Introduction:
Historically, the concept of child maltreatment only appeared late in the literature: whereas in Greco-Roman Antiquity the father had the right of life and death over the children and that, in the Middle Ages, the child remained conceived as A being completely shaped by his education, it was only at the end of the 19th century that his rights were envisaged. It was in 1860 that Ambroise Tardieu, professor of forensic medicine in Paris, made the first clinical description of beaten children, but it was not until 1887 that a law prohibited the corporal punishment of schoolchildren and 1889 for the protection of children Abuse (pardon and forfeiture of parental rights). The State then creates a number of professional institutions and functions to protect the child (in 1912, special juvenile judges, in 1943, the Social Assistance for Children Judges and juvenile courts and maternal and child health centers [PMI]). Later, the Act of 10 July 1989 on the prevention of ill-treatment of minors and the protection of children, renders perpetrators of criminal offenses punishable, together with an international convention on Rights is drafted by the United Nations. This emphasizes the need for physical and moral protection of the child. Since 1994, aggravated sentences have been provided for abusive people with authority over the child.
Clinically, Kempe and Silverman describe precisely the syndrome of beaten children in 1962.
General Definitions:
The law does not define child abuse, presumably because there is an evolution over time and cultural contrasts in education. It is not always easy to mark the limits between parental care (education) and abuse. The National Observatory of Decentralized Social Action (ODAS) nevertheless proposes a definition of abuse: “The abused child is the victim of physical violence, mental cruelty, sexual abuse, gross negligence with serious consequences on its development Physical and psychological. “
In order to develop preventive actions, it also defines “the child at risk”: “Whoever knows living conditions that may endanger his or her health, safety, morals, education or Which is not, however, mistreated. “
Type of Abuse:
Physical violence:
It can result in more or less severe sequelae, or even the death of the child, and is evidenced by lesions (cutaneous, visceral, etc.).
The elimination of a differential diagnosis (accident, constitutional disease, etc.) is often not immediately obvious.
Deficiencies in care and neglect:
This is the non-satisfaction of the child’s physiological needs (drinking, feeding etc.) and / or emotional (parental love, protection from danger, etc.).
It can lead to behavioral disorders as well as developmental disorders (psychogenic dwarfism, etc.).
Mental Cruelty:
The ODAS defines it as “repeated exposure of a child to situations where the emotional impact exceeds the psychological integration capacities: humiliation, verbal or non-verbal, repeated verbal threat, systematic marginalization, systematic devaluation, excessive demand Disproportionate to the child’s age, contradictory or unenforceable instructions and instructional instructions “. In most cases, it causes developmental disturbances. However, there are few reports of this high level of maltreatment (11.7% of US mistreatment in 1984) because it is difficult to assess.
Garbarino describes five types: rejection, ignorance, isolation, terror, corruption.
Epidemiology:
Frequency:
The frequency of maltreatment remains difficult to assess due to the vagueness of the definitions. The numbers are increasing, probably because of the better detection of abuse than because of its real increase.
This better identification is linked to several factors: first, the rights of the child are increasingly affirmed; Second, the reduction of morbidity and mortality from somatic diseases, thanks to advances in medicine, has highlighted the importance of maltreatment morbidity; Finally, the officialization of the collection of data by the 1989 law (annual publication of the ODAS activity reports) centralizes the figures while the creation of the National Telephone Service for Child Abuse (SNATEM), The mobilization of professionals and the population allow for earlier diagnosis. The recent French figures are given in table I (sources: ODAS, National Institute of Health and Medical Research [INSERM]). Maltreatment is also a universally widespread phenomenon: in the United States, for example, the National Center on Child Abuse and Neglect in 1994 counted 1 million children abused by their parents. A particular situation remains little studied, that of violence in institutions: in 1996, however, they accounted for 5% of the 20,000 calls handled by the Seine-et-Marne toll-free number.
Factors of vulnerability:
Parents:
The presence of parental psychiatric disabilities and / or pathologies results in increased frequency of abuse or neglect of children. These may include puerperal psychoses or schizophrenia (delirium neglect and violence), melancholic depression (altruistic suicide), paranoid delusions (Münchhausen by proxi syndrome, violence linked to delirium), perversions, psychopathic personalities (Non-guilty emotional control).
