Psychoanalytic Study of the Child, Volume 7: Page 69-81, 1952.
By ANNA FREUD, LL. D. (London)
When trying to evaluate the role of bodily illness in the mental life of children, we find ourselves hampered by the lack of integration of material at our disposal. With the present-day division between professional teaching, nursing, child guidance work, child analysis and pediatrics, there is little or no opportunity for the trained worker in one of these fields to function, even in the role of observer, in one of the other services for children.1 Nursery workers, school teachers and child analysts see nothing of the children under their care when they are ill; while pediatricians and sick-nurses lose contact with their young patients when they are healthy. It is only the mothers who have the opportunity to see their children in health, illness, convalescence, deviating from the norm bodily and mentally and returning to it. On the other hand, during severe bodily illness the mother's own emotional upset and her inevitable concentration on bodily matters act as distorting factors and leave little room for objective observation of the child's psychological reactions.
In recent years a number of analytic authors have made attempts to deal with the effects of hospitalization on young children, a series of studies which culminated in a documentary film.2 But in the case of these studies the interest of the investigators was directed toward the misery and anxiety which arise invariably when young children are removed from their parents, placed in unfamiliar surroundings and handled and care for by strangers; hospitalization mere serving as a prototype of a first, short term separation from home. Instructive as these investigations are as a demonstration of separation anxiety and its consequences, they did not produce - nor were they meant to - additional knowledge concerning reactions to illness and pain in infantile life.
Data are less scarce where the after effects of illness are concerned. When describing the neurotic disorders of their children, parents date back the onset of the trouble frequently to some bodily illness, after which the child appeared to be "different". Mood swings, changes in the relationship to parents and siblings, loss of self confidence, temper tantrums often appear for the first time during convalescence after a severe illness. Symptoms such as bed wetting, soiling, feeding and sleeping troubles, school phobias, which had existed and been overcome earlier in life may reappear. Some children who had been considered brilliant in their intellectual performance before the illness, reappear afterward in school comparatively dull and apathetic; others surprise their parents and teachers by emerging from the same experience curiously ripened and matured. It is true that changes of this kind may happen after a period of hospitalization. But it is equally true that they happen as well where hospitalization does not take place, i.e. in children who have remained under the care of their mothers during illness and been nursed at home. When considering the effects of bodily illness on the life of the child, it is important to note that hospitalization is no more than one factor among several other potentially harmful and upsetting influences.
Before we can arrive at a correct assessment of this potentially traumatic experience of illness we have to work our way through the action of a large number of factors which, though they are mere by-products of the situation, are for the child's mind inexplicably intermixed with it. The child is unable to distinguish between feelings of suffering caused by the disease inside the body and suffering imposed on him from outside for the sake of curing the disease. He has to submit uncomprehendingly, helplessly and passively to both sets of experiences. In certain instances factors of the latter kind, with their high emotional significance, may even be decisive ones in causing a child's psychological breakdown during illnesses, or in determining the aftereffects.
(i) Change of emotional climate during illness. - There are few parents who do not, imperceptibly or grossly, change their own attitude to the ill child. There are some parents with ascetic leanings, who are afraid of over-indulging and thereby "spoiling" the child at such times, and consequently leave him severely alone, to "sleep out" his indisposition with the minimum of fussing. The majority of parents adopt an opposite attitude. The ill child may find himself more loved and fondled than at any other time of life; for a child of a large family an infectious disease, with consequent isolation from siblings, may be the one occasion when he is in sole possession of his mother's time and care. The mother owing to her anxiety for the child's health, may suspend all considerations of discipline and good behavior and indulge the child's wishes to the extreme. Or, on the contrary, in her preoccupation with the child's safety, she may forget the most elementary principles of psychological handling which she had applied in times of health: Shocks, forcible feeding, evacuation of the bowels, sudden separations (for hospitalization), deceptions (before operations) count for nothing with her so long as they ensure the child recovers. The child on the other hand, reacts to such unexpected handling as to traumatic experiences, feels bewildered by the upsetting of formerly unmovable emotional and moral standards or finds himself unable to renounce the incidental emotional gains after recovery.
