Introduction:
“Taking into account the near and distant consequences” of emotional deficiencies and serious negligence is no longer a preoccupation of researchers and clinicians in child psychiatry. The spread of Spitz and Bowlby’s work in the post-war years, the proliferation of studies in the United States and Europe in subsequent decades, the resulting shifts in placements and communities of The illusion that only a few Romanian orphanages are still concerned. This optimistic view, however, is tempered by the description of various forms of “intrafamilial hospitalization”, the persistence of multiple placements and the observation of a certain “failure of child protection”. It is therefore important to define the present forms of affective deficiencies, to know their manifest semiological expression according to the age of the child and to define their contours in the light of recent knowledge about early interactions and To better understand the circumstances of the infant. It is then necessary to contrast the clinical manifestations directly related to the sudden interruption of affective relationships to psychic, relational, somatic, instrumental or behavioral disorders correlated with the various forms of long-term deficiency. Prognostic uncertainties are due to the resilience of some children where others remain forever impeded by pathological organizations of their personality. Only a thorough psychopathological discussion makes it possible to adjust the therapeutic responses and the preventive measures to be implemented.
From the emergence of the notion of affective deficiencies to the current definitions:
It is first of all a careful observation of the reactions of very young children placed or hospitalized for long periods, the description of the inevitability of their distress despite the care provided, and the observation of the risks of serious evolution for some, Which reveal the vital role of maintaining privileged links with the mother during the first years of life. Thus, while the contributions of psychoanalysts are multiplying on this subject, the clinical picture of anaclitic depression and the theory of attachment impose themselves in the middle of the last century.
Retrospective studies aiming to establish links between psychopathological disorders of the grandchild and early deficiencies, supplemented by some prospective and comparative studies, tend to demonstrate in the long term the detrimental impact on the emotional or cognitive development of the lack of anxiety, Emotional intake. Beyond the reservations formulated on the methodological level, the results of this research are relativized, despite the multiplicity of parameters at play, which make longitudinal assessments random, more attention is paid not only to the suffering caused by the lasting or repeated premature loss of The object of love, but also to the deleterious effects of an inconsistent or inconstant “maternal” investment.
In a World Health Organization (WHO) publication, published in 1961, Ainsworth reports on intrafamily deficiencies caused by poor interactions between mothers, who themselves suffered from early deficiencies, and their infants De facto neglected, or even quasi “abandoned at home”. Only the gross forms of neglect that are also reflected in a lack of physical care are easily identified by the maternal and child health teams. It could be one of the most frequent aspects of child abuse. However, the urgency of responding to the infant’s physiological needs may sometimes leave his / her relationship needs seriously unmet.
Nevertheless, we can not favor a purely quantitative approach to the problems raised by emotional deficiencies, which can also result from a lack of adjustment and even from relational distortions. The devices for observing early interrelationships, by demonstrating the baby’s great sensitivity to minor shifts in the maternal response, artificially produced, confirm the decisive importance of the quality of the exchanges. It is necessary to know how to be attentive to the signs of appeal that testify to the child’s inadequacies and defects in the adjustment of maternal functions.
Semiology of affective deficiencies:
Warning Signs in Infants:
Signs of alert in infants are now well known to early childhood clinicians. It is often the persistence of a poor general state which makes actively seek other signs of appeal. Stagnation of the weight curve, sensitivity to otolaryngologic infections (ENT), inappetence, vomiting or diarrhea, such as sleep disorders, give the child an unattractive illness. The psychomotor retardation often associated with stunting is in fact underestimated if the age of the child is not taken into account.
Hypotonia is almost constant, except for the upper part of the body. There is often tension in the muscles of the neck and arms, clenching of the fists on the thumbs, a lack of grasping of the objects made available or a refusal to let them go. Spontaneous motility and babbling are poor and rarely used to mark, as in most babies, opportunities for shared pleasure. The relational withdrawal is expressed by a mimic “void of expression”, a weak reactivity in exchanges, a lack of initiative in situations of joint attention and a passivity to the solicitations or the distance of others. The child seems to favor, to the detriment of playful interrelations, self-centered motor habits, such as stereotypies, rhythmic oscillations of the body, sad suction of the thumb and monotonous masturbatory behavior.