Alcoholism or drug addiction, associated or not with the aforementioned pathologies, further accentuate the risk, such as the presence of serious medical problems. However, the majority of maltreated parents do not have a proven psychiatric pathology. On the other hand, 30% were themselves maltreated in childhood. Many have undergone multiple investments.
Pregnancy and postpartum:
It is recognized that unwanted pregnancy (especially in the event of a voluntary abortion request [abortion] not met), poorly invested (eg unwanted twins), or even denied, or accompanied by complaints Continuous somatic, remains a vulnerable factor to come for the baby. It is also worrying to see no physical preparation for the child’s arrival (apart from cultural reasons). Particular attention will also have to be paid to mothers who have difficulty resting, who have been constrained by a threatened preterm birth and who express negative views about the baby at the outset.
Of course, any psychiatric episode during pregnancy (attempted suicide, delusional or depressive episode) will have to alert, as well as a prolonged postpartum depressive state or fatigue linked to maternal isolation (after a For example, low-assisted multiple pregnancies). Situations where the mother quickly expresses an abnormal expectation of the baby, or projects its aggressiveness on the child as soon as the child cries (“he does not love me”), are also situations at greater risk.
Child:
From the first months of life, the fact that the real child is too far away from the imaginary child is also a factor of vulnerability: prematurity; Low weight ( < 2500 g); Early pathologies leading to mother-baby separations; Congenital or acquired and / or psychiatric somatic disorders; Child at the birth of the imaginary child (gender, family reactions, mourning during pregnancy). The child’s place in the family may also refer to him as a potential persecutor (adulterine child, unrecognized child, replacement child, unwanted twin). Finally, outside adolescence, adolescence remains a period in which the resurgence of the Oedipal conflict and the parental aging more or less well supported accentuate the risks of maltreatment.
Siblings:
A history of suspicious or unexplained sudden death, placement and / or proven maltreatment in siblings is also a factor of vulnerability.
Social factors:
Families with a single parent and / or a very young mother, a disadvantaged environment (unemployment, difficulties or lack of housing) are more likely to be found, and more or less absolute family isolation (no recourse to an external third party). Recent transplantation, recent bereavement and abandonment of the spouse during pregnancy are also more frequent in the families of abused children.
Clinical diagnosis:
The practitioner will have to collect a set of data, which requires his participation in a multi-professional network (school, social sector, PMI, judicial sector, etc.). However, it is sometimes difficult to distinguish between “deserved” punishment and maltreatment. A French Institute of Public Opinion (FIFG) / Journal du Dimanche (16 November 1994) survey showed that parents classified the educational punishment earned by children in the following order: 73%, TV ban ; 61%, banned from going out and seeing friends; 47%, spanking; 24%, deprivation of dessert; 14,% slap. These figures showed a net increase in corporal punishment compared with 1982, especially among mothers, as if paternal law was increasingly lacking, these rigidified their educational attitude. If the diagnosis of maltreatment is fundamental because of the urgent protection of the child involved, it is dangerous to carry it out hastily without sufficient data, which can lead to real family disasters (parental suicide, Etc.). In Canada, in an attempt to help the practitioner, a Child Well-Being Scale has been in use since 1986. This scale has been validated and translated into France (Inventory of Child Well-Being In relation to the exercise of parental responsibilities “): it appears stable and faithful. It sets a threshold intervention profile in a legal context and assesses the situation of the child and his / her family.
It is important to see the child alone, to let him express himself by drawing if the words are too difficult, to put him in confidence, while remaining very clear on the role of protection of the doctor (he will not be able to keep The secrecy with regard to serious acts suffered by the child). It is preferable to avoid repeated expertises during which the child ends up feeling in the position of accused, as well as to limit the number of speakers with the child. He must be advised that he may be assisted by a lawyer.
