Download Module 6: Psychological Evidence of Torture and Ill Treatment

MODULE 6
Prevention through Documentation Project
Psychological Evidence of Torture and Ill
Treatment
CONTRIBUTORS:
Türkcan Baykal MD, Human Rights Foundation of Turkey
Caroline Schlar, PhD, Human Rights Foundation of Turkey
Emre Kapnın, Human Rights Foundation of Turkey
Kathleen Allden, MD, Indochinese Psychiatric Clinic
Vincent Iacopino, MD, PhD, Physicians for Human Rights
PtD Project (IRCT, HRFT, REDRESS, PHR)
Module 6 Outline

Psychological evaluation
–
–
–
–
Central role
Conducting an evaluation
Findings and diagnostic considerations
Components

Children and Torture

International Statistical Classification of
Diseases and Related Health Problems, Annex
PtD Project (IRCT, HRFT, REDRESS, PHR)
The Central Role of the
Psychological Evaluation

Can provide critical evidence of abuse
among torture victims

Any evaluation of torture should
include a psychological assessment
PtD Project (IRCT, HRFT, REDRESS, PHR)
The Central Role of the
Psychological Evaluation
Because:
– One of main objectives of torture is destruction of
psychological and social integrity of victim
– All kinds of torture inevitably comprise psychological
processes
– Torture :
 Often causes devastating psychological symptoms
 Methods can leave no physical lesions
 Physical findings may resolve or lack specificity
– Contrary to physical effect of torture, psychological
symptoms are more persistent and troublesome
PtD Project (IRCT, HRFT, REDRESS, PHR)
Conducting the Psychological Evaluation:
General Considerations
PtD Project (IRCT, HRFT, REDRESS, PHR)

Torture is an extraordinary life
experience capable of causing
wide range of physical/
psychological suffering

Extreme nature of torture event
powerful enough on its own to
produce mental and emotional
consequences, regardless of
individual’s pre-torture
psychological status
Conducting the Psychological Evaluation:
General Considerations

It is important to recognize that not
everyone who has been tortured develops a
diagnosable mental illness

However, many victims of torture
experience profound emotional reactions
and psychological symptoms
PtD Project (IRCT, HRFT, REDRESS, PHR)
Conducting the Psychological Evaluation:
General Considerations
Even though diagnosis of trauma-related
mental disorder supports the claim of
torture; not meeting criteria for a
psychiatric diagnosis does not mean the
person was not tortured
PtD Project (IRCT, HRFT, REDRESS, PHR)
Conducting the Psychological Evaluation:
General Considerations
Distress and suffering are not in
themselves pathological conditions;
sometimes “normal” response to societal
pathology
PtD Project (IRCT, HRFT, REDRESS, PHR)
Conducting the Psychological Evaluation:
General Considerations
Evaluation and interpretation should always
be made with awareness of cultural,
political and social context as well as
conditions of the interview and assessment
PtD Project (IRCT, HRFT, REDRESS, PHR)
Psychological Findings and
Diagnostic Considerations

Consequences of torture: individual, family and
social levels

Despite variability, clusters of symptoms and
psychological reactions have been observed
frequently among torture survivors

PTSD and Major Depression most common
– One doesn’t have to be tortured to develop PTSD or
Major Depression
– Everyone who has been tortured does not develop PTSD
and Major Depression
PtD Project (IRCT, HRFT, REDRESS, PHR)
Psychological Findings and
Diagnostic Considerations

Psychological effects of torture should not
be oversimplified . Besides PTSD and
Major Depression, consider:
–
–
–
–
–
–

Anxiety Disorders
Substance Abuse
Enduring Personality Change
Somatoform Disorders
Dissociation
Psychosis
Be familiar with ICD-10 and DSM-IV
classifications
PtD Project (IRCT, HRFT, REDRESS, PHR)
Consequences of Torture
TORTURE CAUSES TRAUMA
SOCIETY
FAMILY
INDIVIDUAL
PtD Project (IRCT, HRFT, REDRESS, PHR)
Consequences of Torture

