Definitions, concept history and theoretical models:
Trauma and trauma are terms initially used in medicine and surgery. A trauma is usually a break-in wound; The term trauma is reserved for the consequences on the whole organism of a lesion resulting from external violence. By extension, the term trauma also refers to a sudden and violent event that brutally threatens the physical or mental integrity of an individual. Today we are talking about a “potentially traumatic” or “traumatogenic” event. Indeed, to speak of a traumatic event may imply an almost mechanical action of the event on the individual, not taking into account his subjectivity. A given event does not have a traumatic effect on all individuals exposed to it, even if, as Freud pointed out in 1920, beyond a certain intensity of the event, individual factors Few. To avoid confusion with physical trauma, the term psychic trauma or psychotrauma is used to describe the traumatic effects of the event on the individual. Psychotraumatic syndromes or disorders include all psychopathological manifestations that are observable after a potentially traumatic event. Posttraumatic Stress Disorder (PTSD), defined by the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) and by the International Classification of Diseases, Tenth Revision (ICD-10) or post-traumatic stress disorder defined by the French Classification of Child and Adolescent Mental Disorders (CFTMEA) is the most salient and best known example, Other disorders are also disclosed.
The notion of trauma occupies a central place in psychoanalysis.
For Freud, it refers to an economic conception: “We thus call a lived experience which brings to the psychic life, in a short period of time, an increase of stimulation so strong that the liquidation or the elaboration of it The usual standards fail, which necessarily results in lasting disturbances in energy management. “. In the beginnings of psychoanalysis, the etiology of neurosis is related to infantile traumatic experiences. The traumatic theory of neurosis gradually becomes more complex with the notions of seduction and after-action, since traumatic external events draw their strength only from the fantasies they activate and from the influx of instinctual excitement they trigger. The etiological role of real trauma in neurosis gradually fades, but the recognition of war neuroses renews Freud’s interest in this question. He takes an economic approach to the trauma as an intrusion of the excitation-guard with a putting out of the principle of pleasure, constraining the psychic apparatus to a compulsion of repetition. The notion of trauma takes on an even more important place later, especially in the theory of anguish in Inhibition, symptom and anxiety. The traumatic situation is then defined by the emergence of automatic anxiety in which the self is overwhelmed and without recourse. The ego can therefore be attacked from within as well as from outside; A certain symmetry is established between the internal danger and the external danger.
Studies of traumatic neuroses will continue during the two world wars, including the work on survivors of the Holocaust. Anna Freud and Burlingham in 1943 were the first to take an interest in psychotraumatism in children subjected to the bombing of German aviation in London. They find that children face trauma better when they are with calm, supportive parents, but that the help of those around them does not prevent late disturbances. For Anna Freud, trauma is linked to a sudden and unexpected event of such nature and intensity that it provokes an excess of stimulation and an overflow of the ego’s ability to adapt that does not allow for defensive attitudes. Its visible and immediate effects are tangible signs of the installation of a disorder of the balance of the ego. The first systematic studies were made in the 1970s and 1980s following natural and accidental disasters and attacks, including Terr’s 1976 study in the United States on children taken hostage on their school buses. In 1980, PTSD was defined in adults in the DSM-III, in parallel with the return of Vietnam veterans to the United States, in a well-defined sociopolitical context, resulting in a separation between victims and aggressors, Equivalence between suffering and pathology. The notion of possible harm to the child becomes explicit in the DSMIL in 1987 and in ICD-9 in 1989.
At the theoretical level, as in adults, there are three models of understanding psychic trauma. The first is psychoanalytic and refers to work on traumatic neurosis. The second is cognitive-behavioral, with the hypothesis of negative trauma assessments and an autobiographical memory disorder to explain the persistence of PTSD symptoms. Finally, a biological perspective can be envisaged, with the involvement of the hypothalamohypophyseal axis and the limbic system, and a neurodevelopmental perspective in the child.
