.
• Exposed first to civil war and the loss of her family, then
arriving in Montreal as a refugee with her extended family
where she was abused, this vignette presents issues about
how to create the conditions for listening to the “trauma
story” (Mollica, 2009) as enlightened witnesses and the
emerging understanding of traumatic memory.
• Ref: Mollica, Richard (2009). Healing Invisibile Wounds: Paths to Hope and
Recovery in a Violent World. Nashville, TN: Vanderbilt University Press.

30. “I remember”

31. Trauma

32. “CHANGELINGS”
• Children’s lives are altered by trauma
• They are – in a modern twist on old
folktales – changelings
• With greater or lesser severity, across more
or fewer developmental domains, for
decades or for months, trauma alters lives

33. PSYCHIC TRAUMA
• An exceptional experience in which
powerful and dangerous stimuli
overwhelm the infant and young child’s
capacity to regulate his or her affective
state

34. CONCEPT OF TRAUMA
(Sigmund Freud,1926)
• Conscious ideas that overwhelm the ego
• Emergence of unacceptable impulses
• An unbearable situation with overwhelming
affect
• Feeling of traumatic helplessness (where
external and internal, real and instinctual
dangers converge)

35. TRAUMATIC STRESS
(Anna Freud, 1969)
• A shattering and devastating event that
alters the course of future development

36. DEFINITIONS OF
THE CONCEPT OF TRAUMA
Trauma as an event that is generally outside the
range of usual human experience
—DSM-III (1980)
An event involving actual or threatened death or
serious injury or a threat to the physical integrity
of self or others
—DSM-IV (1994)

37. CRITIQUES OF
THE CONCEPT OF TRAUMA
There has been a loose application of the term
trauma (e.g., divorce or living with a parent who
has an alcohol problem).
When dealing with preverbal children it is difficult to
say if the event has been perceived as life
threatening. For this reason some researchers try
to draw connections between certain events and
PTSD.

38. TYPES OF TRAUMA
Lenore Terr
TYPE I TRAUMA
Description: Single event,
dangerous, isolated, sudden
Response: Recalled vividly,
quicker recovery time,
better prognosis
Examples: Motor vehicle accident,
witnessing homicide or suicide
TYPE II TRAUMA
Description: Multiple, chronic,
repetitive
Response: Memories are fuzzy,
helplessness, dissociation, character
changes, more long- standing
problems
Examples: Institutional care, physical
& sexual abuse, war, social violence

39. TYPES OF TRAUMA
Judith Herman
PTSD DSM-IV (1994): PTSD
(Terr’s TYPE I)
Description: Single event,
dangerous, sudden, isolated
Examples: Motor vehicle
accident, witness to
homicide or suicide
Complex PTSD
Herman (1992): C-PTSD
(Terr’s TYPE II)
Description: Multiple,
chronic, repetitive
Examples: Physical,
emotional or sexual
abuse, conjugal violence,
accumulation of stress in
therapists and healers

40. DEVELOPMENTAL MODEL
• Age of the child
• Characteristics of neighbourhood
• Degree of community resources
• Amount and quality of support
• Experience of previous abuse
• Proximity to violent event
• Familiarity with victim or perpetrator

41. DEVELOPMENTAL FACTORS THAT
INFLUENCE A CHILD’S REACTION
• Appraisal of the threat
• Intra-psychic meaning attributed to event
• Emotional and cognitive means of coping
• Capacity to tolerate strong affects
• Ability to adjust to other’s life changes
• Ability to deal with loss and grieving

42. EARLY ADVERSE EXPERIENCE
• “Derail” a child’s developmental trajectory
• Compromise a child’s ability to regulate
affects
• Compromise early and future relationship
problems

43. EXPOSURE TO VIOLENCE
• Affects the way children think about
themselves and the world around them
• Affects the extent to which they view
relationships as trustworthy and
dependable

44. EFFECTS OF EXPOSURE TO
VIOLENCE DEPEND ON:
• Characteristics of the violence itself
• Developmental phase of the child
• Family and community context
• Response to violence exposure by family,
school, community institutions

45. MEANING OF VIOLENCE
FOR THE CHILD INFLUENCED BY:
• The nature of the threat and the damage
• The child’s relationship with the victim or
perpetrator
• Severity and duration of violence
• Proximity of violence to child

46. PROSPECTIVE FACTORS FOR
CHILDREN EXPOSED TO VIOLENCE
• A supportive person
(parent, relative, friend, teacher)
• A safe place
(home, safe haven in the neighbourhood)
• Resources to find alternative ways of coping
(adaptive temperament, intelligence)

47. PROTECTIVE FACTORS
• Safety in the environment
• Caregivers who can mediate the dangerous
environment and help regulate experiences
• Support systems in the environment