INDIVIDUAL

FAMILY

SOCIETY

PtD Project (IRCT, HRFT, REDRESS, PHR)
can terrorize entire
population
creates an atmosphere
of pervasive threat,
chronic fear, terror,
inhibition, hopelessness
creates repressive
ecology: a state of
generalized insecurity,
lack of confidence and
rupture of social
fabric.
can break or damage
will and coherence of
entire communities
Consequences of Torture

can lead to family
traumas that cause:
– different forms of
family dysfunction
– disruptions in course
of family
development

Assessing the effects
of torture on survivor’s
family dynamics can be
important in torture
assessment
INDIVIDUAL
FAMILY
SOCIETY
PtD Project (IRCT, HRFT, REDRESS, PHR)
Consequences of Torture
INDIVIDUAL

On individual

On relationship
between individual and
his/her intimate
relationship

On relationship
between individual and
society
FAMILY
SOCIETY
PtD Project (IRCT, HRFT, REDRESS, PHR)
Psychological Consequences of
Torture
Torture is a complex mechanism that
can traumatize, damage;
body
personality
cognitive, emotional,
dreams, hopes, behavioral functioning
aspirations for the future
self actualization
Beliefs
Sense of being grounded
system of meaning about
in a family and society
himself and the world
the autonomy
sense of safety and survival
PtD Project (IRCT, HRFT, REDRESS, PHR)
relationships between
spouse,
parents,
Connectedness
children,
community
Attachment
Psychological Consequences of
Torture
There is a complex relationship between
torture and the symptomatology
The psychological responses to torture are
affected by multiple factors
PtD Project (IRCT, HRFT, REDRESS, PHR)
SOCIAL CONTEXT
BEFORE, DURING, AFTER
TORTURE
MEANİNG OF TORTURE
BELIEF SYSTEM
PREPAREDNESS
SUPPORT SYSTEM
CONDITIONS OF TORTURE
PSYCHOLOGICAL
RESPONSE
PREVIOUS
TRAUMAS
ADDITIONAL LOSSES
AGE,
DEVELOPMENTAL
PHASE
PRE-EXISTING
PSYCHOLOGICAL
DISORDERS
COPING CAPABILITIES
PHYSICAL HEALTH
PtD Project (IRCT, HRFT, REDRESS, PHR)
Psychological Consequences of
Torture
Nevertheless, there are clusters of
symptoms and psychological reactions that
have been observed and documented in
torture survivors with some regularity
PtD Project (IRCT, HRFT, REDRESS, PHR)
Psychological Consequences of
Torture
RE-EXPERIENCING THE
TRAUMA
-Intrusive memories of
traumatic event
-Recurrent nightmares
-Distress at exposure to
cues that resemble the
trauma
-Flashbacks
-Foreshortened future
-Damaged self-concept and
self-esteem
-Guilt and shame feelings
PtD Project (IRCT, HRFT, REDRESS, PHR)
AVOIDANCE AND EMOTIONAL
NUMBING
-Emotional constriction
-Personal detachment
-Social withdrawal
-Inability to recall some aspect
of trauma
HYPERAROUSAL
-Difficulty either falling or
staying asleep
-Irritability or outburst of
anger
-Difficulty concentrating
-Hypervigilance, exagerrated
startled response
-Generalized anxiety
-Shortness of breath,
sweating, dry mouth
Psychological Consequences of
Torture
-Constriction of consciousness,
-Narrowing the attention
-Inability to comprehend stimuli
-Disorientation
-Withdrawal from the
surrounding situation
-Agitation
-Autonomic signs of panic anxiety
-Somatic symptoms
-Dissociations, depersonalisation
-Sexual dysfunctions
-Psychotic reactions
-Substance abuse
-Incrased risk seeking behaviours
PtD Project (IRCT, HRFT, REDRESS, PHR)
-Depressed mood
-Anhedonia
-Appetite disturbance
-Disturbed sleep
-Fatigue and loss of energy
-Feelings of worthlessness
and excessive guilt
-Difficulty in paying attention,
concentration or recalling
from memory
-Thoughts of death and dying;
suicidal ideation or attempt
Impact of Torture
Traumaspecific disorders
Torture,
Extreme life
events
Acute Stress
Disorder, PTSD,
Personality
change, Brief
Reactive
Psychosis
Relationship
to torture:
Increase and triggering
of preexisting or
previously „hidden“
disorders
„Unspecific“
disorders and
symptoms, related
to torture
The ICD 10 system- Chapter V
Most Relevant Categories
Reactions to
severe stress
PTSD
Mood
disorders
Personality
Change
“Core” anxiety
mood disorders
Somatoform
disorders
Brief reactive
psychosis
Anxiety
disorders
Dissociative
disorders
Postconcussional
syndrome
Reactions to Extreme Life Events:
ICD 10 *
(must not be all present in each case)
Acute stress
reaction/ disorder
Post-traumatic
stress disorder
(PTSD)
Personality
change after
catastrophic
experience
ICD 10:
F 43.0
ICD 10:
F 43.1
ICD 10:
F 62.0
Hours to days
after event
Days to
years
2 years
or later
*International Classification of Diseases,
Rev. 10, WHO
Posttraumatic Stress Disorder
Posttraumatic Stress Disorder
(PTSD)

