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| PERSPECTIVE/VIEWPOINT |
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| Year : 2022 | Volume
: 4
| Issue : 2 | Page : 106-111 |
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A Psychodynamic Perspective on Psychological Traumas in Children and their Psychosocial Consequences
M Botbol1, T Lebailly2, S Laplace3, S Saint André3
1 Department of Child and Adolescent Psychiatry, University of Western Brittany, Brest, France
2 Department of Child and Adolescent Psychiatry, Vallée Foundation, Gentilly, France
3 Department of Child and Adolescent Psychiatry, University Hospital of Brest, Brest, France
| Date of Submission | 29-Jun-2022 |
| Date of Decision | 29-Jun-2022 |
| Date of Acceptance | 30-Jun-2022 |
| Date of Web Publication | 22-Aug-2022 |
Correspondence Address:
Prof. M Botbol
Department of Child and Adolescent Psychiatry, University of Western Brittany, Brest
France
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/wsp.wsp_21_22
Psychological trauma may occur in children as it does in adults. However, due to children's specific dependency on their caregivers, some cardinal characteristics differentiate common acute psychological trauma from long-lasting ones for which the traumatic stress field has adopted the term “complex trauma,” including abuse and neglect and intrafamilial from extrafamilial psychological traumas. These characteristics are influential on the weight of psychological trauma psychosocial consequences, considerably higher in children than in adults. It is especially the case in infants in whom intrafamilial long-lasting psychological traumas are, by far, the most frequent and the most destructive. The purpose of the present article is not to provide an updated review of the current literature on psychological trauma in children and adolescents but to show how psychoanalytical theoretical approaches contribute to the treatment of childhood trauma. One must remember that considerations of children's psychological traumas were crucial in developing psychoanalytic theories. More than 100 years ago, psychoanalysis comprehensively explained the behavioral and affective symptoms currently considered central in children's and adolescents' psychological trauma. Moreover, these explanations are generally consistent with the theories supporting the current mainstream approach to the question.
Keywords: Children and adolescents development, psychodynamic psychiatry, psychological traumas
How to cite this article:
Botbol M, Lebailly T, Laplace S, André S S. A Psychodynamic Perspective on Psychological Traumas in Children and their Psychosocial Consequences. World Soc Psychiatry 2022;4:106-11 |
How to cite this URL:
Botbol M, Lebailly T, Laplace S, André S S. A Psychodynamic Perspective on Psychological Traumas in Children and their Psychosocial Consequences. World Soc Psychiatry [serial online] 2022 [cited 2023 Mar 24];4:106-11. Available from: https://www.worldsocpsychiatry.org/text.asp?2022/4/2/106/354179 |
| Introduction | |  |
Psychological trauma may occur in children as it does in adults. However, due to children's specific dependency on their caregivers, some cardinal characteristics differentiate common acute psychological trauma from long-lasting ones for which the traumatic stress field has adopted the term “complex trauma,” including abuse and neglect[1] and intrafamilial from extrafamilial psychological traumas.
These characteristics are influential on the weight of psychological trauma psychosocial consequences, considerably higher in children than in adults. It is especially the case in infants in whom intrafamilial long-lasting psychological traumas are, by far, the most frequent and the most destructive.[1],[2]
The purpose of the present article is not to provide an updated review of the current literature on psychological trauma in children and adolescents but to show how psychoanalytical theoretical approaches contribute to the treatment of childhood trauma. They are still, indeed, seen as helpful in several regions of the world, considering successful case studies[3] and innovative research methodologies aiming at evaluating psychotherapies by trying to understand the mechanisms of their effects beyond the label of the theory to which they refer.[4],[5],[6],[7] One must also remember that psychoanalytic theories on trauma gave, more than 100 years ago, comprehensive explanations of the behavioral and affective symptoms currently considered central in children and adolescents psychological trauma.[1] Moreover, these explanations are generally consistent and compatible with the theories (and speculations) on which newer theories are based.[8],[9]
| Acute Psychological Trauma | | |
Acute psychological trauma can result from man-made or natural disasters in children and adults. It can also follow an isolated acute familial traumatic life event at all ages, particularly in children. However, children are often described as remarkably resilient to this type of critical situation when these situations are isolated and not followed by a persistent stressful life, i.e., one of us was consulted by an adolescent patient who, when newborn, remained trapped for several days beside his mother's dead body under the ruins of the maternity ward destroyed by the Mexico earthquake in 1984. Discovered more than 4 days after the event, he was considered a messenger from the infra-world traditional gods and miraculously protected by the Guadalupe Holy Virgin, the primary protector of the Mexican nation. He received an excellent education provided by rich and powerful devotees who adopted him; he developed well without any sign of traumatic disorder. At 18 years of age, he came to study in Paris; some months after his arrival, he showed some minor everyday adaptation difficulties for which he consulted on behalf of a Mexican colleague friend of his adoptive family. He was not showing any present or past signs of a posttraumatic disorder. We, therefore, adopted a nonspecific guidance type of consultations, focusing only on his actual adaptation to his new life at a distance from his family and with no reference to his very early psychological traumatism. Few sessions of such a nonspecific approach were enough for his light adaptation problems.