Relationship Signs in the Larger Child:
“Relational” signs are at the forefront of the larger child. Emotional greed is often evident. Immediately develop passionate attachment behaviors towards any adult with a little interest, which is naturally the case in a consultation situation. The “deficient” child establishes from the outset a bond of familiarity, seeks to touch the consultant, to cling to him, to imitate him, to seize his attributes, or to interfere in his private sphere. This exacerbated sensitivity is translated, on the contrary, by an intolerance to frustration, sudden reversals of mood, aggressive manifestations, oppositional behavior or hostility displayed towards the person initially over-invested. He does not pay as much for criticism as for compliments and attacks his “failed” productions as much as those deemed successful. The neglect of his body and his own interests contributes to accentuate his situation of great emotional dependence. Little concerned about its appearance, its presentation is often neglected, especially since it seems to ignore the possible occurrence of enuretic or encopretic accidents. He shows himself disorderly, disperses or breaks up his toys, forgets his personal belongings, but collects heterogeneous objects recovered without the knowledge of his relatives. His clumsiness and his perilous or untimely undertakings occasioned repeated disappointments and multiple reprimands. The maintenance of regressive behaviors of satisfaction also provokes the reproaches of the entourage.
It is this lack of self-esteem and self-awareness that could constitute one of the most reliable indications of orientation that would prompt the consultant to try to explore the shortcomings or vicissitudes of mothering that have permanently marked the ” Overall development of the child.
Main maternal functions which may be missing in the case of an affective deficiency:
The various “relational” functions that the mother ensures from the beginning of life must be maintained, while evolving very gradually as close as possible to the mature changes and critical moments that the child can experience during his first 3 years. In the case of relational deficiency or neglect, the child is dangerously deprived of some of these functions, which he has not yet been able to internalize, functions indispensable to the construction of his emotional security, as well as his psychic space And its first social connections.
Maintenance function:
The function of maintenance, support, and shoring defines the solidity and reliability of the maternal presence: it is manifested by physical availability, immediate accessibility; It offers a frame of reference, permanence, resistant to attacks and tests: it is “the mother who survives”, whose child can verify integrity and indefectibility. This function is not called to evolve qualitatively, and it is the mother’s unconditional acceptance of being used by the child that would allow an internalization of this support and a less frequent direct recourse. This maintenance function, which is sorely lacking for the child in case of untimely separation, persists in situations of intrafamily deficiency.
Capacity function:
The capacity function is more complex if one takes into account the double aspect of container and “container” that it contains. The function of maternal envelope is to be understood as an emotional availability, a sensitivity to manifest or latent affects, a tolerance to drive movements, a capacity to protect the child from excess excitations, a careful, calming and predictable presence …
The container function is similar to the alpha function linked to maternal reverie, transforming into thought the sensations-emotions that torment the infant.
Stern uses the term tuning to denote this ability to reflect by an expression, an attitude, a gesture, the emotional state of the child. This response is not a mere imitation, but a mimogestrictive interpretation that reinforces “putting into meaning” by words. There would then be a necessary corporeal commitment of the “spokesman”: a playful and just verbal commitment contributing to the development of the illusion space, transitionality … but it is important that this transformative function adapts to the project of The child, opens it to more evolved modes of expression, to a wider relational and cultural field. It is up to him to place and introduce the paternal referent, to promote other modes of exchange. This dual function, which plays an essential role in the psychic organization of the child, rests on the active participation of the mother, and it can be imagined how various forms of maternal unavailability may compromise its exercise.
Self-individuation function:
The function of individuation of the Self presupposes the maternal concern to refer to the child a unified image, the concern to reinforce one’s own identity by appreciating his or her exploits or generosity, encouraging his efforts of autonomy, testifying to his progress, By recounting his daily life. To these statutes of “manager” and chronicler is added that of historian, through which the mother contributes to weave the temporal frame, to inscribe the child in the succession of the generations. We can conceive how this function must be evolutionary: it helps to reinforce in the child the pleasant feeling of being a unique individual, while the demands on him are increased even when they are signified positions to be surpassed , Goals to be attained, models to be matched … Even more than the previous one, this function is accomplished only by reference to a symbolic third party and risks, whatever its competence, to seriously fail the child in case Institutional deficiency or intrafamily neglect in the fertile moments of early development.