Re-experiencing: intrusive distressing memories,
nightmares, flashback/reliving the event,
nightmares, hallucinations

Hyperarousal: insomnia, irritability, angry
outbursts, exaggerated startle response

Avoidance of stimuli associated with the trauma,
detachment and estrangement from others,
foreshortened sense of future
PtD Project (IRCT, HRFT, REDRESS, PHR)
Longitudinal Course
(Acute stress
disorder
Triggers
might be
present)
Time
Symptom
level
A) Chronic PTSD,
Personality change
B) Remission
PTSD might be
missed in
examination
Clinical PTSD
Avoidance
Intrusion
Hyperactivation
Mainly avoidance or low symptom level
Major Depression
Depressed mood
 Anhedonia
 Appetite disturbance
 Sleep disturbance
 Psychomotor retardation or agitation
 Fatigue, poor energy

PtD Project (IRCT, HRFT, REDRESS, PHR)
Major Depression
Feelings of worthlessness
 Poor attention, concentration and
memory
 Thoughts of death
 Suicidal ideation
 Suicide attempts

PtD Project (IRCT, HRFT, REDRESS, PHR)
Trauma and Diagnosis

One doesn’t have to be tortured to
develop PTSD or Major Depression

PTSD and Major Depression appear in
the general population.

Everyone who has been tortured does
not develop PTSD and Major
Depression
PtD Project (IRCT, HRFT, REDRESS, PHR)
Course of Major Depression and
Posttraumatic Stress Disorder

Variable time of onset of symptoms
– Can have delayed onset
– Symptoms emerge over time

Episodes can recur

Need to consider where survivor is in the
recovery process
PtD Project (IRCT, HRFT, REDRESS, PHR)
Frequently Overlooked Diagnoses
Symptoms of complex PTSD,
Co-morbidity (such as
depression, somatoform
disorders, generalized anxiety
disorder)
Behavioural consequences
Functional sexual disorders *
Culture specific reactions
Mild traumatic brain injury
Difficulties in Recalling and Recounting
Factors directly related to the
torture experience
Factors related to the
psychological impact of
torture
Cultural factors
Factors related with the interview
conditons or communication barriers
PtD Project (IRCT, HRFT,
REDRESS, PHR)
Credibility

Accurate details of torture and
trauma experiences necessary
because details will be used in:
– legal affidavits
– political asylum hearings
– human rights investigations
– war crimes tribunals
PtD Project (IRCT, HRFT, REDRESS, PHR)
Inconsistency

If any inconsistency in story:
– Ask for further clarification
– If not possible, look for other
evidence/supporting details that can
corroborate and clarify individual’s story