Physical signs of active maltreatment:
Skin lesions:
These are visible abnormalities, often a sign of appeal for deeper lesions. The practitioner must correlate with what is reported as a cause (accident, etc.), nature, type of injury, age and motor possibilities of the child (possibility of movement, etc.). He must then prepare a dated, documented (photographic) and precise (location, shape, size, color) descriptive account that will serve as proof for the judges and the possible juries. It could be :
– injuries related to the weight or force with which a blunt instrument (excoriation, ecchymosis, hematoma or contused wound) is used, maltreatment being immediately evoked in the case of coexistence of bruises of different ages with localizations ( Buttocks, genital areas, cheeks, thighs, thorax, neck) or forms (reproducing that of a particular blunt instrument);
– wounds by sharp instruments (wounds often in the form of a linear slit) or sharp (linear wounds with sharp edges);
– absence of care for a long period (general dirt, ectoparasitosis, repeated skin infections, abscesses, impetiginized dermatoses);
– alopecia due to deficiency or removal (which, unlike trichotillomania, does not remain circumscribed to temporoparietal regions);
– bacterial skin infections caused by regular subcutaneous injections of substances (fecal matter, etc.) falling within the scope of a Münchhausen syndrome by proxy;
– burns by immersion, splashing, bending or contact (iron, cigarette, etc). This type of lesion, of which the depth is to be specified, concerns 10% of the maltreated children with an average age of 32 months and keeps evocative localizations (perineum, limb extremities, buttocks, anterior hip and abdominal wall for flexion ).
Head injuries:
Twenty to twenty-five per cent of beaten children have severe head trauma (10% of child victims have a fractured skull, which is the second location after that of the limbs). These traumas are more frequent in the first 2 years of life. They are the most important cause of non-accidental trauma deaths (three-quarters). In cases of edema, hematoma or scalp of the suspect scalp, a skull x-ray and cerebral Neurological signs are associated. The lesions can come from different mechanisms (translation, rotation). Shaken baby syndrome, which results from strong translational movements imposed on the child, associates subdural and / or subarachnoid haemorrhages with retinal hemorrhages in a child under the age of 2 years. There are usually no external lesions or skull fractures.
Some bruises and even fractures of the posterior ribs may occur, where the child has been held, and fractures of the arms or legs due to limb movement. The prognosis is daunting (death, severe sequelae with blindness, motor deficit, psychomotor retardation). This is often a single violent episode of loss of control of a parent. In all these situations, cerebral CT and magnetic resonance imaging (MRI) should be repeated to reveal acute and subacute lesions (very evocative if lesions of different ages coexist). Note that parenchymal hematomas may result in sequelae of porencephaly or hydrocephalus, or even cerebral atrophy.
Thorax trauma:
In children, bruises, even violent, cause few intrathoracic lesions (pneumothorax, haemothorax, pulmonary contusion or rupture of mediastinal organs by deceleration) because its ribs are still very flexible. A chest x-ray should, however, be performed in the slightest doubt, in search of costal fractures.
Abdominal trauma:
Intra-abdominal lesions are the second leading cause of death in battered children (bursting, crushing or contusion of the organ, rupture of the vena cava and mesenteric vessels by sudden deceleration, as in the case of defenestration) due to their low abdominal fat and muscle mass. It is the liver, the spleen, then the kidneys and the duodenum that are affected, in order of frequency.
Bone lesions:
Twenty percent of child abuse is diagnosed by bone X-rays that can be used as evidence. Bone lesions occur in 50% of cases in children under 2 years of age. They are produced by indirect mechanisms (forced traction or rotation) or direct (contusion) mechanisms. They are highly evocative when they are multiple, plurifocal, with bone consolidation at different stages (which indicates the repetition of the traumas). They touch epiphyses, metaphyses (epiphyseal detachment, metaphyseal detachment, periosteal detachment) or, more frequently, diaphyses. The ribs are also frequently injured, and more rarely the vertebrae. Silverman syndrome associates bone and cutaneous lesions. In the slightest doubt, a complete skeletal radiograph must be made.
Other lesions:
These may include bites (ellipsoidal or oval form), dental fractures, endobuccal (burns) or ocular lesions, identified by otolaryngological (ENT) and / or ophthalmological examination.
Münchhausen syndrome by proxy:
It is an induced child’s disease (anemia with malaise by bleeding, malnutrition by induced vomiting, skin lesions by local injections of toxins), invented (epileptic seizures described by parents), or simulated (septicemia by contamination A blood sample, diarrhea by adding water to the stool) by a parent. It can also be a real illness of the child, aggravated by parental conduct (treatment voluntarily not given, increased doses). The symptoms of the child lead to his hospitalization, but the examinations practiced do not find a cause “classic” to the pathology. Parents then cause repeated hospitalizations, usually in different services, showing themselves wanting to know what is happening to their child and being very active during hospitalization and care. On the other hand, they do not seem to be overwhelmed by the possible seriousness of the diagnoses mentioned by the doctors, as if the important thing was for their child to be recognized as “sick”.