(ii) The experience of being nursed. - The child's reaction to the experience of being nursed is understood best in terms of comparison with the better known and frequently described reactions of adults to the corresponding situation.3 A normal adult who is nursed though a severe illness cannot help feeling at the same time that he is exposed to a series of indignities. He has to renounce ownership of his own body and permit it to be handled passively. He is dressed and undressed, fed, cleaned, washed, helped with urination and defecation, turned from one side to the other, his nakedness exposed to nurse and doctor, regardless of sex, of decencies and conventional restrictions. He is, as it were, under orders, subjected to a hygienic routine which implies a major disregard for his personal attitudes and preferences. Characteristically enough many adults sum this experience up as being "treated as a baby," or as a "complete return to the conditions of childhood."
On the other hand it would be a mistake to conclude from such statements that the situation of being nursed, by virtue of its similarity to infantile experiences, is less upsetting to the child than the adult. Observation, as well as theoretical considerations show that the opposite may well be the case. The gradual mastering of various bodily functions, such as independent eating, independent bowel and bladder evacuation, the ability to wash, dress, undress, etc., mark for the child highly significant stages in ego development as well as advances in detaching his own body from that of the mother and possessing it at least in part. A loss of these abilities, when occasioned by the nursing procedures (or by the weakened bodily condition itself), means an equivalent loss in ego control, a pull back toward the earlier and more passive levels of infantile development. Some children who have built up strong defenses against passive leanings oppose this enforced regression to the utmost, thereby becoming difficult, intractable patients; others lapse back without much opposition into the state of helpless infancy from which they had so recently emerged. Newly acquired and, for that reason, precariously anchored ego achievements are lost most frequently under those conditions. Many mothers report that after a brief spell of illness their young infants have to be retrained as far as their toilet habits are concerned, weaned once more from spoon feeding, from clinging to the constant company of their mother, etc.
(iii) Restrictions of movement, diet, etc. - In contrast to the comparative ease with which ego skills and abilities are renounced under the impact of being "nursed", children defend their freedom of movement in the same situation to the utmost wherever they are not defeated by the type or intensity of the illness itself. It is well known that, at least under the conditions of home nursing, children with minor indispositions cannot be kept in bed consistently, or at least not lying down in bed. Young toddlers who have only recently learned to walk, are known to stand up stubbornly in their beds from the whole course even of severe illnesses (for instance measles) until exhaustion forces them to adopt the lying position.4. Recently some enlightened pediatricians have accepted this state of affairs and treat their child patients whenever possible, without enforcing bed rest.5
The psychological significance of the children's negative attitude in this respect become apparent in those extreme circumstances when child patients have to be immobilized after surgery or in the course of orthopedic treatment. Several analytic authors have observed and discussed the consequences of such extreme restraint of movement of limbs and have pointed out the possible connection with the emergence of stereotyped, tic-like movements elsewhere in the body (David Levy, 1928, 1944), the difference of this mechanically enforced from psychologically enforced restraint (Mahler, Luke, Daltroff,1945), their bearing on the blocking of aggression discharge as well as on the discharge of stimulation in general with consequent overerotization of the whole body (Greenacre, 1944). Thesi Bergmann (1945), in an observational study carried out during three years work in an orthopedic ward, gives a vivid description of the defense mechanisms which enable the immobilized children to bear the restraint and even to increase the docility when the restraining measures have to be increased. On the other hand she describes the rages and temper tantrums which appear when the restraint is partially, not wholly lifted or when chance deprivations, outside the expected medical procedure, are added to it unexpectedly. She emphasizes, further, a two fold relationship between the immobilized limbs and other parts of the body. According to her experience, on the one hand the restraint of one limb may spread in the form of inhibitions to other, non-affected parts; an the other hand certain ego skills, speech, etc. may undergo an accelerated development to compensate for motor restriction of one limb. The same processes as they occur in children with pulmonary tuberculosis are presented in a highly interesting study by Sara Dubo (1950).