Schedule additional interviews with family and friends
and witnesses
Conduct additional examinations
If still suspect fabrication:
– Refer to another clinician to ask for second
opinion
– Suspicion should be documented by two
separate clinicians
PtD Project (IRCT, HRFT, REDRESS, PHR)
! Beware:
Negative finding in regard to
psychological sequels
Evaluate possible
reasons
Additional diagnostic
strategies,
additional interview
Good coping
or other factors prevent
PTSD development
or other reactions
No diagnosis
- Does NOT exclude
torture
The Psychological Evaluation
Overall goal: assess degree of consistency
between individual’s account of torture and
psychological findings observed during
course of the evaluation.
PtD Project (IRCT, HRFT, REDRESS, PHR)
Clinical Inquiry Must Include

Evaluating presence or absence of
symptoms
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Beliefs about experiences

Beliefs about meanings of symptoms
PtD Project (IRCT, HRFT, REDRESS, PHR)
Psychological Evaluation
Evaluation starts at the very first contact;
appearance/dress
 posture
 the manner of recalling and recounting the trauma
 signs of anxiety or emotional distress
 numbness or over-excitement
 the moments of emotional intensity
 startled responses
 his/her posture and bodily expressions while relating the
events of torture
 avoidance of eye contact
 emotional fluctuations in his/her voice

Can give important clues about the personal history
and psychological functioning of the person.
PtD Project (IRCT, HRFT, REDRESS, PHR)
Components of the
Psychological Evaluation
History of torture and ill-treatment
 Current psychological complaints
 Post-torture history
 Pre-torture history
 Medical history
 Psychiatric history
 Substance use and abuse history

PtD Project (IRCT, HRFT, REDRESS, PHR)
Components of the
Psychological Evaluation
Mental status examination
 Assessment of social functioning
 Psychological testing and the use of
checklists and questionnaires
 Clinical impression
 Recommendations

PtD Project (IRCT, HRFT, REDRESS, PHR)
Components of the
Psychological Evaluation

The entire clinical picture produced by
torture is much more than the simple
sum of lesions produced by methods
on a list.
PtD Project (IRCT, HRFT, REDRESS, PHR)
Identifying Data
Individual’s name, age, ethnicity, country of
origin, marital status, number of children
 Referral source
 Summary of collateral sources (such as
medical, legal, psychiatric records)
 Methods of assessment utilized
(interviews, symptom inventories and
checklists, neuropsychological testing, etc.)

PtD Project (IRCT, HRFT, REDRESS, PHR)
Components of the
Psychological Evaluation
•History of
torture and illtreatment
•Current psychological complaints
•Post-torture history
•Pre-torture history
•Medical history
•Psychiatric history
•Substance use and abuse history
•Mental status examination
•Assessment of social functioning
•Psychological testing and
the use of checklists and
questionnaires
•Clinical impression
•Recommendations
PtD Project (IRCT, HRFT, REDRESS, PHR)

Full history of torture,
persecution and other relevant
traumatic experiences

A method-listing approach may
be counter-productive
Components of the
Psychological Evaluation
•History of torture and ill-treatment
•Current
psychological
complaints
•Post-torture history
•Pre-torture history
•Medical history
•Psychiatric history
•Substance use and abuse history
•Mental status examination
•Assessment of social functioning
•Psychological testing and
the use of checklists and
questionnaires
•Clinical impression
•Recommendations
PtD Project (IRCT, HRFT, REDRESS, PHR)

Affective, cognitive, and behavioral
symptoms
– in detail: include frequencies and
examples

Adaptative strategies and triggers such as
– anniversary reactions
– specific stimuli or places
– situations and topics causing avoidance

Physical and psychological complaints that
appeared since the torture. Include:
– first emergence
– duration
– intensity
– fluctuations
Components of the
Psychological Evaluation

Sources of additional stress
– trauma
– losses
– ongoing persecution of self/family
– refugee displacement