About two hundred cases have been recorded in the pediatric literature since 1977 (after isolation of the syndrome in the adult itself). It is generally a child under 5 years of age, whose mother, often belonging to a profession having a connection with the medical world, is actively abusing the father, giving him or her more or less passive endorsement, Ignorant. The pathology of the underlying parental personality may be paranoid, perverse or narcissistic. The diagnosis of this syndrome remains difficult and often requires hospitalization, including parental separation, which is often difficult to negotiate in the absence of a judicial decision.
Physical signs of neglect:
Undernutrition and Dehydration:
Malnutrition and / or deprivation of access to water can cause severe protidovitamin deficiency with stunted growth or even death. In the case of severe malnutrition, the child presents a prominence of the ribs, an abdominal protrusion with apparent hepatomegaly. The appendages are rare and brittle and a carnal anemia often exists (breath on auscultation, abnormal blood count [NFS]). In cases of associated dehydration (more common in infants), skin folds, fontanelle digging, hypotonia of the eyeballs and low blood pressure are observed. Measurement of the triceps skinfold can be used to assess the adipose panicle and the biological examinations for the different effects of deficiencies.
In an infant, care must be taken when the weight, height and cranial perimeter are below two standard deviations from the mean for age, or below the tenth of a percentile. The inadequacy of the parents’ statements about the child’s state, their lack of concern about his weight loss in a child described as easy to feed, guide the diagnosis. The separation of the family (hospitalization, placement) results in a rapid recovery of weight, then growth and finally of the cranial perimeter.
Negligence:
Neglect must be considered as abuse when its consequences can cause harm to the child. They are often very young parents, sometimes alcoholics and / or addicts, sometimes mentally deficient, mostly in a great social isolation. Negligence may include delays in consulting with a child’s symptoms (fever, pain, etc.), delay in treatment in case of illness, lack of supervision in risk situations Depending on the age of the child (baby left alone, young child left alone in front of a body of water, alcohol, drugs or medicines left in the reach of children).
The repetition of poisonings or accidents in the same child must cause the diagnosis to be evoked.
Voluntary Intoxication During Pregnancy:
It can pose the problem of direct maltreatment (maternofoetal alcoholism with baby with dysmorphia, microcephaly, with intrauterine growth retardation and various malformations, the prognosis remains difficult) and vulnerability to future maltreatment (Risk situation).
Refusal of medical treatment:
This may include, for example, refusal of blood transfusion.
Psychic Signs:
They remain difficult to describe because they are far from being univocal or pathognomonic. They must be evaluated according to the stage of development of the child. The earlier the maltreatment, the more traumatic the center of personality construction. In cases of sexual abuse, these disorders may have a particular tone (sexual deviance, sexual perversions, etc.). In any case, they participate because the child, weakened, later reveals the abuse and often retracts if it is not supported, especially when the parents exploit their mental pathology (designation of the child as mad or incapable Major, etc.).
In the case of abuse, the fundamental trauma that the child experiences emotionally is treason by those in whom he or she should have complete confidence, a betrayal coupled with feelings of helplessness and negative self- even. Cognitive disorders are often observed (inattention, memory deficit, intellectual delay with academic failure). Some studies show developmental delays (39% of pre-school-age victims), while others point to specific relational patterns associated with a deficit (12 to 18 months of child abuse victims compared to controls , Have an anxious attachment to their mother and lowered performance).
In infants, bias, arrest or regression should be sought in early development, since these phenomena change in the event of separation (if the latter does not intervene too late). These developmental pathologies can lead to autistic-looking pictures (withdrawal, cessation of communication), sometimes to more partial pictures (mistrust, “frozen” motor skills). In other cases, the baby sinks into a severe depressive state with apathy, autostimulatory swing, and various psychosomatic pathologies. Some infants have permanent hypertension and hyperextension of the trunk and limbs, secondary to hyperexcitation during treatment. Finally, anorexia, merycism (vomiting with rumination), sleep disorders (insomnia, nightmares, refuge in hypersomnia) can also alert. The essential work is of course preventive, as soon as an inadequacy of the mother to her baby is observed.