INITIAL DESCRIPTIONS OF PSYCHIC TRAUMA IN THE CHILD:
A detailed description of the clinical signs of child psychic trauma was proposed by Terr. This author differentiates type I trauma, characterized by exposure to a single sudden and massive event, and type II trauma, due to exposure to repeated or sustained events that can then be anticipated. Four categories of symptoms common to both types of trauma were identified:
– intrusive and repetitive memories perceived primarily visually (but also at the tactile, olfactory or proprioceptive level);
– repetitive behaviors, ie repetitive acts or recreations recreating aspects of the traumatic situation, repetitive dreams being rare in children and being most often frightening, without recognizable content;
– specific trauma-related fears that are easily identified, or fears that can spread to other non-traumatic objects or situations;
– a change of attitude towards people, such as loss of confidence, certain aspects of life and a pessimism about the future.
In trauma type I, these characteristics are recognizable either in their totality or partially. There is also the avoidance of traumatic situations, faults in the perception of reality initially and at a distance from trauma (such as false recognitions, visual hallucinations, illusions and temporal distortions), and a compulsive search for explanations In relation to the event. Symptomatology typically occurs in type I trauma after a free interval.
In Type II trauma, there may be other signs, some of which bear witness to defense reactions to the repetition of events, such as significant denial, affective anesthesia, more severe avoidance symptoms, whole-face amnesia Childhood memories, reactions of depersonalization and dissociation, manifestations of anger, self- or hetero-aggression by identification with the aggressor and by turning the aggression against oneself. These factors raise the question of the future of such disorders and their possible responsibility for the development of personality disorders. The distinction between Type I and Type II trauma, however, has certain limitations, a unique and sudden event that can preferentially induce disorders such as repression, dissociation and denial. In addition, some paintings, when the traumatic event produces lasting consequences in reality (death of a parent, child’s disability) realize mixed forms type I-type II. The traumatic and bereavement problems seem to be potentiating, hindering development and potentially leading to severe depressive syndromes in addition to Type I and Type II manifestations.
Whatever the situation, other disorders are likely to appear:
– anxiety disorders in the form of obsessive ideas, phobic manifestations, free anxiety or separation anxiety;
– depressive or dysthymic disorders;
– behavioral disorders with unusual psychomotor instability, symptoms of attention deficit hyperactivity disorder or oppositional disorder;
– somatic disorders, in particular dermatological disorders;
– regressive behavior (enuresis in particular);
– signs related to the early development of personality disorders (borderline, narcissistic, psychopathic …), more often in the context of type II traumas.
STATUS OF POST-TRAUMA STRESS AND ITS LIMITS:
The definition of PTSD in the DSM-IV includes some of these signs along three lines: repetitive syndrome, avoidance syndrome, and neurovegetative hyperactivity.
The traumatic experience comes back compulsively, repetitively, in the form of memory reviviscences (ideas, images), sensations, emotions, behavioral reactions, dreams, in children’s games. The subject can neither prevent nor prevent this re-experience which invades his life and which always has a painful character.
In the avoidance syndrome, the subject gradually develops more or less conscious strategies to combat repetition. For example, this may be a restriction of affective reactions to prevent affects related to the traumatic experience, with a risk of blunting the overall emotional life.
The withdrawal may be very marked because avoidance reactions can take over, develop on their own account, partly because of their relative inefficiency. The mechanisms are varied, but the most expensive is cleavage which can give the appearance of a loss of consistency and give rise to serious personality disorders.
The state of alertness, hypervigilance, also has the sense of an adaptive reaction too late in relation to events than to prevent, prepare the subject for new events. This condition results in sleep disorders, difficulties in concentration, hyperemotion with irritability and sometimes outbursts of anger with attitudes of anxious vigilance with respect to the environment.
Most authors pointed out that the PTSD model was insufficient to account for the psychic trauma clinic, with other manifestations of psychotraumatic syndromes not receiving equal attention, particularly in clinical research. These authors emphasize the frequency of psychosomatic manifestations in children and adolescents. Dermatological diseases (eczema, alopecia areata), respiratory diseases (bronchitis, asthma …), associated with many somatic complaints (headache, abdominal pain …), can occur after traumatic events. The potential impact on the child’s emotional and cognitive development, but also on its socialization, should also be better understood.
VARIATIONS IN CLINICAL EXPRESSION:
Different types of factors can modify the clinical expression of disorders.