Formal and/or informal social support
resources
 Marital and family situation
 Employment status, livelihood
 Vocational, social status and conditions
 Life conditions and quality of life of
the interviewee and his/her family
•History of torture and ill-treatment
•Current psychological complaints
•Post-torture
history
•Pre-torture history
•Medical history
•Psychiatric history
•Substance use and abuse history
•Mental status examination
•Assessment of social functioning
•Psychological testing and
the use of checklists and
questionnaires
•Clinical impression
•Recommendations
PtD Project (IRCT, HRFT, REDRESS, PHR)
Components of the
Psychological Evaluation

•History of torture and ill-treatment
•Current psychological complaints

•Post-torture history
•Pre-torture
history
•Medical history
•Psychiatric history
•Substance use and abuse history
•Mental status examination
•Assessment of social functioning
•Psychological testing and
the use of checklists and
questionnaires
•Clinical impression
•Recommendations
PtD Project (IRCT, HRFT, REDRESS, PHR)
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


Developmental history
Family history: family background,
family illnesses, family composition
Educational history
Occupational history
History of past trauma: childhood
abuse, war trauma, domestic violence,
etc
Cultural and religious background
Components of the
Psychological Evaluation


•History of torture and ill-treatment
•Current psychological complaints
•Post-torture history
•Pre-torture history


•Medical history
•Psychiatric history
•Substance use and abuse history
•Mental status examination
•Assessment of social functioning
•Psychological testing and
the use of checklists and
questionnaires
•Clinical impression
•Recommendations
PtD Project (IRCT, HRFT, REDRESS, PHR)
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
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Pre-trauma health conditions
Current health conditions
Body pain, somatic complaints
Physical injuries and findings: physical
findings that might be related to
trauma should be noted
Use of medications, including possible
side effects and obstacles in using
medications
Relevant sexual history
Past surgical procedures and other
medical data
Components of the
Psychological Evaluation
•History of torture and ill-treatment
•Current psychological complaints
•Post-torture history
•Pre-torture history
•Medical history
•Past Psychiatric
history

Past history of mental or
psychological disturbances

The nature of the problems

Previous treatment or
psychiatric hospitalisation

The use of any psychotropic
medications
•Substance use and abuse history
•Mental status examination
•Assessment of social functioning
•Psychological testing and
the use of checklists and
questionnaires
•Clinical impression
•Recommendations
PtD Project (IRCT, HRFT, REDRESS, PHR)
Components of the
Psychological Evaluation
•History of torture and ill-treatment
•Current psychological complaints
•Post-torture history
•Pre-torture history
•Medical history
•Psychiatric history
•Substance use
and abuse history
•Mental status examination
•Assessment of social functioning
•Psychological testing and
the use of checklists and
questionnaires
•Clinical impression
•Recommendations
PtD Project (IRCT, HRFT, REDRESS, PHR)

Substance use before and after
the torture

Changes in the pattern of use
and abuse

Reason for substance us:
specifically are they being used
to cope with insomnia or
psychological problems
Components of the
Psychological Evaluation
•History of torture and ill-treatment
•Current psychological complaints
•Post-torture history
•Pre-torture history
•Medical history
•Psychiatric history
•Substance use and abuse history
•Mental status
examination
•Assessment of social functioning
•Psychological testing and
the use of checklists and
questionnaires
•Clinical impression
•Recommendations
PtD Project (IRCT, HRFT, REDRESS, PHR)

All aspects including:
–
–
–
–
–
appearance
speech
mood and affect
thinking and perception
sensorium





alertness
orientation
concentration
,emory impairment
judgement
Components of the
Psychological Evaluation

–
–
–
–
•History of torture and ill-treatment
•Current psychological complaints
•Post-torture history
•Pre-torture history
•Medical history
•Psychiatric history
•Substance use and abuse history
•Mental status examination
•Assessment of
social functioning
•Psychological testing and
the use of checklists and
questionnaires
•Clinical impression
•Recommendations
PtD Project (IRCT, HRFT, REDRESS, PHR)
Assess individual’s ability to:

care for self
earn a living
support family
pursue education
Inquire about:
– daily activities
– social role function (as
housewife, student, worker,
etc)
– social and recreational
activities
– perception of health status
Components of the
Psychological Evaluation
•History of torture and ill-treatment
•Current psychological complaints
•Post-torture history
•Pre-torture history
•Medical history
•Psychiatric history
•Substance use and abuse history
•Mental status examination
•Assessment of social functioning
•Psychological
testing and
the use of
checklists and
questionnaires
•Clinical impression
•Recommendations
PtD Project (IRCT, HRFT, REDRESS, PHR)

