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1 KISEP Original Article Korean J Child & Adol Psychiatr 15:61~74 심한정신적외상경험을한학령전기아동의정신적표상에대한예비연구 PRELIMINARY STUDY OF MENTAL REPRESENTATIONS OF PRESCHOOL CHILDREN EXPERIENCING SINGLE, SEVERE TRAUMA 엄소용 * 신의진 * 송원영 * 오경자 ** 최의겸 * 심은지 * So-Yong Eom, M.A., * Yee-Jin Shin, M.D., Ph.D., * Won-Young Song, M.A., * Kyung-Ja Oh, Ph.D., ** Eui-Gyum Choi, M.D., * Eun-Ji Shim, M.A. * 연구목적 방법 결과 결론 중심단어 Department of Psychiatry, College of Medicine, Yonsei University, Seoul Department of Psychology, Yonsei University, Seoul

2 서론

3 연구대상및방법 1. 연구대상 2. 연구방법 3. 검사도구 1) 한국웩슬러유아지능검사 (K-WPPSI)

4 2) MacArthur Story-Stem Battery(MSSB) ) 나무-집-사람그림검사 (HPT) 4) 아동용인성검사 (Korean Personality Inventory for Children;KPI-C)

5 Table 1. Characteristics of Korean children with single, severe trauman9 Variables Division N Age Sex 3 years 4 years 5 years 106 months 712 months 106 months 712 months 106 months 712 months Male Female 000% % 222.2% 333.3% 222.2% 111.1% 666.7% 333.3% 결과 1. 아동의구성과배경정보 Table 2. Background information and severity of impact on traumatic exposures Girl 1 Girl 2 Girl 3 Boy 1 Child Age at the time of Past history the trauma 3 years 7 months 4 years 6 months 4 years 7 months Afer being stitched at the hospital of hitting by chair 3 years ago, scared of white-dressed 4 years men 1 year ago, older sister s head trauma by falling down S.E.S* Parents Years of education father/mother Severity of impact on traumatic exposure Severity of trauma Moderate-high 16/16 Severe Moderate 16/16 Severe Moderate 12/12 Mild Moderate 12/12 Moderate Boy 2 4 years Moderate 12/12 Moderate Boy 3 Boy 4 Boy 5 Boy 6 4 years 9 months 5 years 2 months 5 years 4 months 5 years 9 months S.E.SSocial Economic Status on I, 3 years, kawasachi disorder Moderate 09/12 Severe Moderate 14/12 Severe Mild autocycle accident Moderate 16/16 Mild Divorce of parents Moderate 16/16 Mild

6 2. 심리평가결과 1) 인지기능 2) MSSB 전반적내용및정서적반응분석 - Table 4. Frequencies of emotional responsesn9 in play narrativemssb* Number of children Frequency Anxiety 8 53 Denial 8 21 Anger 6 14 Distress 5 13 Joy 2 04 MSSBMacArthur Story Stem Battery Table 3. Frequencies of content themesn9 in play narrativesmssb* Content theme Number of children Frequency Examples Aggression 8 40 Mother and father came and took the knife to cut the legs of bad guy A dinosaur carelessly stepped on sitting family and stabbed them with his tail Personal injury 7 27 Chul-su fell down from the rocks and covered with blood all over by head broken Atypical response 6 30 All characters were made to lie down described as sleeping..., not solved out their conflicts Punishment 6 18 Children or parents hit and punished the bad guy breaking into their kindergarten Empathy/helping 6 10 On the crisis of children, their parents comforted and helped them. Reparation/guilt 3 14 Chul-su made an apology to his father about spilt juice MSSBMacArthur Story Stem Battery

7 3) HTP 전반적내용및정서적반응분석 Table 6. Frequencies of emotional responsesn9 in H-T-P* Number of children Frequency Anxiety 9 21 Fearfulness 4 10 Aggression 4 09 Helplessness 2 05 Dysphoric mood 1 03 Loneliness 1 01 House-Tree-Person Drawing Test Table 5. Frequencies of content themesn9 in drawing testh-t-p* Content Theme Persecutor or fearful object Number of children Frequency 5 6 Examples This person in thinking of the devil" It seems to be scary...those eyes are terrible Aggression 4 4 A tiger and a lion bit each other... Wish to be powerful, strong figure 3 4 Thought of death 3 3 I wanna be a wild boar to hit snakes and stab other animals with its horns" This tree seems to feel bad and to die... because of too many ants..." Negativistic view about future 2 2 This is going to die in future Fantastic punishment to victimizer 2 2 This man wanna be a policeman to rrest bad guys... Rescue fantasy 2 2 There lives four mushroom elves. They save people living in village when they got hurts, give ices when the village is on fire and rescue them when bad monsters come... Caring 1 1 I take care of my sister Negative self-image 1 1 This tree seems to be seek...burning... Absence of caregiver 1 1 House-Tree-Person Drawing Test I m scared of being eaten by the tiger because my mother isn t at home