Nevertheless, acute psychological trauma symptoms are frequently observed in many other cases, although generally more common and less spectacular, with considerable impact and burden on the child. Several scientific articles have thoroughly described these effects.
The WHO SEARO[10] recommendations based on these findings show that these impacts and burdens are direct and indirect.
Direct: many pieces of evidence show that the immediate impact can be (a) normal acute responses to stress or (b) a psychiatric disorder. (c) Only a few articles discuss the risk of somatic disorders, but (d) most of them emphasize the frequency of psychosomatic disorders (Diagnostic Statistic Manual 5 Somatic Symptom Disorders[11]).
Indirect: many articles highlight the importance of indirect impacts on the children, resulting from the psychological trauma impact on the parents' and caregiver's mental and physical health and the parents' sensitivity to their children's needs. Disorganization of the attachment pattern and parental reflexive capacities (Fonagy et al.[12]) can account for these psychological effects and the long-lasting inadequacies they can induce in parent–children interactions. Several articles in this report (the post-Fukushima-Earthquake tsunami-affected population)[10] emphasize the importance of their consequences on younger children's early psychological and physical development.
Several types of impacts and burdens in this context
Classical acute stress responses
They associate emotional, cognitive, social, and physical reactions.
In preschool children, these reactions include a great diversity of symptoms: Irritability and excessive crying, intense fears, excessive dependency, excessive quietness, regressive behavior (such as reemergence of thumb sucking or bedwetting), temper tantrums, replays of a traumatic event, frightening dreams, and night waking, and psychosomatic manifestations.
In children of school age: The lack of attention and learning difficulties, expression of guilt, loss of interest, feeling of failure, anger, rage and aggression, low mood and anxiety, recurrent memories, the fantasy of being a rescuer, preoccupation with details of the event, reactivation of specific fears, abdominal pains, headache, vomiting, fainting, and rapid breathing.
In Adolescents: The same symptoms, with the addition of diffuse excitation and opposition, change in preferred relation, risk-taking, or alexithymia-like “nothing wrong” attitude.[10]
Psychiatric disorders
Quoted publications find significant correlations between acute psychotrauma and psychiatric disorders: Conduct disorders, anxiety and phobic disorders, depression, substance abuse, and posttraumatic stress disorders (PTSD).[11] However, the mechanisms underlying these correlations remain generally unclear or mainly speculative. For example, in the psychodynamic model of traumatism, acting, depression, repetitive fantasies, and obsessive thoughts can be seen as the last available solution to elaborate or discharge the excessive anxiety load generated by the stressful situation.
Somatic symptom disorders
Adverse effects of acute traumatic experiences on somatic health status are well-documented in adults but not demonstrated in children, with a striking lack of direct data. However, functional or psychosomatic expressions are frequent in childhood, especially in infants. They may be seen as the most distinctive way to express psychological distress or mental disorders, especially those due to inadequacies in parent–children interactions. There is, for instance, strong evidence that the children's physical health status is heavily dependent on the caregiver's holding and that acute psychological traumatic events experimented on by the caregivers negatively impact their holding capacity. There is also evidence that impaired early relations are risk factors for cardiovascular diseases later in adult life.[13]
Due to the numerous confounding variables, it is also challenging to know if this indirect evidence is explained by direct or indirect effects of stress in childhood.
Psychopathology
As mentioned earlier, Freud and psychoanalysis were the first to propose a systematic psychopathological theory of psychological traumas.[14] Moreover, the first stake of psychoanalytic theory was to establish the psychotraumatic etiology of neurosis. The base of this theoretical hypothesis is the psychodynamic stance that there is a psychological trauma whenever an event induces anxiety which load overpasses the usual processing capacities of the subject's psychic apparatus.
From a psychodynamic point of view, psychological trauma is indeed the result of a two stages process:
The first stage goes from the psychic disorganization following the traumatic event to the figuration of the event to give meaning to the catastrophic experience. In other words, the traumatized person (adult or child) builds a conscious or unconscious theory to explain what happened to him (why this way, why to him, and with what logic and purpose). This theory is a source of relief at that stage because it reorganizes the person's psychic life. However, it is simultaneously a source of suffering because it can induce conscious or unconscious feelings of guilt and persecution in the affected person.