Nature of the traumatic experience:
Another typology of potentially traumatic events can be proposed according to their nature, sexual when the subject is confronted with the violence of a sexual desire incomprehensible to him, or mortifies in the event of a missed meeting with death, and also as a function of Their main belonging to external reality or internal psychic reality, these components being, of course, intimately intertwined. The distinction between intentional human-to-human violence and other types of events must also be taken into account. For example, repeated abuse or forced coercion (such as child soldiers) may not have the same consequences for the child as natural disasters, in the sense that they Constitute an attack on what underlies the identity of the subject and its relation to the world. The interplay between post-traumatic symptoms and bereavement work is also possible.
Level of development of the child:
Preschoolers, ages 3 to 6, may exhibit repetitive behaviors and patterns, avoidance behaviors, regressive behaviors (enuresis and / or secondary encopresia), sleep disorders (nightmares, night terrors) , Phobias (fear of going to the toilet alone), seizure reactions and separation anxiety, sadness, somatic manifestations (abdominal pain, headache).
Developmental delays (language, psychomotricity) can also be found. In children undergoing latency, anxious, depressive or inhibitory symptoms and the expression of guilt may occur. Hypervigilance, changes in play, loss or change in the usual interests, concentration difficulties are more marked than in the young child. Educational difficulties and declining performance may be at the forefront.
In adolescence, the work of constructing identity can be upset both at the level of inscription in filiation and at the level of the appropriation of affiliations, with in particular processes of cleavage or excess of repression . Adolescents may have conduct disorders, self- or hetero-aggressive behavior and substance abuse (alcohol or other).
The aggressiveness that has been recognized when directed against the enemy is sometimes manifested in the family environment or in the peer group, but also in the reversal, with the risk of depression, loss of confidence in the future . Self-aggressive impulses can also be interpreted as attempts to escape from painful conditions of emptiness or blunting.
Cultural and social context:
PTSD is not the only possible expression of psychological trauma in transcultural situations. Other clinical pictures, such as the susto in South America, the khal’a in the Maghreb, may reflect the same problematic, that of fear or fright, but these aspects have hitherto been little studied in children .
For Baubet and Moro, the concept of psychic trauma is relevant in transcultural situations; However, cultural invariants are not so much about symptoms as processes: fear, change in the world’s apprehension and metamorphosis of the subject. Cultural belonging will also influence the expectations of the patient and his / her family relative to care, in relation to the possibility of adherence to the etiopathogenic model that implicitly underlies the therapist’s ways of doing. Rousseau stresses the importance of the context of organized violence, which, beyond its effects on individuals, also affects families, groups and communities, leading to a dissolution of the social bond.
Most of the available epidemiological studies use the American nosography and therefore generally seek only symptoms of PTSD.
STUDIES IN GENERAL POPULATION:
In children, there is no epidemiological study on large samples of the general population, as is the case in adults. The study by Kessler et al in the National Comorbidity Survey (5,877 subjects across the US), however, systematically included the age range of 15-24 years. This age group, although less exposed to these events, appeared more sensitive to PTSD. Some authors have focused specifically on groups of adolescents. Giaconia et al. Evaluated 384 adolescents aged 18 years. More than 40% had experienced a potentially traumatic event; Among them, 14.5% had PTSD (6.3% of the total group). The prevalence of PTSD was higher for girls than for boys. Adolescents with PTSD also had more emotional, behavioral, relational, academic, and more suicidal behaviors and somatic problems. Interestingly, teens who experienced a traumatic event, even though they did not have PTSD, also had more of this type of difficulty than those without a history of traumatic events. This shows that PTSD does not summarize all psychotraumatic disorders. Cuffe et al. Found a prevalence of 3% current PTSD among girls and 1% among boys in a group of 490 subjects aged 16-22 years. Perkonigg et al. Conducted a study in Germany, Munich, of 3,021 subjects aged 14 to 24 years. The lifetime prevalence of potentially traumatic events reported was 26% for men and 17.7% for women, and only 1% of men and 2.2% of women had PTSD during their lifetime. The prevalence was therefore lower than in North American studies, but the risk of presenting PTSD after a traumatic event and the association with high psychiatric comorbidity were similar.
STUDIES AMONG SPECIFIC GROUPS OF POPULATIONS OR SUBJECT TO A SPECIAL EVENT:
Numerous studies have investigated psychotraumatic disorders in children and adolescents subjected to different traumatic events, although there are very few longitudinal studies. All events are not equivalent; Some traumas are said to be extreme and some intentional. Traumatic events may include physical and / or sexual aggression, natural or accidental disasters, acts of terrorism or war scenes, and more recently somatic illnesses or life-threatening medical procedures. The development of humanitarian psychiatry in situations of war or disaster has, moreover, deeply renewed reflection on the trauma.
