Introduction:
Interest in psychotraumatic syndromes young child has developed recently, after that suffering has long been denied.The work of several teams worldwide, as well as the interest in this issue in the humanitarian field have confirmed the existence of such clinical pictures that are better recognized and treated today. We deal here with preschool children (0-3 years), avoiding the term “infant” (non-access to language), “toddler” (complete lack of access to walking), infant or baby (who must be fed). These different names however well reflect the heterogeneity of this age group.
Epidemiology:
The traumatic stress disorder (IS) of very young children, as defined in the Diagnostic Classification 0-3 years (CD 0-3) has been described in a variety of contexts: accidents, physical or sexual interpersonal violence, disasters, wars, but also in somatic disease conditions such as cancer. Publications available relate to isolated cases or small series, but there is not yet data on the prevalence of the disorder in the general population. Among victims of potentially traumatic events, only one study has been published on a population of 300 Kosovar children of 0-6 years with traumatic events (forced displacement of families under death threats): 31% had an EST ( according to the criteria CD: 0-3), 50% had new symptoms nonspecific, while 19% were asymptomatic.
Clinic:
CLINICAL EVENT:
Different types of situations may be the cause of psychological trauma: it can be a unique event, a series of related events or chronic stress. The young child may have been directly confronted or to have witnessed. It is about real death or threat of death, injury or harm to the physical or psychological integrity of the child or others. The traumatic event is usually described as being about incurring the risk of death; but the notion of irreversibility of death is not acquired before 7 years. Various developmental factors will mediate the impact of the event, contributing or not to give it a traumatic effect: development of sensory organs (vision is first possible only short distance), psychomotor (which determines the ability to move, to flee, to avoid the danger), the development of language in receptive (conditioning the understanding of what is said) or expressive (for the call and verbalization). The traumatic impact of an event is partly related to age, which has led some authors to propose to define as any traumatic event can overwhelm the defensive capabilities of the child. Bailly, an event can be traumatogenic not only because of the fear perceived by the child but also because of the brutal destruction of his belief in the invulnerability of his parents and in the infallibility of their protection.
For Winnicott “the trauma is a destruction of the purity of individual experience by too sudden and too unpredictable intrusion of a real fact, and by the appearance of hatred in the individual hatred of the good object, not proven not as hatred, but the delirious mode of being hated. “ The environment impinges on the infant, jeopardizing its continued existence, and imposing on it a risk of annihilation at the origin of primitive anxieties dissecans.
CLINICAL EXPRESSION:
The clinical picture is organized more frequently around four axes.
Symptoms of revival:
Symptoms of revival are the different ways in which the event is relived:
– Distress at exposure to cues recalling the event;
– Flashback episodes of dissociation: the child seems to relive the event without there has been particular reminder, as if his behavior was divorced from its purpose or intentionality;
– Nightmares, either related to the event or increased in frequency;
– Posttraumatic game: an aspect of the traumatic event is repeated endlessly, monotonously and compulsively, without preparation and without calming effect on anxiety;
– Reconstruction (re-enactment) by the game: also taking an aspect of the event but the repetitive nature or other characteristics of posttraumatic game;
– Recurring memories (fascination, or about repeated questions, without the anxiety is necessarily apparent).
Decreased reactivity and numbing:
It is :
– The accentuation of social withdrawal;
– The restriction of the field of affects;
– Developmental regression;
– The reduction of the “imaginative” game (not excluding the existence of posttraumatic game).
Arousal Symptoms:
It’s about :
– Night terrors;
– The refusal to go to bed, protest at falling asleep;
– Frequent nocturnal awakenings outside nightmares and night terrors;
– The decrease in attention and concentration abilities;
– The hypervigilance, exaggerated startle response.