In the older child, behavioral disorders are very different according to the criteria used by the studies. Sphincteric disorders or somatic complaints (abdominal pain, headache) may represent messages sent more or less consciously by the child for help. Autoculpiness with anxiety of variable intensity (separation anxiety, panic disorders, post-traumatic stress state with reviviscence of nightmarish violence) is almost constant.
The child may also be alerted by the loss of interest in the activities he / she enjoyed, avoidance or, on the contrary, a relational collage, hyperexcitability with irritability, anger, impulsivity, sleep disorders, concentration.
In adolescence, there are often runaways, addictive behaviors, suicide attempts, a leak in delinquency or perversion (sadistic heteroaggressivity) and / or sexual disorders, especially if the abuse has been associated with sexual abuse (Prostitution, decreased desire, inhibition of orgasm).
Postpartum warning signs:
There are signs of early interactive dysfunction.
They need to be spotted early, as they can translate into abuse.
This may be an indifferent, even hostile or even sadistic mother in relation to her baby, who does not respect her needs (to make her voluntarily wait to feed her, for example): this one, quickly, will present Anger, episodes during which he finds it difficult to calm down and will be described as a tyrant. Separation with an adapted behavior of the referent calms these reactions. In other cases, the mother, whose need for control over the baby is expressed by requirements not adapted to the age of the child, will cause her baby to behave in a way that is always out of step with She (for example, the baby’s great nervousness due to her need for sleep, while her mother decided it was time for him to eat, the vicious circle settled quickly: baby more and more enervated, Increasingly demanding mother). After a period of active reaction of the baby (crying, nervousness, etc.), it can close, passively undergo maternal constraints (risk of depression, delayed development, dysharmonic and / or psychotic evolution).
Additional tests:
The clinical examination may be supplemented, in case of lesions, by photographs or descriptive diagrams. Furthermore, the examinations requested can be used to confirm the diagnosis of maltreatment directly or indirectly (elimination of differential diagnoses).
Radiologically, a complete skeleton must be carried out in the slightest doubt. In a toddler, a transfontanellar ultrasound can help in the diagnosis of intracerebral lesions. An abdominal ultrasound can guide in case of suspicion of visceral lesions. CT and MRI supplement the assessment in the case of brain or visceral lesions.
On the biological side, a toxic test must be carried out in the slightest doubt, such as the determination of transaminases. In all cases, an NFS with hemostasis (sedimentation time [TS], prothrombin [TP], activated partial thromboplastin time (TCA), platelets) may be useful (screening for anemia, elimination of Coagulation). In the case of undernutrition and / or dehydration, NFS, serum iron with ferritin, folates (carnal anemia), protidemia with protein electrophoresis (intake deficiency), lipidogram, sedimentation rate and An assay of C-reactive protein (underlying inflammatory or infectious pathology). In cases of persistent doubt, a hospitalization can help to make precisely and completely the point while protecting the child.
Differential Diagnosis:
Psychopathological issues:
Parents:
Some situations of maltreatment appear as punctual: it is a relative brutally overcome by its affects, exhausted, isolated, often depressed. He then talks about his gesture by often feeling guilty intensely (suicidal risk).
But in most cases, abuse is prolonged and remains linked to the quality of the child’s parental investment, which is closely linked to the child’s place in the family (sometimes with the weight of ” Transgenerational mandate “).
Goubier-Boula isolates different types of parent-child interaction:
– a relationship of control and control (obsessive or paranoid mechanisms) with rigidity (parents can mistreat “in good conscience”, influenced by rigid cultural and familial models, advocating “strong” punishment so that the child stays in The right way) ;
– inconsistency and instability of the parental framework (little differentiation between parents and children);
– narcissistic expectation of parents (early parentification of the repairing child);
– avoidance and distancing because there are aggressive, murderous impulses;
– perversity with enjoyment of the physical suffering of the child.
The parental couple can be conflictual, violent (conflicts settled by interposed child), unstable, fusional (the child becomes a possible rival) or non-existent (single mothers).