The second stage goes from the figuration of the traumatic event to a process the psychodynamic perspective considers to be the working through of the conscious or unconscious meaning it has taken for the person. In other words, this second stage leads the person to give up or reconsider the figurations and intentions he gave to his psychotraumatism in the previous stage of the process, without denying it or forgetting it.
From this point of view, psychological trauma is then, always, a contradictory process, mobilizing the psychic life of the traumatized person far beyond the mere effects of the traumatic event, whatever destructive it has been.
This perspective describes specific psychic risks at each of the two stages of this process.
The first stage's failure can lead to the patient's traumatic disorganization with mental confusion and psychotic expression. This risk is more frequent in adults than in children, who, as we already mentioned, seem to be remarkably resilient to the direct traumatic effects.
The failure of the second stage leads to posttraumatic fixation of the traumatic explanation, favoring various expressions of PTSD or other anxiety disorders. The result of fixation is to focus the traumatized person's psychic life upon his persistent attempt to obtain concrete reparation of his trauma's alleged cause and condemning him/her to the endless suffering of not reaching this goal.
Impacting factors
This model is consistent with the findings concerning the factors impacting the consequences of acute psychological trauma in children. These factors are more related to the child's previous functioning and environmental resources than the type of traumatic event. For instance, the child's temperament and past (melting genetics and relational factors) are crucial to explaining the person's resilience capacities. It has to do with his abilities not only to bear an adverse life event but even to benefit from it, as in the numerous examples brought by Cyrulnik's book[15] and its evocative title (”This Marvelous Misfortune”).
Authors also insist on:
- The level of the child's actual fantasied responsibility in the occurrence of the traumatic event
- The influence of the family involvement in the occurrence of the event.
The child's developmental stage: more indirect burden in preschool children and extrafamilial events and more direct impacts with adolescents and familial events.
The type of traumatic event: Some data indicate that man-made disasters are more impacting on children than natural disasters, but it has not been thoroughly studied, especially in the current context in which media tend to stress man's involvement in natural disasters or natural disasters' consequences, reducing the differences between both types of tragedies (i.e., the postearthquake Haitian or Japanese disasters or even the COVID crisis).
As we already mentioned, convergent data show that traumatic psychological consequences on caregivers are crucial determinants of children's outcomes; some data also show the importance of social reparation, especially in man-made disasters. However, a balance has to be found to avoid a too strong fixation of representations in the traumatized person because it could jeopardize what we already mentioned as the second stage of the psychological process aiming to overcome the traumatic psychological experience.
Effects on caregivers
The famous Winnicott assumption: “there is not such a thing as a baby alone,” can be extended to older children and many adolescents. Together with immaturity, this dependency is the main specificity of childhood.
It is not surprising that much data indicates that, as Choquet et al.[16] put it: “when the family is all right, everything is all right, but when it is not, everything is not, and the school cannot achieve its educative aims.”
Therefore, how parents and carers work through their traumatic experiences is crucial for children and adolescents' outcomes. Everything affecting this elaboration can be considered a potential risk factor for them. For instance, in man-made disasters, the parents' fixation on a traumatic figuration can be consciously or unconsciously a way to resist the aggressors' destructive project and to deny the changes it has induced in posttraumatic life. In other words, an ultimate attempt to stop the time around the traumatic experience itself, reducing the parental capacities to invest their children's future and development.[17]
A substantial psychodynamic literature has thoroughly studied the transgenerational transmission between parents and their children, mainly in infancy. These studies have been reported in internationally famous publications: The Ghosts in the Nursery,[18] The Life Tree,[19] and the baby's relational constellation.[20]
Numerous works demonstrate the role of microbehavior and parent–child interactions in this transmission, directly or through attachment transmission.[21]
Specific situations
Two specific situations were mainly studied: The effect on children's development of psychological trauma experienced during their mother's pregnancy and postnatal depression in mothers. Animal models bring evidence of the adverse effects of stress on outcomes at birth and in their later biological and behavioral development. There are also some direct pieces of evidence of the negative impact on babies of maternal traumatic experiences during pregnancy.[22]
Articles also bring direct and indirect evidence of the negative effect of mothers' postnatal depression on children's development.[23]
Long-term consequences
Retrospective studies[24] have shown extensively that acute psychological trauma has long-lasting effects on children, directly through their impact on children and indirectly, mediated by the traumatic effects on their parents.