Note limited utility because
interpretations limited by lack
of established norms for
torture survivors

May complement clinical
evaluation as secondary source
of corroborating information

Should not be given more weight
than clinical evaluation

Clinician decides when to use
psychological tests
Components of the
Psychological Evaluation
•History of torture and ill-treatment
•Current psychological complaints
•Post-torture history
•Pre-torture history
•Medical history
•Psychiatric history
•Substance use and abuse history
•Mental status examination
•Assessment of social functioning
•Psychological testing and
the use of checklists and
questionnaires
•Clinical
impression
•Recommendations
PtD Project (IRCT, HRFT, REDRESS, PHR)




History of detention and
torture
Pre torture conditions
Post torture conditions
Behavioral, cognitive and
emotional aspects of
individual observed during
verbal and non-verbal
communication; symptoms
with details should be
described
Components of the
Psychological Evaluation
•History of torture and ill-treatment
•Current psychological complaints
•Post-torture history
•Pre-torture history
•Medical history
•Psychiatric history
•Substance use and abuse history
•Mental status examination
•Assessment of social functioning
•Psychological testing and
the use of checklists and
questionnaires
•Clinical
impression
•Recommendations
PtD Project (IRCT, HRFT, REDRESS, PHR)

Findings should be
considered altogether

Relationship of individual
components to each other
should be taken into
consideration
Components of the
Psychological Evaluation
•History of torture and ill-treatment
•Current psychological complaints
•Post-torture history
•Pre-torture history
•Medical history
•Psychiatric history
•Substance use and abuse history
•Mental status examination
•Assessment of social functioning
•Psychological testing and
the use of checklists and
questionnaires
•Clinical
impression
•Recommendations
PtD Project (IRCT, HRFT, REDRESS, PHR)
• Trauma history, clinical
history, mental status
exam and physical exam
• Knowledge of political
context of country
where the torture took
place
• Cultural idioms, beliefs,
and social customs
• Barriers to full
disclosure
Components of the
Psychological Evaluation
•History of torture and ill-treatment
•Current psychological complaints
•Post-torture history
•Pre-torture history
•Medical history
•Psychiatric history
•Substance use and abuse history
•Mental status examination
•Assessment of social functioning
•Psychological testing and
the use of checklists and
questionnaires
•Clinical
impression
•Recommendations
PtD Project (IRCT, HRFT, REDRESS, PHR)

Medico-legal
investigations require
understanding of the
psychological
phenomena, not only
diagnosis
Interpretation of the Findings and
Clinical Impression
Critical questions for establishing a clinical
picture:



Are the psychological findings consistent with the
alleged report of torture?
Are the psychological findings expected reactions to
extreme stress within the cultural and social context
of the individual?
Given the fluctuating course of symptoms over time,
what is the time frame in relation to the torture
events? Where is the individual in the course of
recovery?
PtD Project (IRCT, HRFT, REDRESS, PHR)
Interpretation of the Findings and
Clinical Impression
Critical questions for establishing a clinical
picture:

What are the coexisting stressors and their impacts
on the individual?

Are there physical conditions complicating the clinical
picture?

Does the clinical picture suggest a false allegation of
torture?
PtD Project (IRCT, HRFT, REDRESS, PHR)
Interpretation of the Findings and
Clinical Impression

If the individual has symptom levels consistent with
one or more DSM IV or ICD 10 diagnosis, the diagnosis
should be stated.