Child:
He is a victim of physical trauma, but also psychic in the psychoanalytical sense of the term (Laplanche and Pontalis): “An event of psychic life defined by its intensity, the incapacity of the subject to respond appropriately, And the lasting pathogenic effects that it causes in the psychic organization. In economic terms, trauma is characterized by an influx of excitement that is excessive in relation to the tolerance of the subject and his ability to control and psychically elaborate these excitations. “The younger the child is, the more his ability to manage the excitement (whether internal or external) remains dependent on parental support, which acts as a shield. In case of abuse, not only is this function not fulfilled, but the trauma is inflicted by the one who is supposed to protect. Moreover, any psychic suffering of the child, which is close to fright, is generally disqualified by the aggressor, which causes confusion between what is felt by the child and what is explicitly dictated by the child, adult. This paradoxical situation can lead, secondarily, to a disorganization of the processes of symbolization and psychic empowerment.
In addition, the intrusion of the excitation guard system, coexists with the introjection of the projected guilt of the adult, culpability quickly turning into hateful shame. This usually results in a difficulty for the child to imagine and elaborate what is happening. He then finds himself compelled to repeat his traumatic experiences (being rejected, ill-treated or mistreated himself) on himself (masochism) or on others (identification with the aggressor). This repetition is accentuated by the fact that physical pain simultaneously leads to an experience of fright (where the signal function of anxiety is largely exceeded) and eroticization (any other excitement now seems bland). All this can lead to a prevalent sadomasochistic functioning, with a more erogenous than secondary masochism. Yet, as he drowns in repetition, the child retains the certainty that his decisions are totally related to the present situation (repetitive mechanisms therefore remain unconscious). In fact, he believes he is able to dump and eliminate the extra excitement he has had to manage in the past. He thinks he can regain control by not being an impotent actor, ‘aggressor. Moreover, from the very beginning of the abuse, the child cleaves the parental object (the hostile part disappears under the effect of dependence and regression), which later promotes these mechanisms Identification with the aggressor. These allow the child to play a therapeutic role with his abusive parent, while making him less agonizing, much like the Stockholm syndrome among hostage-takers.
Other mechanisms of defense are also in place, witnessing a severe narcissistic attack: cleavage, denial, avoidance, inhibition, need for control over the object with “addiction or addiction of the object”, etc. Their prevalent use, initially reactionary, gradually becomes structural and it is then the whole capacity of the psychic apparatus to “link the instinctual motions that happen to it, to replace the primary process, to which they are subjected, by the Secondary process “, which is being challenged. Finally, the child often remains for many years in the vicious circle of abuse. Indeed, he can not defend himself by the revelation of the violence inflicted on him, because he fears losing the tender and close relationship that binds him to the abusive adult (cleavage of the parental image). It may also feel empty (loss of excitement) and abandoned (loss of special status due to parental guilt buy-back: gifts, given freedom, etc.), while at the same time it is generally subject to Strong pressure from his family. In rare cases, one way to solve this problem is to carry out the murder of the abusive parent before his denunciation (as Freud evokes it in connection with Dostoevsky’s writings), usually in adolescence.
Evolving risks:
After teenage years:
Adolescence is sometimes “after the blows” for several reasons: the abusive parent ceases his or her abuse, fearing the denunciation or strength of the adolescent; The young person leaves his family or denounces the facts.
However, it also generates symptomatic after-effects, more or less behavioral, especially in terms of the quality of the choice of object.
These aftershocks are underpinned by the prevailing defense mechanisms set up in childhood (failure of the excitation-guard system causing pathologies of the action, by the need to regain a level of Excitement comparable to that experienced in childhood).
It should also be noted that denunciation, when the abuse affects several children of the same sibling, is often done by the first child who has become a teenager. He generally states his fear of seeing one of his brothers or sisters suffer the same violence as himself. This reparative movement is also underpinned by an unconscious movement of rivalry with the young sibling who will “take the place” of the adolescent, by the very fact of his transition to adulthood.
Pathological Organizations:
The psychopathological development of child victims of maltreatment is influenced by various factors directly related to trauma. The quality of the parental path (psychotic, perverse or depressive), the circumstances of the violence, the participation or not of other siblings, the more or less late revelation, but also the age at which abuse Are all factors to be taken into account.
However, in order to understand the repercussions, it is fundamental to consider the child as a whole, that is to say to evaluate all the dynamics involved (family dynamics, the nature of parental investment Relative to this child, possible transgenerational history and mandate, general educational background in the family, etc.). They
Obviously greatly the redevelopments involved.
