The Psychological Implications Of Traumatic Amputation In Children
Bernard Hebert, L.Ps.
"In discussing the psychological problems which are peculiar to disability, the time of onset of the impairment is especially important, since it leads to very different consequences ...if impairment is congenital or takes place in early childhood. The developmental process may be powerfully affected, so that the individual may grow into a sort of person different from what he otherwise might have been."
This statement by Gilbertl cannot but point to the possible unpleasant, and even tragic, consequences of traumatic amputation in children at various age levels, each level bringing its own specific burden of disturbances. Defining and circumscribing the theoretical and actual disturbance factors is not an easy task, since only a small portion of the scientific literature on physical disability relates to the psychological problems of young amputees.
This paper will not, therefore, report structured research data. Rather, it will list and briefly define some of the emotional factors common to all children, and show how these factors may in some cases increase psychological difficulties, and in others alleviate the stress caused by an acquired disability. A better awareness of psychological principles may help to limit the number of possible problems, even if a program of prosthetic rehabilitation has met with a measure of success.
The general tone of this article may appear somewhat pessimistic. However, not all children develop severe neurotic problems after a traumatic amputation. For instance, Fishman and Peizer2 mention that successful prosthetic training does provide a great measure of emotional stability, school adaptation, and self-confidence. Yet a prosthesis does not always completely solve the problems caused by an acquired physical disability, even though it may reduce their impact.
Wright3 reports that children with congenital limb anomalies do not suffer traumatic alteration of their body image, as do those with an acquired disability. The need to reorganize one's body perception is always a source of anxiety, as revealed by fantasies or by projective drawings children make of "the person" and "the self." Most children tend to project their image with its pretraumatic integrity. Many factors may explain this phenomenon. Simmel4 found the presence of a phantom limb in children as young as two years of age, and it appears to be experienced by all amputees eight years of age and older.
The younger the child, the more disturbing may be the presence of this phenomenon, since he cannot understand the disparity between the objective reality of his body and his own feelings and sensations. The lost limb may hurt, or it may appear sensitive to touch and pressure. The child himself may be able to contract some of the severed muscles to give an illusion of movement, while his own visual or tactile perceptions or explorations of his body clearly indicate that his limb ends at the tip of the stump.
There also exists the problem of acquired automatisms which are no longer possible: he is denied the act of grasping, and his balance is temporarily impaired. Many other activities of daily living or psychomotor autonomy are felt to be severely limited. Even with a successful prosthetic rehabilitation program, the child must acquire new automatisms and often try to compensate with the other healthy extremity.
When a child is very young, less than four years of age, for instance, new abilities may be easy to acquire, yet adjusting to the new dimensions of his body in an environment that does not appear to react as it used to may be a difficult and at times painful process.
Many children whose programs of prosthetic rehabilitation have been delayed develop strong mechanisms of denial, which help both the child and the parents to diminish the emotional intensity caused by a painful reality. This mechanism is further increased by the existence of the phantom limb phenomenon. Although often intellectually desired by the total family, prosthetic training may at times meet with failure because this denial has not been recognized nor abreacted during the preprosthetic training period.
Observations of the behavior and fantasies of upper-extremity amputees suggest that many activities performed with the stump may serve to increase the nonacceptance of the reality of the amputation, whether traumatic or congenital. Introduction of the prosthetic program often causes strong resistance, not so much to the artificial limb itself, as to the awareness of the lack of integrity of the body. Delayed prosthetic rehabilitation can also be viewed as a threat to a painfully reorganized body image.
It is well-known that the concept of an "accident" is not completely acquired until a child is about six or seven years of age. Even simple occurrences in his daily experiences must be interpreted in terms of cause and effect, although the causal relationship follows anything but a logical process, whatever happens to a child, whether indifferent, pleasant, or unpleasant, must have a cause. It may be the child himself or some other responsible agent with the ability to produce some effect intentionally.
Laurendeau and Pinard5, in a study to validate scientifically Piaget's theory on causality, defined five main forms of a process they call "precaus-ality." The first consists in establishing a causal relationship between phenomena that are contiguous in space or time, or between facts that have a subjective similarity. Secondly, reality is perceived as a whole, organized according to well-defined plans which are always "for the benefit or ill-effect of a human activity" (dreams come to amuse or punish the sleeper). A third form suggests that any event or even object is the responsibility of an acting agent who is perceived as the source of the existence of all objects, natural or manufactured. Fourth, the child may give life and awareness to objects that surround him. Finally these objects may be endowed with a type of energy similar to muscular strength, capable of efforts or of conscious, voluntary movements.
In ordinary life, the inability to grasp the concept of an accident and the need to relate any effect to a cause, no matter how objectively inadequate, may not lead to disastrous results. The child is able to compensate with his fantasies, sometimes living in a world of magic to explain some of his daily experiences. Later the child tries to objectify his fantasies and to better understand the surrounding reality. However, the very young victim of an accident resulting in the loss of a limb or in any other type of disability, permanent or temporary, can think only in terms of precausality. He has not attained the stage of mental development to understand the accident, which may explain his perplexity, helplessness, and terror.
Types of Fantasies
Play activities and projective drawings shed some light on the workings of the child's mind when he is faced with a need to find some "logical" explanation for a dramatic event. It is not possible here to provide statistics on the number of times each type of fantasy occurs. Nevertheless, certain types have been observed often enough to deserve mention. The car that caused the accident may be perceived as endowed with evil intentions and wanting to hit the child, or the child may project evil intent onto the surgeon responsible for the amputation.