Differential Vulnerability of the Deficient Child:
The sensitivity of the very young child to the loss of his favorite object of attachment between 6 months and 2 years was widely emphasized. We know that his reactions of protest and sadness will be all the more vivid as his previous relations have been satisfactory. It seems that the very quality of her relational experiences will also help to mitigate the risks of psychological disorganization that more severely threaten those who, before separation from their mother, have not sufficiently benefited from her capacity of capacity and individuation Of the Self. The little-invested baby is “disinterested” in the world around him, “no longer launches messages to induce interest, the pleasure of the adult” responsible for relaying maternal care. It is not excluded that the poor quality of the very first mothering also contributes to reinforce certain traits of temperament that do not facilitate the adaptation of the child to its environment.Irregular biological cycles, shrinkage responses to novelty, slow adaptation, and negative and intense emotional reactions that characterize a difficult temperament make the child less able to cope with shortcomings and defects in fitting His relatives, who, in return, feel little rewarded or incompetent. The excessively strong incompatibilities between the temperament of the child and the disappointed expectations of his mother and the resulting difficulties of reciprocal adaptation might provide some insights into the great diversity of evolution in subjects who appear to have been subjected to Deficiencies or negligence. Similarly, premature babies or those suffering from sensory impairments or organic affections are necessarily more vulnerable to changes in environment or the indifference of their caregivers.
Circumstances of the occurrence of the deficiency:
Institutional neglect and neglect:
Deficiencies and neglect in institutional settings are best known. They are primarily attributed to the absence of the mother, but also to the insufficient stability of the maternal substitutes which exposes the child to incessant breaks in connection. Despite the precautions taken in the nurseries to facilitate privileged exchanges, babies remain alone most of the time, can live “long periods of uncomfortable discomfort” or “move from a relational desert to over-stimulating manipulations that” They can neither understand nor anticipate. “ Opportunities for shared pleasure, playful complicity, and tuning are too rare. Caregivers sometimes protect themselves from their own emotional investment by absorbing themselves in material tasks. David and Appell insist on the multiplicity of factors of affective deficiency in the community, factors which are organized in “circular systems of interactions in which they tend to generate” and reinforce each other to form a resisting whole Change efforts. Transitions from one unit to another, hospitalizations, failures of “home” returns, or breaks in family placements, confront the child with drastic changes in interactive styles to prejudicial changes in his or her benchmarks, Possibility to rely on secure attachment links. Even closely accompanied by their parents, babies who must stay for long periods in neonatal resuscitation or in highly specialized care units, are subjected passively to “deviant sensory experiences”, to sudden and unpredictable variations in the level of stimulation, To a succession of bodily experiences that necessarily overflow their capacity for integration. The constraints of functioning of the medical-technical world in the face of vital stakes impede the relational implication of the parents who, in such a context, find it difficult to ensure that their child acts as an excitation and a transformer of sensations.
Emotional deficiencies in the family environment:
Emotional deficiencies in the family environment are often difficult to appreciate when serious neglect is at the forefront of the concerns of social workers who often “gravitate” in vain around “multiple problem families” from very disadvantaged backgrounds. The babies, immersed in a chaotic world, are, of course, often carried in their arms, kept in close contact with their mothers, but this physical proximity is rarely accompanied by a psychic availability towards them. Depending on the material hazards, the relational reconfigurations, the chance of “falling points”, these children are frequently entrusted to passing adults for indefinite periods. This relational discontinuity is often aggravated by temporary or repeated hospital stays. Negligent mothers also have fairly high depression scores. This additional factor of risk of affective deficiency is largely highlighted by recent works that demonstrate the sensitivity of babies to variations in mimic expressions of their mothers and the negative impact of maternal suffering on the quality of interactions. Comparisons with control dyads make it possible to objectify the “difficulties of mutual adjustment” in depressed baby dyads, which do not seem to affect the children’s “communicative profiles” and attentional processes.The fluctuations in the mood of mothers who are crossed by abandonment anxieties or archaic fears also expose their babies to discontinuities of emotional investment that aggravate even more disturbing disturbances of the mother-child bond.