New symptoms:
Any new symptoms may come within this framework but particularly observed:
– Aggressiveness towards peers, adults, animals;
– A separation anxiety and reactions gripping;
– Fear / refusal to go to the toilet, fear of darkness, other new fears;
– Relational changes: masochistic provocative attitudes (calling the violent responses or rejection), manipulative attitudes in control attempts;
– Depressive affect, and about autodépréciatifs behavior;
– Inappropriate sexual behavior for age;
– Psychosomatic symptoms, including skin, algic.
The clinical expression of suffering of young children, however, is related to the level of psychomotor development and aspects of family dynamics.
EFFECTS OF DEVELOPMENT ON THE CLINICAL EXPRESSION:
Before 18 to 24 months, mainly are observed psychomotor developmental disorders, loss of acquisitions, state of apathy with passivity, or shaking with tears and incessant crying, irritability, fear, sleep disorders and Food, psychosomatic manifestations (including dermatological), separation difficulties.
Around 18 months appears access to thought and symbolic play. This evolutionary step could condition the ability to record, express and re-experience the traumatic memories. Symptoms of revival are more frequent when the trauma occurred after 18 months, however, called into action and repetitive behaviors have been reported for children who have experienced a traumatic event before the age of 1 year and, in the absence of any verbal memory, which suggests the existence of a “behavioral memory”.
The proposed Terr that the child would not have the opportunity to fully verbalize trauma when this occurred before the age of 28 to 36 months is contradicted by some clinical observations since children could verbalize traumatic memories for the events at the age of 1 year. Recently Gaensbauer reported a series of cases of children who have experienced trauma in the preverbal period, and in whom the memories of these events could be identified later. This means that a form of internal representation could settle and persist for traumatic events in children who have not yet access to language, and poses interesting questions in terms of therapeutics, on a theoretical level.
INJURIES AND PARENT-CHILD INTERACTIONS:
The issue of parent-child interactions in situations of psychological trauma must be analyzed in three ways we consider successively: the effect of the trauma of a parent to his parenting, the effect of the trauma of a child on his parents, the consequences of this effect on the child back.
The effects of post traumatic stress disorder mothers about their babies begin to be specifically studied. Some arguments lead us to believe that they could significantly disrupt the mother-child relationship.
Behavioral changes induced by the psycho-traumatic symptoms in the baby (either type of excitement or, conversely, avoidance and withdrawal) can contribute to the development of dysfunctional interactions in the mother-baby dyad up be at the forefront. In contexts of war and disaster, where are observed mother-infant dyads traumatized, serious disorders of the interaction have been described: it can include severe malnutrition and resistant to medical treatment, maternal rejection reactions, etc. In our experience the serious conflicts of land such as in Kosovo, we have frequently observed spasm of tables sob, especially when multiple family members have been traumatized. This dramatic symptom, leading to a child’s death apparently can become a real family symptom, prompting a collective revival.
The term “post-traumatic stress disorder two” was proposed to describe situations in which the parent traumatic response to the trauma suffered by the child creates a complex interaction system that perpetuates the problems in both partners interaction. For some, this could be related to the reactivation of not developed past trauma in the mother. The concept of “relational post-traumatic stress disorder” developed by Scheering qualifies the co-occurrence of situations of psycho symptoms in the baby and the adult who cares, in which the symptoms of one of both partners exacerbates that of the second. They state that the parents may have been absent at the time of the traumatic event and describe three rules for relational post-traumatic stress disorder:
– Withdrawal / non-readiness / availability: parents are emotionally unavailable to the child, this is often encountered when parents themselves have suffered previous traumas;
– Overprotection / constriction: parents are concerned about the fear of a new trauma and occur with guilt for not having been able to protect their child from the trauma;
– Reconstruction of the traumatic scene / endangered / alarm: the child’s trauma is reactivated by incessant questions about the event or repeated allusions to it, the child is placed in situations where new traumas may occur.
According to these authors, the effect of parental reaction to the child’s trauma on the child itself can take different forms:
– Minimum: the child is not affected significantly by the event;
– Mediator: the child does not feel the direct effect of the event but rather the consequences of the traumatic impact of the event on his mother;
– Moderator: the mother’s responses affect the evolution of the state of the child;
– Combined: both partners are traumatized and emotional manifestations are exacerbated each other.