Too often, the child unconsciously puts the burden of the trauma on the parents themselves. In the child's troubled mind, the mother is felt to be indirectly guilty for not protecting him. This often causes a conflictful state that is not easily resolved. In the posttraumatic period, the parents' concern and the care they try to provide can only reinforce the normal ambivalence any young child feels toward parental figures. Many times the child resolves his conflict by turning his hostility against himself. This reaction is typically expressed in the child's mind as follows: "My parents are good, they love me, they can't wish me to be sick, so I must be very bad for such a terrible thing to happen to me." Apparently no other resources are available to help the child understand his handicap.
A traumatically acquired physical disability may also be perceived as a form of retaliation or punishment. One five-year-old boy suffered an accidental amputation of a leg after disobeying a parental prohibition for which he felt that he was somewhat deserving of punishment. It was not learned whether the child felt the disproportionality of his punishment. Nevertheless, his guilt feelings and fear were so great that he suffered two more minor accidents during his hospitalizations. These accidents were apparently directly related to the first traumatic experience, and presumably showed a need to alleviate his guilt feelings and to test whether minor acts of nonconformism would result in other painful happenings.
In general, the relationships within the child's fantasies are not so clear-cut. Many young amputees perceive the accident as the effect of a disobedience to vague parental prohibitions which are rarely objectified in the child's mind.
In a well-planned study of the factors involved in accidents to preschool children that led to hospitalization, Meyer6 provides further understanding of the causation and possible prevention of serious accidents. He stresses the need to acquire a thorough knowledge of all the factors and circumstances preceding an accident. He discovered, among other things, that "children over three years of age were more severely disabled because of the greater number of injuries from vehicular trauma than the younger group."
The study further revealed that "there was a circumstantial web of events usually involving a distracted or careless parent, a susceptible child, and an attractive and hazardous environment drawing the young child progressively towards accidental injury." Those responsible for the welfare of the child appeared unaware not only of the environmental threats, but also of the child's basic needs, his level of development, his emotional maturity, and even his need for protection at some moment before the trauma.
Illness and other stresses in the family seemed to have a greater influence on the accident than is usually believed. In many instances, a disruptive situation appeared in some way to lead to the trauma. Fatigue, hunger, and more often hyperactivity were consistently found to have some influence on the accident. Although somewhat influential, environmental hazards apparently played only a secondary role in the chronological history of the accidents. Meyer stresses "the family's failure to realize the danger or attractiveness of the injuring circumstances, leaving the child to his own devices in the hope that he would be able to cope with situations that would normally be dealt with satisfactorily by adults." These situations can only lead to disaster in the case of young children, whose knowledge of environmental threats is limited or whose experience of reality is still in the process of differentiation.
In some of the cases we have evaluated and diagnosed, we have often noted stresses and illnesses in the family, the mother's overanxious and prohibitive attitudes, together with a resulting hyperactivity in the child.
In some instances, we found deep-seated rivalry between siblings suffering from different types of limitation. One amputee had a mentally retarded younger brother, another had a cerebral-palsied older brother, and a third had two sisters suffering from cleft palate. In each of the three cases, we found guilt-laden hostility, directed not only toward the siblings, but also toward the mother, whom the child felt to be rejecting and unable to gratify some of his own basic needs. In each instance, the young amputee was trying to model himself on some type of ideal image - to be the "more mature son," the "only normal child," or the one who could function best on his own.
Prosthetic training was successful in these three cases. However, one child developed severe guilt reactions, which were felt to be related, at least unconsciously, to his inability to cope with his mother's wishes and to his adding to the physical and financial burdens of the family. After amputation, another child resorted to counterphobic acting-out in order to escape the pain of a dreaded anxiety state. He unconsciously sought conditions under which his fear occurred in constant renewed attempts to master it. The third had severe and painful symptoms of anxiety with strong aggressive undertones.
This article may appear to have overstressed some of the pathological factors which may affect children with traumatic amputations. Its purpose, however, is "only to point out the need for a thorough investigation of all the complex circumstances that led to the accident and to the reactions following the loss of a limb. The age at which the trauma occurred is important, in order to adequately consider the child's ability to face all the stresses related to this event -pain, phantom limb, separation from the family, etc.-and also the level of intellectual and emotional maturity attained.
Meyer suggests the need for preventive, protective, and educational measures to forestall all types of accidents to children. Unfortunately, one becomes aware of the need for measures of this type only after the accident itself, since it is not feasible to reach directly each family and each child in a community. An accident involves such complex factors, and the human (if not pathological or emotional) factors are so important, that only a door-to-door campaign might prevent all possible occurrences of this type.
Nevertheless, rehabilitation specialists must examine the detailed circumstances (human and others) that lead to an accident and try to break their vicious circle of cross-influences. Thorough psychodiagnosis and treatment or counseling of the child and parents may result in successful total rehabilitation and perhaps prevent the young amputee from becoming an accident-prone adult.
Bernard Hebert, L.Ps. is Head of Psychological and Guidance Sections Rehabilitation at the Institute of Montreal Montreal, Quebec, Canada
1. Lippay, A.L., et al., "The Rehabilitation Man-Machine," Bio-Medical Engineering (in press), 1967.
2. Fishman, S., and Peizer, E., The Clinical Treatment of Juvenile Amputees (1953-1956), New York University, 1958.
3. Wright, Beatrice A., Physical Disability: A Psychological Approach, Harper and Row, New York, 1960.
4. Simmel, Marianne, "Developmental Aspects of the Body Scheme," Child Development, 37 (l):83-96, 1966.
5. Laurendeau, Monique, and Pinard, A., La Pensée Causale, Presses Universitaires de France, Paris, 1962.
6. Meyer, R.J., "Accidental Injury in Childhood," Proceedings of the 9th World Congress of the International Society for the Rehabilitation of the Disabled, Copenhagen, 1963.