Recent Articles of Interest
(The following is an abstract of Dr. Ronald R. Kyllonen's article, "Body Image and Reactions to Amputations," which appeared in the January 1964 issue of Connecticut Medicine, Volume 28, No. 1. Dr. Kyl-lonen is Assistant Professor, Division of Child Psychiatry at the University of Wisconsin in Madison, and part-time psychiatric consultant at the Newington Hospital for Crippled Children in Newington, Conn.)
Dr. Kyllonen discusses the emotional reactions of children who have absent or deficient limbs of congenital etiology, or experience amputation due to trauma or other causes. He stresses the supportive role the surgeon can play in relation to the concept of the body-image.
The formation of the body-image, or perception of self, begins in infancy, with the barrage of stimuli, internal and external, received by the child's central nervous system, and continues as the child matures. The quality as well as the quantity of sensory experience helps form the body-image. The parents' feelings and attitudes, whether positive or negative, are communicated to the child by the nuances of physical interaction.
The parents' attitude is of particular relevance in the case of the congenital amputee. If the parents are comfortable in their reaction to the defective limb, the child will learn a comfortable attitude as well.
Successful management of the congenital amputee should include earlier fitting than has been past practice, and more intensive supportive work with the parents of such children. Where surgery is required, it should be done during the child's first year, if at all possible, in order to fit into the developing patterns of the body-image. Otherwise, it should be delayed until the child is solidly entrenched in his personality development.
Equipping the child amputee with a prosthesis early in life facilitates its integration into the body-image before the pattern is set. In the case of leg amputees, the practice of early fitting permits them to learn to walk as soon as they are sufficiently mature, even though the impetus to walk is strong enough that they will accept the device if fitting is delayed. However, there is greater difficulty, both from a mechanical and psychological point of view, with upper extremity amputees. The ideal age for fitting upper extremity amputees is five, six, or seven months. This is the time when the pattern of hand use is being established and it can be observed that children rapidly acquire a sense of possessive-ness toward the prosthesis as if it were literally a part of themselves. If the fitting is delayed, they establish a pattern of use of the stump which has to be unlearned if they are to use the prosthesis effectively.
There are further advantages to early fitting. A prosthesis with the passive-mitt as terminal device is generally held to be the most satisfactory from birth to age 2-1/2. It offers a degree of cosmetic restoration and permits palmar prehension. Further, it enables the child to adapt to quadripedal, rather than tripedal crawling, using and developing the associated musculature, and therefore avoiding the marked asymmetry seen in children fitted later in life.
In addition, early fitting requires parents and child to keep frequent appointments with the clinic team. These meetings - with their demonstrations of the prosthesis, inspections of the stump, and straight-forward discussions of the disability - create an atmosphere which encourages parents and child to consider the defect calmly, and helps to facilitate acceptance.
The psychological circumstances are different when the amputation occurs after the formation of the body-image. These patients must adjust to an insult to their previously intact self-image. Another difference that has been observed is that the parents of "acquired" amputees accept the deficit more readily than parents of "congenital" amputees. Some of the differences in reaction are illustrated by four cases described in the article.
Understandably, the usual hospital practice in amputation cases has been to focus on the surgical problem. Unless other problems interfere with the surgical management, they are sometimes assumed not to exist. But children undergoing surgery have strong emotional reactions, frequently masked. The psychological considerations in elective surgery are of great importance.
The preparation of most children for surgery need not require the services of a psychiatrist. However, the physician should take the required time to work with the total child, encouraging the patient to form a temporary attachment as a substitute for the parents. The child, dependent as he is on parents, is simply unable to go through any major stress without strong support, and will undergo pathological reactions of major proportions if such support is not given.
A period of mourning and a sense of anger inevitably follow amputation. Children often express these feelings indirectly, with somatic symptoms, regression to more infantile levels, and the like. Repeated contact at all stages of the surgical and treatment regimen is needed to help child amputees express and dispose of their feelings of rage and grief so that they will become ready to invest energy and effort in moving forward.
Most patients undergoing surgical amputation experience phantom limb sensations. In the search for an explanation of phantom phenomena, the preoccupation in the past has been with the physiological factors, and these investigations are still necessary. However, current experience indicates that phantom sensation frequently represents an emotional response to the loss of an important part of the body, and supportive treatment is often indicated in cases where the phantom limb is painful.
Time is the major requirement needed to develop a positive supportive relationship between doctor and patient. This will occur if the physician makes himself available to the patient before and after surgery, to explain the procedures as fully as possible, and to correct distortions and misinformation the child may reveal when asked what he believes is going to happen. The adequate preparation of any patient for surgery requires careful consideration of his emotional needs. The concept of body-image has not received much attention in considering a child's reaction to amputation, yet it is a useful and workable approach.
(The following is an abstract of "Congenital Anomalies of the Limbs, Part II. Psychological and Educational Aspects", by G. Gingras, M.D., M. Mongeau, M.D., P. Moreault, M.D., M. Dupuis, M.D., B. Hebert, L.Ps., and C. Corriveau, C.P.O., Montreal. The article appeared originally in The Canadian Medical Association Journal, 91, 115-119, July 18, 1964.)
As a preparatory step towards the development of a complete habilitation program for children with congenital limb anomalies associated with maternal ingestion of the drug thalidomide, the medical records of all patients with congenital limb anomalies referred to the Rehabilitation Institute of Montreal in the past decade were studied, and a thorough reassessment made of 41 patients (21 males and 20 females).