Clinical expressions of the suffering of the child subjected to an acute deficiency of his privileged affective ties:
Reactional manifestations directly caused by separation:
The reactional manifestations directly caused by the separation are well known since the work of Spitz and Bowlby.The phases of protest and despair are commonplace in children aged 12 months to 3 years “far from the maternal figure to which they are attached and placed with strangers in an unknown place”. No one can remain indifferent to the disarray of young children placed at this age, and manifesting in “body and cries” their distress, in which anguish, anger and grief mingle, and which can deploy a fierce energy to recover their object of attachment.
“The evil of placement” described by David is more or less marked according to the age of the child, and the insecurity that he has experienced since his birth. But at the age of 16 months, a child seems to be able to preserve the image of a missing parent and to periodically reactivate the memories of the well-being experiences associated with it. Indeed, for several weeks, the child often alternates moments of anger and sadness, and manifests his suffering through his regressive behavior or active opposition to the educational requirements of the adults responsible for supplementing his mother’s absence.
Short-term sequelae:
Short-term “sequelae” are usually not very marked after reunion with the mother or the investment of another attachment figure that is sufficiently reliable and available. Beyond a sensitive period of a few days, brutal experiences of separation may, however, predispose the child to develop an anxious and ambivalent mode of attachment, or even suffer from a more or less disabling separation anxiety.
Long-term sequelae:
Long-term “sequelae” are more hypothetical. Psychiatric morbidity would be higher among adults who had experienced mourning during childhood, but other pathogenic factors were likely to increase the fragility of the subjects.
Clinical manifestations related to an insidious and lasting affective deficiency:
The registers of expression of a suffering most often torpid are multiple and hardly systematizable. However, affective or somatic disorders are to be understood as warning signs that directly testify to suffering, whereas behavioral or behavioral disorders are mainly used to measure the harmful consequences in terms of sociocognitive development and the construction of the personality. Certain expressions are more or less convincing according to the age of the child, the nature and the duration of the deficiencies undergone.
Emotional disorders:
Affective disorders are still present in younger children. Anxiety often results in demands considered excessive, fears of abandonment, an exacerbated vigilance with regard to the acts and actions of their entourage, a need for proximity with the adult who compromises any autonomous initiative.
In almost 75% of cases, neglected children would develop an anxious / ambivalent attachment style.
The thymic atony, motor inertia, interactive withdrawal and psychosomatic disorganization that characterize the infant’s “white depression” for Kreisler are also the main symptoms. The same goes for the “empty behavior syndrome” occurring during the second year, in an emotional “desert” context where, on the same background of apathy, moments of excitation and motor instability occur . These different modes of relational withdrawal, which, if they do not respond to the privileged partner, touch the foundations of the Self, do not constitute a real depressive response, presupposing a painful interiorization of loss by a constituted Self. The usual “emotional sequel” of these pathologies of emptiness, when they were able to be revived by new relational openings, is for Soule “a tragically masochistic compulsion to claim affection within intolerable limits for the entourage”.
Somatic manifestations:
Somatic manifestations are obviously one of the major components of these syndromes belonging to the pathology of the relational vacuum. However, anorexia, weight loss, sleep disorders, repeated infectious complications are also indicators of severity. Widespread signs of undernutrition or dehydration have not aroused the concern of the entourage, the rapid resolution of symptoms through hospital care, and the flattening of the back of the skull naturally lead to neglect.
But psychosomatic disorders, such as merycism, stunting, or even psychogenic dwarfism, which are spectacularly reversible due to a change in the emotional environment, are more particularly evidence of the extent of physical dysfunction Link with the dysfunction of early interactions. The frequent persistence of gluttony or sphincter disorders in placed children can also, in this perspective, be understood as a “residual” sign of affective deficiency.
Instrumental and cognitive disorders:
Instrumental and cognitive disorders, which are almost constant in such a context, are sometimes regarded as mere developmental delays that the child will be able to compensate for, provided he / she benefits from a more favorable living environment.