If not,
the relationship and consistency between the
psychological findings, symptoms and the history
of the individual should be evaluated as a whole and
stated in the report.
PtD Project (IRCT, HRFT, REDRESS, PHR)
Components of the
Psychological Evaluation
•History of torture and ill-treatment
•Current psychological complaints
•Post-torture history
•Pre-torture history
•Medical history
•Psychiatric history
•Substance use and abuse history

Recommendations may depend on
purpose of the evaluation

Note: Medico-legal role does not
absolve clinicians of making
appropriate therapeutic
referrals

Recommendations can be for:
•Mental status examination
•Assessment of social functioning
•Psychological testing and
the use of checklists and
questionnaires
•Clinical impression
•Recommendations
PtD Project (IRCT, HRFT, REDRESS, PHR)
– further assessments
– neuro-psychological testing
– medical or psychiatric
treatment
Treatment Considerations

Address basic human necessities (food, shelter, source
of income)

Be aware of local clinical and social support resources

Refer for clinical treatment and rehabilitation
programs, with individual’s consent

Online course available on “Caring for Torture
Survivors” offered by the Boston Center for Refugee
Health and Human Rights. See
http://www.bcrhhr.org/pro/course/course_index.html
#
PtD Project (IRCT, HRFT, REDRESS, PHR)
Neuro-psychological
Assessment

Torture can involve physical trauma that
leads to various levels of brain impairment

Symptoms of brain impairment may overlap
with PTSD and major depressive disorders

Neuropsychological assessment:
– may be useful in discriminating between
neurological and psychological conditions
– performed infrequently and to date
neuropsychological studies of torture survivors
is limited in the literature
PtD Project (IRCT, HRFT, REDRESS, PHR)
Children and Torture

Torture can affect a child directly or indirectly

Child should receive support from caring individuals
so he/she feels secure during evaluation

Children often do not express their thoughts and
emotions regarding trauma verbally, but rather
behaviorally

Degree to which a child is able to verbalize thought
and affect depends on age and developmental level
as well as on other factors, such as family dynamics,
personality characteristics and cultural norms
PtD Project (IRCT, HRFT, REDRESS, PHR)
Children and Torture

Developmental Considerations
– < 3 yrs: reactions typically involve hyperarousal, such as
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–
–
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restlessness, sleep disturbance, irritability, heightened startle
reactions and avoidance
> 3 yrs: often tend to withdraw and refuse to speak directly
about traumatic experiences
8 or 9 yrs: develop the ability to provide a reliable chronology
of events
About 12 yrs: able to construct a coherent narrative
Adolescence: effects of torture can vary widely (i.e. profound
personality change resulting in antisocial behavior, similar to
those seen in younger children)
PtD Project (IRCT, HRFT, REDRESS, PHR)
Children and Torture

Clinical Considerations
– PTSD symptoms similar to adults
– Fears and aggressive behavior that were non-existent before
the traumatic event may appear, such as aggressiveness toward
peers, adults or animals, fear of the dark, fear of going to the
toilet alone and phobia
– May demonstrate sexual behavior inappropriate for age
– May experience somatic reactions
– Anxiety symptoms may appear, such as exaggerated fear of
strangers, separation anxiety, panic, agitation, temper tantrums
and uncontrolled crying
– May develop eating problems
PtD Project (IRCT, HRFT, REDRESS, PHR)
Children and Torture

Role of the Family
– Dysfunctional behaviors and delegation of roles may
occur
– Family members, often children, can be assigned the
role of patient and develop severe disorders
– A child may be overly protected or important facts
about the trauma may be hidden
– Alternatively, the child can be “parentified” and
expected to care for the parent
PtD Project (IRCT, HRFT, REDRESS, PHR)
Children and Torture

Role of the Family
– When loved ones around a child have been tortured
or the child has witnessed severe trauma or torture,
he/she may develop dysfunctional beliefs, such as
that he/she is responsible for the bad events or
that he/she has to bear the parent’s burdens
– These types of beliefs can lead to long-term
problems with loyalty conflicts, guilt, personal
development and maturing into an independent adult
PtD Project (IRCT, HRFT, REDRESS, PHR)