The results are very variable according to the studies. The prevalence of psychotraumatic disorders in children and adolescents is generally high and can be as high as 70-80% of subjects after a major traumatic event (eg after the 1988 earthquake in Armenia ). This frequency is, of course, variable depending on the traumatic event and the time elapsed since. The diagnosis of PTSD appears to be more common in girls than in boys. The association with other disorders (especially depressive or anxious) is often very high. The partial forms of PTSD appear to be more frequent than the complete picture. These situations, however, pose the question of the possibility of distinguishing between what can be considered a pathological reaction, especially in situations of war or organized violence, what would be an expected and transitory reaction. Too often this distinction is made according to PTSD criteria. However, in this type of situation, the validity and relevance of these criteria in children and adolescents remain, in our view, to be demonstrated.
Etiopathogenesis and pathogenesis, risk and protective factors, evolution:
The risk of developing psychotraumatic disorders after exposure to a given event depends on many factors related to the traumatic event itself, as well as many individual or family factors (vulnerability and risk factor model). In a literature review of 25 studies, Foy et al. Showed that three factors were most often associated with PTSD symptoms in children: the severity of exposure to the event, the time elapsed since the event and the distress of the parents. In parallel with the vulnerability model, another model was proposed, namely resilience and protective factors. Resilience is a descriptive concept that refers to the ability to resist shocks and to continue to develop under difficult conditions. It does not amount to an invulnerability which would imply the ability to bear everything without harm. For Bourguignon, resilience is approached as a “process of risk negotiation”. Many studies have sought to identify these protective factors.
Some work in cross-cultural psychiatry and the social sciences has shown that exposure of children and adolescents to potentially traumatic events can lead to the acquisition of additional qualities and abilities and a new creativity. Care must therefore be taken not to assimilate systematically the consequences of potentially traumatic events to psychopathological phenomena.
The long-term evolution of psychological trauma in children and adolescents is not fully known, but it should be stressed that even if only PTSD is taken into account, the transition to chronicity for several years is Possible in a non-negligible proportion of cases, and even in the absence of a repetition of events.
FACTORS RELATING TO THE CHARACTERISTICS OF THE TRAUMATIC EVENT:
The traumatic event is the central etiological element of psychotraumatic disorders. Its characteristics of unexpected suddenness or prolonged repetition (type I or II trauma) have already been discussed (see above). The degree of physical but also emotional exposure to the stressor is another essential factor. It should be remembered that, although there are few studies on this subject in children, in adults psychic dissociation at the time of the event could be a predictive factor for the onset of symptoms, PTSD. In addition, the perceived threat to life is another important factor as well as the type of event (caused by man or accidental). For example, the impact is different depending on whether the perpetrator is a relative or a foreigner or, in the event of war, whether it is a civil war or a war against an external enemy.
INDIVIDUAL AND FAMILY FACTORS:
Age, level of development, pre-existing disorders:
The severity of the symptomatology of psychic trauma does not seem to depend on the age of the children exposed to the event, such as Pynoos et al. Have shown this in the aftermath of the earthquake in Armenia in 1988. The cognitive development of the child also has no influence on the onset of the disorder. Age and level of development have a greater role in the type of symptomatic expression of the disorder than in its prevalence, although of course the question of what constitutes a death threat or Threat of the physical integrity of oneself or others depends on his age and his perceptual and conceptual capacities on the cognitive and affective level, the concept of death gradually being established. This is why, in children, the protection of parents in relation to the traumatic impact of an event is very important. Pre-existing psychopathological disorders are, of course, also a risk factor.
Sex: Male Location
Girls appear to have symptoms more often than boys, and perhaps more sustainably and severely, but it is far from consistent in the various studies.
It corresponds to the cohesion of the group and the mutual support of its members. It would be a protective factor when it persists after the event. The protective effect of social support seems all the more clear when the event constitutes a collective trauma and upsets the social organization of the group.