Several retrospective studies showed[25] that an acute psychotraumatic experience in childhood is a risk factor for somatic diseases (particularly cardiac and metabolic) in adulthood. However, there is no convincing data that acute psychotrauma in childhood may induce somatic disorders directly. Their retrospective methodology is another weakness of these studies. Comprehensive longitudinal studies are needed to assess these risks more precisely.
| Long-Lasting Psychological Trauma | | |
General description
They are the more frequent problem in childhood, generally intrafamilial. Long-lasting psychological trauma can take various forms: from neglect to abuse through physical or psychological mistreatment. In general, less visible than acute psychological trauma, they can still have very negative consequences on the child's development, directly (on the child's physical and psychological health) or indirectly (through the impairment of attachment and self-esteem). Their long-lasting somatic consequences are well documented,[26],[27] explaining symptoms such as failure to thrive, and are generally considered a risk factor for many systemic diseases in adulthood (particularly cardiac diseases or dementia).[27]
Nevertheless, mechanisms underlying these correlations remain widely debated due:[28]
- To the number of confounding variables with other familial dysfunctions
- To the possibility of an effect of transgenerational transmission of acute psychotrauma
- To the frequency of such long-lasting trauma in the past of patients with antisocial and borderline personality disorders and individuals with hyperviolent behavior, raising a nature–nurture controversy.
Physiopathology
Among the psychological mechanisms underlying these effects, growing importance is given to the impact of disorganized attachment, that is to say, the disorganized pattern of the primary relational system, Bowlby[29] described in humans, as described in animals, is constituted by all the behaviors favoring the baby's proximity to his central attachment figure (generally his mother). For Bowlby, this system is implemented during the baby's 1st year based on his innate needs. Still, this attachment pattern results from an interaction between the baby and his mother, creating an internal working model of mental representations built on this innate and interactive behavioral system. Psychological traumatism in children, as in mothers, affects this construction, disorganizing the child's attachment pattern and inducing long-lasting effects on the way the child builds up his representation of the relation to others and, finally, their intersubjective development.
Other authors insist on the consequences of cognitive and intellectual impairments induced by such long-lasting traumatic behaviors based on affective, cognitive, or behavioral responses triggered by cerebral alterations.[26]
| Therapeutic Consequences | | |
For acute psychological trauma
In the immediate aftermath of an acute psychotraumatic experience, it is first necessary to help the child build his figuration of the event and then work it through. In general, this means favoring the children's verbalization of fear, guilt, or questions about the event or their meaning and values as much as possible.[10]
In most cases, there is a need for parallel work with the parent's psychotrauma with the aim:
- To improve their social condition
- To help them to work through their traumatic figuration of the event
- So that they can give enough attention to their children's psychological and physical needs.
In a man-made disaster, this may require solid social reparation of the event:
- To free the person from the conscious or unconscious obligation to stop the time at the moment of the traumatic event's onset in what some authors consider an attempt to avoid forgetting it before its sufficient social recognition and reparation And to diminish the risk of an abusive conscious or unconscious fixed figuration favoring the occurrence of PTSD and the transgenerational transmission of the trauma.[19]
In long-lasting psychological trauma
The first obligation is to end the child's exposure to mistreatment and long-lasting stressful familial situation. This may require a separation from the family if there is a persistent risk of mistreatment or neglect and if the family refuses social protective and preventive assistance and control.
There are, of course, intense controversies on what next: Maintaining separation until the majority or reducing it to the shortest length possible, limiting it to the most critical moments of family life. In this fierce debate, an important issue is monitoring the quality of the protective institutions and the availability of specialized resources to address familial dysfunctions.
Psychotherapies
In acute and long-lasting psychological trauma, psychotherapeutic approaches should be proposed whenever available and accepted by the child and his family. It can take various forms, from speech therapy for the oldest to drawing and creative therapy for the youngest. Family therapy, group therapy, and psychoanalytic psychodrama can be very efficient options but are expensive because they need very skilled therapists.[30]
| Conclusion | | |
Acute and long-lasting psychological trauma can severely affect children's mental and physical development.
Due to the specific dependency of children and adolescents, indirect impact and burden through the carers play a significant role in trauma on children. Consequently, social and therapeutic efforts to address and reduce this indirect impact of psychotrauma may be, by far, the most decisive action to improve affected children's physical and psychological health status.
Treating family and caregivers is then particularly important for children, as much for those directly exposed to the psychological trauma and those exposed to the transgenerational transmission of its psychological consequences (particularly the parents' fixation on their traumatic figuration of the traumatic event).
It is, therefore, a social and public health issue, mainly when referring to the WHO definition of health, with long-lasting mental, physical, social, and cultural consequences.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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