Joint, speech and language delays:
The articulation disorders, speech and language delays, which are more or less marked, are generally part of a series of more profound disturbances in communication, as evidenced first by the scarcity of visual contact or by the poverty of expressions Sound or mimogest. Specific learning disabilities may result from this.
Cognitive delays:
Cognitive delays that are easily “quantifiable” would be proportional to the duration of the deficiency. A difference of several months between mental age and real age affects nearly 70% of babies raised in adverse conditions. The progress of the overall efficiency in the case of positive evolution sometimes obscures the maintenance of a dysharmonic intellectual functioning, of disorders of reasoning or of archaic processes of thought.
Psychomotor Difficulties:
The psychomotor difficulties, often less apparent, are reflected in disorders of the tone and coordination, a certain clumsiness but especially by a often lasting defect of the temporospatial organization. For a long time, there is often a weak capacity to be in a time frame, a psychomotor instability, or even some rhythms of falling asleep.
Behavioral disorders:
Behavioral disorders manifesting at an early age are often more pronounced in older children and near puberty.
Conduct of global inhibition:
The global inhibition pathways sometimes prolong the motor deficiency of the deficient infant. The children working on this register remain passive, withdrawn, unable to assert themselves, to take an initiative or to satisfy their curiosity.They sometimes show themselves hyperadapted to the expectations of the adults to which they submit in a constant search for approval.
Opposition conducts:
Particularly frequent opposition behaviors at about 2 or 3 years of age in children who are under-supported in the critical phases of their separation-individuation process are sometimes permanently established in the form of an “oppositional defiant disorder”. Intolerance to frustration, the need to grab the attention of others, the feeling of never being taken into account that testify to the lack of healing of narcissistic wounds, provoke inevitable anger Self- and heteroaggressive manifestations.
Antisocial Conduct:
“Antisocial” behavior often completes this array of clumsy emotional demands. Flights, fugues, fabulations, insults, deterioration, cruelty with animals, various assaults carried out without regret risk engaging these children, managed to deny their deep suffering, on the way to delinquency.
Uncertainties in prognosis: severity criteria and protective factors
The question of a complete reversibility of the disorders in relation to an affective deficiency remains. Even in the absence of residual symptoms, the development of a secure mode of attachment is not common.
Severity criteria:
Several severity criteria have been identified and each agrees on the pejorative nature of early (pre-1 year) and prolonged (over 6 months) deficiencies, accompanied by multiple ruptures, severe neglect, sexual abuse Or various forms of relational distortion.
Protective factors:
On the other hand, the protective factors would be the quality of the first links and, above all, the substitution of “resource” persons to ensure that the child has a minimum of continuous emotional investment. As Soule insists, it becomes, in the long term, random “to attribute to the only deficiency the aetiology of the disorders observed, for the complexity of the evolution of development and conflicts does not authorize causal simplicity”. Other environmental factors interfere with inflecting the child’s skills in a positive or negative direction. Other relational breaks, the lack of support in hardships or at the time of the “adolescent passage” sometimes help to reactivate a sense of loss that seemed forgotten. On the other hand, it is sometimes sufficient that only one point of support is offered to prevent collapse.
Cyrulnik recalls that in Spitz’s study, of the 123 infants deprived of their mothers, 81 of them showed no trouble.Probably due to easier temperament and better emotional security, these children were able to take advantage of the rare opportunities for emotional exchange with adults at the time of care. Finally, many unknowns remain concerning the neuroendocrine and neurochemical implications of early deficiencies. Studies in primates, however, seem to show the existence of long-lasting perturbations of the serotonergic system of young Rhesus monkeys deprived of their mother.
Impacts of affective deficiencies on pathological personality organizations:
Limit pathologies:
Borderline pathologies could constitute a major evolutionary risk for children who have suffered serious defects in their emotional environment. This is certainly not a sufficient condition, given the resilience shown by some.
A number of them, particularly marked by the accumulation of disruptions in their emotional ties, are caught at random by bad encounters in the cycle of transgressions, addictive behavior or delinquent acts.
Some young girls, who have become prematurely mothers, risk, for want of a model of capacity, to disinvest their baby very quickly and thus reproduce the emotional deprivation they have undergone in the next generation.