These authors' observations are confirmed by much non-recorded experience of parents and teachers. The heightening of aggression during and after motor restraint (in plaster casts, etc.) is especially well known to the general public. The most usual ways in which this dammed-up aggression appears are restlessness, heightened irritability, the use of bad language, etc.6
In comparison with this massive blocking of a whole system of discharge, the food restrictions imposed on children during illness are of minor importance. Normally, in acute illnesses, the physiological lessening of the child's appetite prepares the way for the acceptance of a reduced diet; it is only the children with strong oral fixations, for whom food and deprivation of food have heightened libidinal significance, who react to the situation with fantasies of being badly treated, unloved, rejected. In chronic illnesses (such as diabetes, kidney trouble, colitis, allergies) where dietary restrictions have to be maintained for long periods of time, children are known to feel "different," singled out, discriminated against, or, in defense against being passively deprived, to develop ascetic self-denying tendencies.
On the whole, considerably less harm is done by the necessity of withholding desired foods by an anxious mother, urging or even forcing unwelcome food on an ill child. It is these latter situations which turn ever minor, short illnesses into starting points for serious and prolonged eating difficulties, usually by reviving feeding battles which have raged between mother and child in the nursing period.
For some children the taking of medicines presents a major difficulty. Though the bad taste or smell of the drug is in the foreground so far as the child's conscious reasons are concerned, analytic investigation discloses invariably behind these rationalizations the existence of repressed ideas of being attached by the mother through the symbol of the drug (Melanie Klein), of being poisoned, impregnated, by her. Laxatives which may force the bowels to move, though the child intends otherwise, may form the connecting link between the reality and these unconscious fantasies.
In this connection it is interesting to remember that the punitive character of these restrictive measures has always been known to parents and has been exploited by them. To send a child to bed, confine him to his room, deprive him of favorite dishes have been used as punishments over the ages. In certain societies over the forcible administration of laxatives is used for the same purpose.
(iv) Operations. - Ever since the discovery of the castration complex analysts have had ample opportunity in their therapeutic work to study the impact of surgical operations. on normal and abnormal development. By now it is common knowledge that surgical interference with the child's body may serve as the focal point for the activation, reactivation, grouping and rationalization of ideas of being attacked, overwhelmed and (or) castrated. The surgeon's action, from minor surgery to major operations, is interpreted by the child in terms of his level of instinct development, or in regressive terms. What the experience means in his life, therefore does not depend on the type or seriousness of the operation but on the type and depth of the fantasies aroused by it. If, for example, the child's fantasies are concerned with his aggression against the mother projected on to her person, the operation is experienced as a retaliatory attack made by the mother on the inside of the child's body (Melanie Klein); or the operation may be used to represent the child's sadistic conception of what takes place between the parents in intercourse, with the child in the role of the passive sexual partner; or the operation is experienced as a mutilation, i. e., as punishment for exhibitionistic desires, for aggressive penis envy, above all for masturbatory practices and oedipal jealousies. If the operation is actually carried out on the penis (circumcision, if not carried out shortly after birth), castration fears are aroused whatever the state of libidinal development. In the phallic stage, on the other hand, whatever part of the body is operated on will take over by displacement the role of an injured genital part.7 The actual experience of the operation lends a feeling of reality to the repressed fantasies, thereby multiplying the anxieties connected with them. Apart from the threatening situation in the outer world, this increase in anxiety presents an internal danger which the child's ego has to face. Where the defense mechanisms available at the time are strong enough to master these anxieties, all is well; where they have to be overstrained to integrate the experience, the child reacts to the operation with neurotic outbreaks; where the ego is unable to cope with the anxiety released, the operation becomes a trauma for the child.