The longer-term evolving risks are varied, although some elements appear central, in particular the intensity of the repetition compulsion.
Schematically, on a psychopathological level, we are generally far from neurosis. The sequence described by Freud in L’Homme Moses and the monotheistic religion is like accelerated and biased; We do not see the sequence: early traumatism in childhood – defense by repression – phase of latency – establishment of neurotic symptoms with partial return of the repressed; But more to the following sequence: early trauma in childhood – archaic defenses (denial, cleavage, etc.) – establishment of behavioral symptoms in close relationship with the type of defense mechanisms introduced in childhood. We are then more often in the register of borderline pathologies, with dominant narcissistic elements (decreased self-esteem, narcissistic depression leading to suicide attempts), or in that of psychopathic pathologies. In both cases, antisocial behavior is frequent. The analysis proposed by Winnicott here seems quite appropriate: “When there is an antisocial tendency, it is because there has been real withdrawal (not just a simple deprivation); That is to say, there has been a loss of something good, which has been positive in the child’s experience up to a certain date and which has been taken away from him. This withdrawal has exceeded the duration during which the child is able to keep the memory alive … The child is able to perceive that the cause of the misfortune lies in the bankruptcy of the environment. Knowing that the cause of depression or disintegration is external and not internal causes the distortion of the personality and the need to seek a cure in the new dispositions that the environment can offer. In most cases, the difficulty of thinking, mentalising, representing, symbolizing, rivals that of being able to refer to internal non-failing or persecutory objects. The result is generally difficulties in schooling, repeated failures, which only place the young person more in a bad image of himself and in recourse to the act of acting of any kind, in order to feel himself existing . The Egeland study of child maltreatment between 12 and 18 months with witnesses shows that children between the ages of 42 and 56 months have a lack of perseverance, distractibility, negative feelings, Adaptability, and lack of control and enthusiasm. Of course, this picture is linked to an interplay of factors (repeated stress, unfavorable social conditions, poor hygiene, etc.) in which it remains difficult to evaluate the precise weight of the maltreatment.
Handicapped by sublimation and addicted to acting, dependent on external objects multiplied, never invested as such, but only as providers of ersatz of good narcissistic milk, these young people, if they are not helped by Are preferred candidates for drug abuse, delinquency, attempted suicide. Only they become eternal unsatisfied globetrotters, always in search of narcissistic pleasures commensurate with the excitement, yet mad and destructive, that the past has made them undergo.
Sometimes the repetition of violence and mastery reappears only when the roles are reversed to the next generation. The former victim, whose identifications with the aggressor are then updated, acts his guilt by evacuating him on new victims projectively identified.
Therapeutic aspects:
Prevention:
It seems fundamental to identify at-risk situations early and in particular to develop the possibility of psychological support during difficult pregnancies. The more ambivalent the unborn child can be quickly verbalized, the less likely it is to act later.
Medicolegal aspects:
The doctor may be in different situations.
Reporting:
Since 1995, the New Penal Code imposes an obligation on physicians to report child abuse (medical secrecy is forbidden for the abuse or deprivation of a minor under 15 years of age or a person who is not Age or mental or physical condition: article 226-14 of the Penal Code) except in special circumstances (otherwise it may fall within the scope of article 62 of the Criminal Code concerning the non- Assistance to persons in danger). It must alert the judicial authorities (public prosecutor 24 hours a day), medical (inspector of the Department of Health and Social Affairs [DDASS]), and / or administrative (PMI chief medical officer, inspector Social Assistance for the Child [ESA], Social Service Technical Advisor). He may also have recourse directly to the judge of the children in case of real, present, certain and serious danger. The Code of Medical Conduct (decree 79-506 of June 28, 1979) states that “when a physician discerns that a minor with whom he is called is the victim of abuse or deprivation, he must implement the most appropriate means To protect it with caution and circumspection, but without hesitating, if necessary, to alert the competent authorities if it is a minor under 15 years of age “.
Expertise:
Any physician may be required as an expert. The judicial authorities (generally the brigade of minors) then instruct the physician in writing to carry out a medical or forensic mission. He / she then carries out an examination and draws up a certificate stating his / her identity, his / her quality, the precise text of his / her mission, his status as an applicant, the date of his requisition, the time and place of the examination, The person examined, details of the detailed medical examination as well as photographs, patterns and duration of the total transient disability (for the child, it is the total functional disability to perform the usual daily activities: Dress, wash, go to school, etc.).