Other personality organizations:
Other personality organizations are less directly concerned with the potential etiopathogenic role of emotional deficiencies. However, it is not excluded that separations, mourning or various forms of parental unavailability may be at the origin of the depressive sensitivity of otherwise well-structured neurotic patients. Some very early deficiencies are sometimes responsible for spectacular withdrawal reactions and stereotypies suggestive of an autistic syndrome, but the rapidly favorable evolution thanks to the capacity of the caregivers makes it possible to rule out this possibility.The discussion is more open for some tables of serious evolutionary disharmonies occurring in an evident context of early and prolonged affective deficiencies. Finally, the backwardness of intellectual development that is frequent in the “institutional” deficiencies naturally led to fears of a risk of organizational deficit, which is also only present in the case of severe and lasting deficiencies.
Psychopathological Discussion:
The theoretical debate between Spitz’s conception of the loss of the libidinal object and that of Bowlby on the loss of the object of attachment has lost its relevance with the many works exploring the complexity of early interrelationships.As we have seen, the infant may suffer from an affective deficiency without being physically separated from his mother if he does not sufficiently benefit from his capacity of countenance.
Above all, it is the absence of mutuality in exchanges that could lead to “primary narcissistic undernourishment”, to prevent the elaboration of the depressive position and to compromise the work of psychic separation on a long-term basis. The result would be a profound insecurity for these “deficient”, “abandoned” or “limited” children, a persistent difficulty in delimiting a psychic space of their own and, in fact, the maintenance of a parasitic-type psychic economy, which always seems ” In derivation “from that of others.
Therapeutic measures:
Recognition of the suffering of the child:
The recognition of the suffering of the child in its various modalities of expression is a determining therapeutic first step. The absence of distress manifest in the torpid forms of deficiency may nevertheless underestimate the clinically less obvious consequences.
Strengthening and qualitative improvement of the relational offer:
The reinforcement and the qualitative improvement of the relational offer do not arise in the same terms in the family environment as in the institutional milieu. It is important first of all, when conditions permit, to try mother-infant psychotherapy to restore mutuality of exchanges. But the seriousness of the situation of deficiency or neglect may impose placement to protect the child.
However, this measure of social or judicial separation is not therapeutic in itself. In such a context, the child must certainly benefit from a mothering that is adapted to the nature of his suffering and to the particularities of his defensive arrangements, but also to a system of listening, accompaniment and care.
Family therapeutic care services, specialized kindergartens and various group psychotherapies are some of the adapted responses to the coordinated management of these complex situations.
Preventive measures:
Fight against the factors of deficiency within the structures of reception:
The fight against the deficiencies in childcare has undoubtedly borne fruit.
The staff of the nurseries, warned of the risks incurred by the children placed, strives to develop a “privileged, stable and reliable relationship” with each one of them.
The interest of individualizing each baby by valuing its spontaneous activity was particularly demonstrated by the work of Emmi Picler at the Loczy Foundation. The presence of psychologists trained in the observation of the newborn with the teams of care early is very often useful to better “think baby” in the long term.
Preventive interventions for “families at risk”:
Preventive interventions with “at-risk families” remain difficult to implement, despite the efforts of the PMI services and home support systems. Mother-infant psychotherapies have, however, been attempted in families with multiple problems. A positive identification with a therapist, sometimes aroused by the weekly sessions of home infant observation, opens up promising prospects. Aid for parenthood can indeed bear fruit in the case of a genuine alliance, but it must be admitted that there is sometimes “a risk of desperation to want a mother-child relationship to be established” While everything demonstrates that this project is doomed to failure. Some advocate preventive action among young couples, and even adolescents as future parents. A certain amount of psychological work seems possible with “difficult” adolescent girls, thanks to the changes that take place at the time of their access to parenthood.
Conclusion:
The delimitation of the field of emotional deficiencies and serious negligence remains difficult as everyone agrees on the potential gravity of their impact on the child’s overall psychic organization. Therefore, it is necessary to know well the various registers of expression of the suffering induced by a loss or a lack of mutuality in the early interrelations, to try to palliate them as quickly as possible.
As Cyrulnik points out, “the future is less bleak when we have around the child some development tutors.” It is necessary to do so without delay so that he has every chance of becoming a full grown adult and an attentive parent.