Part I of the article discusses the medical and prosthetic aspects. Part II, the subject of this abstract, describes the results of psychiatric, psychological and educational assessments.
The selection of the subjects did not conform to the strict laws of sampling and, since the group was sufficiently heterogeneous, conclusions were drawn only for the population as a whole, without reference to specific age groups or types of disability.
The sample consisted of six children aged 14 months to five years, 11 aged six to 11 years, 10 adolescents of 12 to 18 years of age, and 14 adults of 19 years and over. All had more or less severe handicaps, including a 14-month-old boy who lacked both arms and one leg, one girl who had no arms, and another, no legs.
Each patient was interviewed by both a psychiatrist and a psychologist. The latter also assessed intelligence and personality by standard intelligence scales and a projective technique-drawings of a "person" and of the "self". Approximately half of of the parents were questioned about the child's development, schooling and social background, and information concerning the reactions of the parents immediately after the child's birth and their subsequent adjustment to the disability was secured.
Intelligence and Education
Only four adults, between the ages of 25 and 36, and one five-year-old child functioned at a low-average level of intelligence. The intelligence quotients of the other 36 subjects ranged from 92 to 135 (i.e., average to superior), the mean I.Q. being 104.5.
The intellectual level of functioning was not found to be a causal or precipitating factor to psychological maladjustment. Nevertheless, intellectual assets fostered the healthiest modes of adaptation through strong defense mechanisms and greater possibilities for compensation and sublimation.
In general well adjusted subjects even if severely handicapped integrated in the school setting with minimal difficulty. This was particularly true of children in rural areas who had established friendly pre-school relations with their non-handicapped classmates. Greater difficulties were experienced by youngsters who attempted to integrate into new social and school groups in semi-urban communities.
Motor and Emotional Development
The study revealed that congenitally malformed children of normal and superior intelligence developed an early curiosity about their environment comparable to that of non-handicapped children. Their success or failure in understanding their world and developing and mastering motor activities was determined less by physical limitations than the anxiety level of the mother. In most cases, the mother was found to be over-protective.
No major emotional disorders were noted in any of the patients, except in the case of one adolescent who had delinquent tendencies attributed to family background and social environment. Nevertheless, many of the amputees exhibited neurotic conflicts or character defects similar to those found in non-handicapped individuals.
It was observed that by utilizing the mechanism of denial toward their child's limitation, mothers with "obsessional" or "compulsive" personalities (characterized by rigidity, perfectionism, stubborness and related tendencies) accepted the handicap more easily. Their children also reacted with less anxiety and, provided that their needs to overcompen-sate were gratified, readily adapted to a prosthesis. However, the healthier adjustment to disability of these children should not be overemphasized, since conflicts do remain. Children of mothers with "hysterical" personalities (characterized by suggestibility, self-display and attempts to control the environment) reacted with greater emotional intensity to the handicap and did not readily accept a prosthesis at any age.
During the first five years of life, the limb-deficient child lives in a close family circle and accepts the overprotection of his parents (usually the mother) against environmental threats. Later, unless he enters a special school for crippled children, where he can identify with other disabled persons, the child is forced to work out his own adjustment to the new school world and to make himself acceptable to others. The ability to make a satisfactory adjustment is influenced by the earlier parent-child relationships.
Children with congenital limb anomalies do not suffer a traumatic alteration of their body, as do those with acquired disabilities. They experience the same normal structuring process regarding body image as do normal children. The "person" and "self" drawing tests, and interviews, indicate an early awareness of the partially or totally absent limb.
The child's concern with his disability increases with the beginning of the latency period, reaching a peak at the onset of adolescence. The drawings reveal that amelic patients between six and 13 years of age invest the deficient limb with all their anxiety, regardless of their level of maturity. The disability is always a source of self-devaluation, even if tendencies to overcompensate are developed.
The individual's sense of self-value is strongly linked with bodily appearance, particularly during adolescence. The authors found that beginning in adolescence, these subjects felt threatened by any social relationship (whether real or imagined) which was in any way related to their disability, and therefore tended to limit their social contacts and to camouflage the involved body segment. This reaction was more marked in those with upper extremity malformations. During later adolescence, patients with "obsessional" personalities were less sensitive to the reactions of strangers, but those with "hysterical" personalities were never able to attenuate their sensitivity.
The earlier a child is trained to wear a prosthesis, the more easily it becomes accepted as part of his body image, although differences occur among individuals according to personality structure. When fitted even as early as the sixth or seventh year, adjustment is more difficult. While children readily accept an artificial leg or foot, the artificial arm or hand is often regarded as a device which forces the child to surrender well-established motor habits and to integrate into the body image an object that appears to be of limited value. Parents, too, tend to accept artificial legs more readily than upper extremity prostheses.
The existence of phantom limbs was not reported by any of the patients in the group. A nine-year-old girl, with amelia of both upper extremities, described what could be interpreted as a phantom right arm but this was thought to be the product of an active phantasy life and wishful thinking.
Parents react more intensely to congenital absence or malformation of a limb than the child. The latter first perceives his handicap and limitations through the parental attitudes of acceptance or rejection. A sound understanding of the problem by the parents can help to bring about a better emotional adjustment by the child and foster an adequate use of habilitation, social and educational services and facilities.
The management of the mother's emotional reactions is so important that it requires more intensive psychological aid than lies within the competency of the general medical doctor and his staff. The authors conclude that the medical profession should be made fully aware of the physical and emotional problems which may arise after the birth of a deformed child and the need for the mother to receive psychotherapy as soon as the child is born.