For many authors, family factors, ie, parent reaction, availability, psychic functioning, potential psychopathological history, and quality of interactions among different family members, are the factors that influence The more the development of psychotraumatic syndromes in children (and especially in the baby) and the adolescent. Parents can cushion the psychological impact of the event but, conversely, a significant distress response from one parent may be the agent of the child’s psychic trauma. In addition, trauma also has a transgenerational impact in some situations.
Comorbidity, differential diagnoses and methods of assessment:
The most common disorders associated with PTSD in children and adolescents are depressive disorders and anxiety disorders (including separation anxiety). Comorbidity was also found with substance abuse, conduct disorders, oppositional disorders, and attention deficit disorders.
These disorders, like all comorbid disorders, may be a clinical expression of psychotraumatic syndromes in the same way as PTSD or, if pre-existing, may become worse after a traumatic event.
According to the DSM-IV, the diagnosis of adaptive disorder can be made either when the traumatic event does not have the extreme character required for the diagnosis of PTSD, or when the event is very extreme but the symptoms Do not meet the PTSD criteria.
Parents, as always in the child, constitute an important source of information. The circumstances of the assessment must always be clearly defined. Clinical maintenance is, of course, the first step in evaluating the various symptoms of psychotraumatic syndromes. In the context of research interviews, non-specific instruments, to assess associated disorders (especially anxiety and depressive disorders), and specific symptoms of PTSD can be used, provided they know the limits. The latter usually involve structured diagnostic interviews and scales that allow for a quantitative approach to symptomatology.
They focus on the evaluation of PTSD, dissociative symptoms and the traumatic event itself.
The modalities of therapeutic interventions are diversified to respond to situations very different from one another. In general, parents and family, whether or not they have experienced the traumatic event, are always included in the care. Depending on the context, care is directed only at a subject and his family or is a collective act, for example in situations of war or disaster, by setting up specific mechanisms, while knowing that a model Uniformity of intervention can not be applied mechanically in any context. These two modalities can be combined, the choice of one or the other depends in particular on individual, family, social and cultural factors. Psychotherapies are of analytical or cognitive-behavioral inspiration according to the theoretical orientation of the participants. The narrative of traumatic events, the abridgment or disclosure of the trauma, when the conditions of the narrative are established, are conventionally desirable, but must be done only within the framework of a sufficiently solid therapeutic relationship taking into account the individual, familial defenses And cultural. It can not be a forced catharsis. The speech on the trauma can either allow an elaboration or, on the contrary, be violent and effractive.
Sometimes it is more important to talk around the traumatic event and its consequences. Most authors point out that there is no evidence to support the opportunity to respect or, on the contrary, to combat denial and avoidance.
These symptoms can have deleterious effects for psychic functioning, but can also have protective effects and are then to be preserved, at least initially. It seems important to evaluate the protective and pathogenic potential of defense mechanisms erected against the effects of trauma and to adopt a therapeutic attitude.
The play between several therapeutic spaces of enunciation and silence, between several universes of meaning and nonsense, reintroduces a movement that allows us to emerge from the suspended and immobile time that follows the traumatism (the traumatic sideration). An antidepressant or sedative drug treatment is rarely useful, especially since there is no reliable data on the efficacy of psychotropic drugs in children on post-traumatic symptomatology unless, of course, , a
Associated and patent depressive symptomatology. Integration in the care of the cultural dimension as a dynamic element and not as an obstacle to the care is essential to be able to put in place original and mixed mechanisms, both in humanitarian situation and with migrant patients or children of migrants, And should not be reduced to a “social treatment” of disorders aimed at promoting the adaptation of patients to the society in which they live. The individual, familial or social etiological theories that children or their families must use to think about the event and rebuild themselves in the face of unthinkable and traumatic nonsense must be sought. These theories then serve as a basis for reconstruction.
Children and adolescents, such as adults, may present various types of violent events (physical or sexual assaults, disasters, wars, etc.), various and sometimes severe psychopathological manifestations, regardless of their age. The post-traumatic stress disorder described in the nosographic classifications (DSM-IV and ICD-10) with its symptomatic triad (repetition, avoidance and neurovegetative hyperactivity) does not summarize the whole. The prognosis depends on the type of traumatic event, the severity of the exposure to the event, the psychic functioning of the child or the adolescent, the intensity of the distress of the parents and, of course, The therapeutic management put in place. The modalities of therapeutic interventions, in order to prevent history from turning into destiny, must take into account the individual, family and cultural dimensions of each situation.