8 4) KPI-C에서의부모보고결과 5) 아동의정신적표상과부모보고식적응상태와의관계 - - 6) 아동의정신적표상과 DSM 진단과의관계

9 Table 7. Results of HTP, MSSB, KPI-C and DSM-IV diagnosis Girl year Girl year Girl year Boy 1 4 year Boy 2 4 year Boy year Boy year Boy year Boy year Anxious HTP MSSB* KPI-C T60 Persecutor, fearful object Fantastic punishment to victimizer Wish to be powerful, strong figure Absence of caregiver Curing theme Caring theme Thought of death Anxious, fearful, aggressive, elplessness Anxious Anxious Persecutor, fearful object Anxious, fearful, aggressive Persecutor, fearful object Rescue fantasy Fantastic punishment to victimizer Wish to be powerful, strong figure Anxious, aggressive Persecutor, fearful object Negative self-image Thought of death Negativistic view of future Anxious, fearful, helplessness Persecutor, fearful object Wish to be powerful, strong figure Anxious, fearful, aggressive Negativistic view of future Anxious, dysphoric, loneliness Empathy/helping Anxiety, denial Empathy/helping Punishment/discipline Reparation/guilt Personal injury Atypical response Anger, anxiety, denial Empathy/helping Punishment/discipline Personal injury Atypical response Joy, anger, denial Personal injury Atypical response Anger, distress, anxiety, denial Empathy/helping Punishment/discipline Personal injury Atypical response Joy, anger, anxiety, denial Empathy/helping Punishment/discipline Distress, anxiety Exclusion Empathy/helping Refused empathy/helping Dishonesty Punishment/discipline Reparation/guilt Verbal conflict Personal injury Atypical response Distress, anxiety, denial Punishment/discipline Reparation/guilt Personal injury Atypical response Anger, distress, anxiety, denial Personal injury Anger, distress, anxiety, denial DLQ60T ANX65T DEP66T AUT61T PSY78T ANX72T DLQ62T SOM57T DEP68T AUT63T SOC60T DLQ60T Diagnosis DSM-IV PTSD SAD PTSD SAD Not PTSD PTSD SAD PTSD PTSD SAD MDD Not PTSD, suspicious of ADHD Not PTSD, suspicious of Asperger s disorder Not PTSD, ODD** MSSBMacArthur Story Stem Battery, House-Tree-Person Drawing Test, Korean Personality Inventory for Children, Posttraumatic Stress Disorder, Separation Anxiety Disorder, Major Depressive Disorder, Oppositional Defiant Disorder. content themes, emotions in HTP and MSSB

10 고 1. 아동들이어떠한정신적표상을가지고있나? 찰

11 2. 아동의정신적표상과 PTSD 진단과의관련성 - 3. 학령전기아동에서정신적표상의임상적유용성

12 4. 본연구의제한점 5. 후속연구를위한제안 References 1) Pynoos RS, Frederick C, Nader K, Arroyo W, Steinberg A, Nunez F, et al. Life threat and posttraumatic stress in school-age children. Arch Gen Psychiatry 1987; 44: ) Terr LC. Childhood traumas: an outline and overview. Am J Psychiatry 1991;148: ) American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders(DSM-III). 3rd ed. Washington DC, American Psychiatric Association; ) Terr LC. Chowchilla revisited: the effect of psychic trauma four years after a school bus kidnapping. Am J Psychiatry 1983;140: ) Kinzie JD, Sack WH, Angell RH, Manson S, Rath B. The psychiatric effects of massive trauma on Cambodian