Protective factors and vulnerability:
FACTORS EVENT:
Their role is established among the older child: proximity to the event, the level of violence, human origin (especially if there is a protective figure) could be aggravating factors.
FACTORS CHILD:
Many factors are well documented in the older child (gender, IQ, existence of prior trauma) but have not been demonstrated in very young children. The level of development mainly affects symptomatic modes of expression but “protects” no trauma.
FAMILY FACTORS:
Anna Freud emphasized early on the importance of parental reaction by highlighting that parents who loudly expressed their anguish could transmit their terror to their children. The importance of maternal reaction was well demonstrated in children greater in the context of war: the psychological state of the mother and trauma exposure level are the two major predictors of adjustment of capacities ‘child. According to Bailly, it is between 1 and 3 years the terror of parents would be most disturbing for the child, “the adult he believed omnipotent wisdom and carrier suddenly finds himself powerless and helpless.” Scheeringa showed that the caregiver was also exposed to the traumatic event increased the likelihood that the baby develops a traumatic stress disorder as well as the phenomena of revival.However, the presence of a parent during the event, allowing, to some extent, physical protection and by language, would be a protective factor. According to a study in Macedonia, being elder siblings or only child would represent a vulnerability factor for the development of a traumatic stress disorder among children 0 to 6 years in a context of war.Winnicott stressed the major importance of the family in child protection who have experienced a traumatic event, as well as the therapeutic process in affected children.
Diagnostic:
The diagnostic procedure is necessarily complex as it involves direct observation of the child, the mother-child dyad of and interview with the mother or caregiver. The need to go through a hétéroévaluation problem: the distorting effect induced by the emotional state of the mother on the assessment of child behavior has been well demonstrated in the context of war.
Different assessment instruments have been proposed, all based on the DSM-IV and that have not been specifically studied in young children. An interview guide semistructured “Post traumatic stress disorder semi structured interview and observational record for infant and young children 0-48 months” was developed by Scheeringa and his team, but has not been published to date.
Cases of traumatic stress of limited duration have been reported by discussing the interest to include in the CD 0-3 a category that correspond to acute traumatic stress disorder in DSM-IV, differentiated from traumatic stress disorder by a criterion period.
Diagnostic Criteria:
In 1995, a group of authors demonstrated that the DSM-IV for post-traumatic stress disorder were not suitable for very young children. The main reason was the inability of these children to make verbal account of their subjective experience, which is necessary for 8 of the 18 DSM-IV diagnostic criteria.
The clinician is thus led to infer the thoughts and feelings of the child, which opens the way to numerous biases. The criterion A2 of the DSM-IV which designated the subjective experience of the traumatic event is deleted. Symptoms are divided into four clusters corresponding to the first three clusters of DSM-IV (revival, numbing of responsiveness and arousal) which is added a new cluster ‘fears and aggressiveness news. “ After a traumatic event, a symptom at least each cluster must be present for more than 1 month for the diagnosis to be worn. Other recent work from the same team support the validity of these criteria. The proposed alternative criteria were the basis of the criteria used by the CD: 0-3.
Diagnostic classification from 0 to 3 years (CD 0-3), published in the US in 1994 and translated into French in 1998 proposed a temporary system of multiaxial classification of children’s disorders of 0-3 years. The system has five axes: I: primary diagnostics; II: the relationship of classification; III: fitness; IV: psychosocial stress; V: operating level of emotional development. CD: 0-3, focused on the development and taking into account the dynamic and interactional process, is particularly relevant to a number of early childhood specialists. According to the CD: 0-3, when the diagnostic criteria are present and that a traumatic event has occurred, the diagnosis of TSE outweighs other primary diagnoses.
Some other diagnoses, however, pose special problems.
DIFFERENTIAL DIAGNOSIS:
Among the disorders affect, mood disorder: prolonged grief / loss reaction may be difficult to distinguish the IS. The trend is less anxious and compulsive revival as depression, apathy and detachment after an initial protest phase.