Testimony:
At trial, the physician may be required to testify: he must then deliver the items he holds or invoke medical confidentiality when they are not directly related to the abuse.
Treatment:
The situation must be considered in a comprehensive way, which usually involves a multidisciplinary team (school doctor, attending physician, PMI, nursery, childcare, etc.) whose actions must be coherent and concerted. Treatment must be early, in order to avoid both physical and psychological sequelae. Repeated assessments (by teams with different roles: PMI, social sector, child psychiatry, etc.) can help judge the effectiveness of the measures taken.
There is no unequivocal treatment of abuse. In some cases, it is the medical and surgical treatment of the child that is at the forefront at the time of diagnosis (resuscitation for severe malnutrition, surgery of a subdural hematoma, etc.). In others, it is on the contrary the psychological aspect that seems primordial (autistic aspect, depressive episodes, etc.). It is sometimes the educational side that takes precedence over the need to set limits for the child (delinquency behavior). Finally, sometimes an exhausted parent who is afraid of becoming a maltreatment can be reassured by the regular visit of an area nurse; An overwhelmed mother, by the help of a family worker. The redevelopment of childcare (nursery, day-care center) can also help to defuse a potentially dangerous situation.
In a number of cases, the protection of the child seems to require immediate separation (placement in foster families, boarding schools, pediatric hospitalization, child psychiatry). However, this distance is not enough: the bond with a parent, even when ill-treated, remains very strong and, if family retention is not appropriate, it would be illusory to think that the problem was solved only in Protecting the child. In order for everyone to find his or her place, work with the child and with parents where possible (reinstatement of the parenting process) remains to be done (psychotherapy or support interviews, etc.). The punishment of the abusive adult is surely fundamental for the child who feels recognized as a victim but the payment of compensation to the majority of the child often remains a difficult time (reactivation of guilt and shame, Impression of situation of prostitution, etc.) which would require the continuation of a psychotherapeutic follow-up.
To behave:
It is summarized in the paragraph below.
Evaluate degree of urgency and risks
If immediate danger
Hospitalization if:
– vital risk, traumatic injuries outside an accidental context, psychomotor and / or growth retardation, attempted suicide or repeated endangerment of the child;
– seek first to have the agreement of the parents;
– if refusal: make a report.
Reporting whether:
– situation where “the health or bodily integrity of a minor is likely to be understood by the refusal of treatment by the legal representative of the minor” (Decree of 14 January 1974);
– seizure of the public prosecutor’s office (the doctor is not obliged to do so but may be prosecuted for lack of assistance if he does not);
– immediate danger of ill-treatment or related to the after-effects of previous maltreatment:
– urgent legal notice to the public prosecutor in case of present and certain danger for the child ± application for provisional placement order in the hospital (OPP);
– administrative reporting to the ESA inspector outside the emergency;
– descriptive certificate including the assessment of the total incapacity for work (including the duration of hospitalization if there is one).
In all cases, it seems important to expose the report to the child and the family, explaining its aid dimension.
If no immediate danger but certain or risky miscarriage ++
– Join the social sector and seek additional information from the PMI, the school doctor, the attending physician.
– Report to the ASE Inspector, the PMI Chief Medical Officer or the Social Service Technical Advisor.
– Hospitalization with the agreement of the parents to take stock (additional exams, setting up a psychological follow-up, etc.) or close consultations.
Legal action:
The public prosecutor shall issue a protective measure (placement under OPP, referral of the juvenile judge, police investigation, referral to the investigating judge).
A civil procedure may also take place (Educational Orientation Investigation [EOI], Educational Assistance in an Open Environment [AEMO] administrative or judicial). The judge hears the child who can be assisted by a lawyer. An ad hoc administrator may be appointed when, in proceedings, the interests of the child appear in opposition to those of the parents.
Child maltreatment is a situation often encountered by the practitioner. He must be able to diagnose it, but must also be sufficiently aware of his reporting duties. Therapeutic actions should be considered on a case-by-case basis, linking protective measures to a psychotherapeutic approach involving parents, where possible.