13 children, I: the children. J Am Acad Child Adolesc Psychiatry 1986;25: ) Almqvist K, Brandell-Forsberg M. Refugee Children in Sweden: Posttraumatic Stress Disorder in Iranian Preschool Children Exposed to Organized Violence. Child Abuse Negl 1997;21: ) Dowling S. Dreams and dreaming in relation to truma in childhood. Int J Psychoanal 1982;63: ) Anthi P. Reconstruction of preverbal experiences. J Am Psychoanal Assoc 1983;31: ) Terr LC. Children of Chowchilla: study of psychic trauma. Psycho and Study 1979;34: ) Terr LC. Children traumatized in small groups. In: Pynoos RS. editor. Posttraumatic Stress Disorder in Children. Washington DC: American Psychiatric Press;1985. p ) Scheeringa MS, Peebles CD, Cook CA, Zeanah CH. Toward establishing procedural, criterion an discriminant validity for PTSD in early childhood. J Am Acad Child Adolesc Psychiatry 2001;40: ) Fantuzzo JW, McDermott PA, Mnz PH, Hampton VR & Burdick NA. The pictorial scale of perceived competence and social acceptance: Does it work with lowincome urban children? Child Development 1996;67: ) Buchsbaum HK, Toth SL, Clyman RB, Cicchetti D & Emde RN. The Use of a narrative story-stem technique with maltreated children: Implications for theory and practice. Development and Psychopathology 1992;4: ) Perrin S, Last CG. Do childhood anxiety measures measure anxiety? J Abnormal child Psychol 1992;20: ) Van Hutton V. H-T-P/D-A-P as measures of abuse in children: a quantitative scoring system. Odessa, FL, Psychological Assessment Resources; ) Weiner IB. Principles of Rorschach Interpretation. Mahwah, New Jersey: Lawrence Erlbaum Associates, Publishers; ) 신의진, 이경숙, 이혜란. 학령전기아동의심적표상 ( 부모에대한심적표상과의관계를중심으로 ). 소아 청소년정신의학 1999;10: ) Pynoos RS, Spencer. Witness to Violence: The Child Interview. J Am Acad Child Psychiatry 1986;25(3): ) Warren SL, Oppenheim D, Emde RN. Can emotions and themes in children s play predict behavior problems? J Am Acad Child Adolesc Psychiatry 1996;34: ) Sroufe LA. An organizational perspective on the self. In Cicchetti D & Beeghly M Eds. The self in transition: Infancy to childhood. Chicago: University of Chicago Press;1990. p ) Mordock JB. Interviewing Abused and Traumatized Children. Clin Child Psychol Psychiatry 2001;6: ) Bretherton I, Oppenheim D, Buchsbaum H, Emde RN. MacArthur Story-Stem Battery. Unpublished manual. The MacArthur Narrative Group; ) Toth SL, Cicchetti D, Macfie J & Rogosch FA & Maughan A. Narrative representation of moral-affiliative and conflictual themes and behavior problems in maltreated pre-schoolers. Journal of Clinical Child Psychology 2000;29: ) Toth SL, Cicchetti D, Macfie J, Rogosch FA, Maughan A & Vanmeenen K. Narrative representations of caregivers and self in maltreated pre-schoolers. Attachment & Human Development 2000;2(3): ) 박혜원, 곽금주, 박광배편저. 한국웩슬러유아지능검사 (K-WPPSI). 서울 : 도서출판특수교육 ; ) 이경숙, 정석진, 신의진. 학령전기학대아동과정상아동의이야기표상차이에관한연구 : 양육자, 자기, 표상구조를중심으로. 한국심리학회지 : 발달 ; ) 유영미, 이영. 어머니에대한유아의표상에대한연구. 한국심리학회지 : 발달 2001;14: ) Buck JN. The H-T-P technique: a qualitative and quantitative scoring manual. J Clin Psychol 1948;4: ) 김동연, 공마리아편역. 인물화및집, 나무, 사람그림에의한심리진단법. 한국미숙치료학회미술치료연수회자료. 30) Blain GH, Bergner RM, Lewis ML, et al. The use of objectively scorable House-Tree-Person indicators to establish child abuse. J Clin Psychol 1981;37: ) 김승태, 김지혜, 송동호, 이효경, 주영희등. 한국아동인성검사 (Korean Personality Inventory for Children) 실시요강. 한국가이던스 ; ) 신의진, 엄소용, 최의겸, 송원명, 오경자. 한번의심각한외상경험을한학령전기아동의발달정신병리. 신경정신의학 2004;43(2):

14 ABSTRACT Korean J Child & Adol Psychiatr 15:61~74, 2004 PRELIMINARY STUDY OF MENTAL REPRESENTATIONS OF PRESCHOOL CHILDREN EXPERIENCING SINGLE, SEVERE TRAUMA So-Yong Eom, M.A., Yee-Jin Shin, M.D., Ph.D., Won-Young Song, M.A., Kyung-Ja Oh, Ph.D., Eui-Gyum Choi, M.D., Eun-Ji Shim, M.A. Department of Psychiatry, College of Medicine, Yonsei University, Seoul Objectives:This study was performed to introduce a psychoeducational family therapy model for the families of schizophrenic patient and to investigate the effect of this model on the changes in coping style and depressive symptoms of the family members, and in perception of emotional support by families and depressive symptoms of patients. Methods:Nine preschool children, 3-5 years old, experiencing physical injuries caused by attack from a psychotic patient at kindergarten, were evaluated for psychological assessments;intelligence test, MSSB(MacArthur Story-Stem Battery), H-T-P test(house-tree-person test). And their parents completed rating scale, KPI-C(Korean Personality Inventory for Children about children s psychological conditions). Results:With respects to the contents and emotional reactions of MSSB, 9 preschool children showed generally high levels of anxiety, depression, avoidance, aggression, probably related to the traumatic experiences. Even though children couldn t verbally report directly about their traumatic experiences, in both MSSB, structured play narrative assessment tool, and HPT, free drawing and association test, they demonstrated psychiatric problems through reenactment plays, regardless of clinical diagnoses. Conclusion:Present study allowed us the chance to see beyond the outer pathological behaviors of PTSD in preschool children, through deeper evaluations of their mental representation. These preliminary data suggest deep understanding of internal representation would be of help for thorough evaluations and treatment plan for preschool children, experiencing severe trauma. KEY WORDS:PTSD Preschool children Mental representation Single trauma

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