48. EFFECT ON CAREGIVERS
• Caregiver’s ability to listen may be limited
• Caregiver may not be able to hear child’s
distress
• Caregiver may need to protect herself from
feelings of vulnerability and trauma
• Parent may have more trouble tolerating
child’s resultant anxiety and aggression

49. COURSE OF PTSD
• PTSD is a chronic illness in 50% of adults
• In children, signs and symptoms do not decrease
• In a longitudinal study (Laor, 1997), more severely
stressed pre-school children decreased their
symptoms after 30 months, but less stressed
children did not.
• A plausible explanation is the vulnerability of the
rapidly developing and immature central nervous
system (Schore, 2002).

50. DEVELOPMENTAL OUTCOMES
WITH TRAUMA
• Greater risk for children who have not yet
attained optimal potential development
• Knowing developmental status is crucial to
understanding the experience of infant and
childhood exposure to violence and trauma

51. Percentages of PTSD Diagnosis
• Israeli Children (Laor, 1997) 22-25%
• Palestinian children from Gaza 41%
(Thabet, 1999)
• Cambodian refugees children 48%
(Kinzie, 1996)
• Iraqi children with destroyed shelter 78-88%
(Dyregrov, 2002)
• Palestinian children exposed 54% severe
to military violence 33.5% moderate
(Quonta, 2003) 11% mild or doubtful

52. Relationships Are the
“Active Ingredients”
of Early Experience
• Crucible of infant experiences are in caregiving
relationships
• Nurturing and responsive relationships build
healthy brain architecture that provides a strong
foundation for learning, behavior and health.
• When protective relationships are not provided,
elevated levels of stress hormones disrupt brain
architecture by impairing cell growth and
interfering with the formation of healthy neural
circuits.

53. Reflection
Childhood is a knife
planted in your throat.
You don’t remove it
easily.
– Wajdi Mouawad
playwright

54. TREATMENT
• Ambulance arrives AFTER the
traumatic experience
• Principles of triage, crisis intervention
• Identify, remove child from traumatic
situation
• Secondary prevention:
- attenuate symptoms
- redirect the traumatic pathway

55. TREATMENT
• Before any possibility of treatment we must establish a
relationship with traumatized children
• We create a healing environment that includes our own
self-care based on empathy in order to hear the trauma
story (Richard Mollica, 2006)
• We must honour interpersonal ethics in working with
children and families (Di Nicola, 2011)
• The face-to-face encounter – the ethics of meeting
strangers (Emmanuel Levinas, 1998)

56. TREATMENT
• Cognitive therapy (mentalization)
• Critical Incident Stress Management (CISM)
• Eye Movement Desensitization and
Reprocessing (EMDR)
• Medications (treat symptoms)
• Treatment of comorbidity (substance
abuse)
• Cultural family therapy
• Combined therapies

57. HOW CLINICIANS CAN PREPARE
THEMSELVES FOR TRAUMA WORK
• Become well informed about trauma
• Engage in de-briefing about event
• Engage in ongoing self-care
• Frequently examine responses, resistances,
and tensions related to trauma materials

58. “Traditional diagnostic categories and
instruments, such as PTSD, are limited.
Specific new assessment tools have to be
developed.”
– Denton, et al. (2016)

59. Conclusion
• Exposure to protracted trauma at an early age brings alterations in the spheres
of affectivity, autoregulation in social contexts, and in the concept of the self.
• Current neuroscience research approaches intersubjectivity as incarnated
permitting the investigation of physiological and neurobiological mechanisms
which subtend implicit and preverbal understanding of others’ actions,
emotions and sensations.
• The exposure of protracted trauma in childhood brings about adaptations and
the modulation of physiological mechanisms that support intersubjective
abilities that may be responsible for specific behavioral manifestations.
• The body remembers trauma. It is through our own bodies that we seek the
keys for the interpretations of others’ actions, emotions, and sensations.
• Source: Martina Ardizzi (2017)

60. Conclusion
• Development
– Attachment and neurobiology
• Family
– “The crucible of experience”
• Culture
– “Looking across at growing up”

61. Conclusion
• Children are the “canary in the goldmine”
• They are the most sensitive indicators of trauma,
embodied and enacted in their own lives
• Truth-tellers of the trauma of their community
• Telling their stories through their play, drawings,
embodiment and enactment

62. Acknowledgments
Sharon Bond, PhD
Director, Couple and Family
Therapy Program, ICFP
Associate Professor
School of Social Work McGill
University
Jaswant Guzder, MD
Professor of Psychiatry
McGill University
Turku, Finland

63. Questions
&
Comments