Other disorder of affect disorder or attachment reaction to deficiency situations or abuse in infancy (CD 0-3), very similar to the reaction attachment disorder of infancy described in DSM -IV is characterized by the occurrence of difficulties in the baby to establish harmonious social interactions. These may be ambivalent, contradictory, inhibited or inappropriate. Symptoms improve in part with the child’s environment.
Finally, adjustment disorder (CD 0-3), equivalent to adjustment disorder (DSM-IV) is characterized by emotional symptoms and / or behavioral occurring after net change in transiently environment (from a few days to 4 months).
EASTERN can be confused with the disorder deficit hyperactivity disorder (ADHD), especially when it comes to chronic stress or repeated traumas. Arousal Symptoms often in the foreground, are the source of overdiagnosis of ADHD, especially when the DSM-IV are used.
Evolution:
There are no available prospective study. Traumatic reactions may persist in the absence of therapeutic intervention.From a neurodevelopmental perspective, some authors believe that the initial reactions that combine variously symptoms of hyperarousal and dissociation and constitute a “state” could, if they occur in the early stages of brain development, lead the emergence of “traits” of personality. Gaensbauer emphasized the consequences of traumatic events on the stages of child development. Thus the consequences, which depend on the age, would be key to the development of attachment patterns and psychophysiological regulation process in the first year of life, then, when the traumatic event occurs between 2 and 3 years the process of separation / individuation, regulating aggression, development of gender identity and socialization skills. The stumbling such early process is likely to lead to future problems, when they will be re-mobilized during later stages of development, especially in adolescence.
Winnicott had the intuition of the possible consequences of the traumas of childhood to adult life, through symptoms such as fear of the collapse (fear of breakdown), of death, of emptiness. These symptoms translate the fear of the occurrence of a collapse that is, in fact, already happened, which has already been tested in the form of primitive anxieties dissecans.
Treatment:
The treatments involve parents psychotherapeutic interventions babies, allowing both direct work with children and work on family interactions. Psychotherapeutic device is however to be developed in different situations.
When parents themselves have a posttraumatic pathology, keep in mind that the protective role of the parent face the child’s distress must be sustained and supported. In these cases, treatment should avoid catharsis and the emergence of traumatic flashbacks in the parent in the child’s presence, and it is necessary to provide a space for individual care for the affected parent. From 2 to 3 years, an individual space can be provided for the child. In therapies to young children with disorders related to psychological trauma, transference relationship and cons-transference appear frequently intense and violent. The first can be characterized by immediate and total commitment to an all-powerful therapist or contrary to total opposition, passive or active. The second face the risk of rejection and rage of impotence or the elation of the omnipotence of the therapist. Clinically, it is therefore important to work on the direct effects of traumatic events on the baby, the consequences of her parental posttraumatic syndromes and the consequences of breaches of environmental disruptions that cause insecurity and discontinuity for him beyond the traumatic event itself.Cross-cultural situation and the organized violence of such situations we can meet in the framework of humanitarian interventions, or from migrant families in France, special attention should be paid to cultural factors (language, representations concerning child and the troubles it has, the possibilities for affiliation to a community or to a group, etc.) and the collective dimension of the violence experienced.
Finally, now the question of the mechanisms of direct and indirect transmission of traumatic events experienced by parents, especially the mother, children; effects that are expressed here and now and throughout the life of the child.Treatment should therefore concern what is observed on the child and that is expressed in the body of the child or in the interactions and what is projected.
Few formal studies, apart from monographs are currently available on the evaluation of such treatments. A team has recently published the results of a psychotherapeutic care program dyads mother-child preschool victims of domestic violence. They show a significant improvement of the interaction, cognitive performance of children, decreased child behavioral disorders and posttraumatic symptomatology of the mother.
There is no indication to pharmacological treatments. In extreme cases, a sedative treatment may be considered very timely manner, purely symptomatic and very limited sight.