In a recent symposium on the Emotional Reactions of Children to Tonsillectomy and Adenoidectomy, a representative group of analysts, psychiatrists, pediatricians, and psychologists discussed the subject in the light of these ideas with a view to lessening the traumatic possibilities of the three main factors involved in the situation: reaction to anesthesia, to hospitalization, and to the operative procedure itself. Finding the optimal time for carrying out an operation (Hendrick, Escalona, Sylvester); careful preparation before the event (Fries, 1946); avoidance of separation anxiety (Jackson, 1942), Putnam, Butler; psychiatric support (Rank), feelings for expression of feeling (Spock) were brought forward as the most important precautionary measures (Levy, 1945; Pearson, 1941).
When studying the aftereffects of childhood operations in the analysis of adult patients we find that is not the castration fear but the feminine castration wish in a male child which is most frequently responsible for serious postoperative breakdowns or permanent postoperative character changes. In these instances the surgical attack on the patient's body acts like a seduction to passivity to which the child either submits with disastrous results for this masculinity, or against which he has to build up permanently strong defenses.
(i) The mental interpretation of pain. - The manner in which the child invests bodily events with libidinal and aggressive cathexis and significance creates a phenomenon which has baffled many observers. Parents and others who deal with young children comment frequently on the remarkable individual differences in children's sensitivity to bodily pain; what is agonizing for one child may be negligible to another. The analytic study of such behavior reveals as different not the actual bodily experience of pain but the degree to which the pain is charged with psychic meaning. Children are apt to ascribe to outside or internalized agencies whatever painful process occurs inside the body (accidental hurts, fall, knocks, cuts, abrasions, surgical interference as discussed above, etc.) Thus, so far as his own interpretation is concerned, the child is pain is a child maltreated, harmed, punished, threatened by annihilation. The "tough" child "does not mind pain," not because he feels less or is more courageous in the real sense of the word, but because in his case latent unconscious fantasies are less dominant and therefore less likely to be connected to the pain. Where anxiety derived from fantasy plays a minor or no part, even severe pain is borne well and forgotten quickly. Pain augmented by anxiety on the other hand, even if slight in itself, represents a major event in the child's life and is remembered a long time afterward, the memory being frequently accompanied by phobic defenses against its possible return.
According to the child's interpretation of the event, young children react to pain not only with anxiety but with other affects appropriate the the content of the unconscious fantasies, i. e., on the one hand with anger rage and revenge feelings, on the other hand with masochistic submission, guilt or depression.
The correctness of these assumptions is borne out by the fact that after analytic therapy formerly oversensitive children become more impervious to the effect of pain.
(ii) Pain and anxiety in infants. - Where the direct observation of infants in the first year of life is concerned, the relative proportion of physiological and psychological elements in the experience of pain is an open question. At this stage, any tension, need or frustration is probably felt as "pain," no real distinction being made yet between the diffuse experience of discomfort and the sharper and more circumscribed one of real pain arising from specific sources. In the first months of life the threshold of resistance against stimulation is low and painful sensations assume quickly the dignity of traumatic events. The actual response of the infant, whether it occurs instantaneously, or after a time lag of varying length, or remains invisible altogether, is no reliable guide to the assessment of the shock caused by the pain.
From what age onward the bodily event is supposed to carry psychic meaning for the infant will depend altogether on the analytic observer's theoretical assumptions concerning the date when unconscious fantasies begin to exist.
For the observer of children under the condition of medical treatment it is interesting to note that older infants (two or three years) may react with almost identical distress to the experience of injections or inoculations and to the experience of sunlight treatment, although the former involves pain (plus anxiety) the latter is merely anxiety-raising without any pain involved.
(iii) Passive devotion to the doctor. - It is the psychological meaning of pain which explains why many doctors, and other inflictors of pain, are not merely feared but in many cases highly regarded and loved by the child. The infliction of pain calls forth passive masochistic responses which hold an important place in the child's love life. Frequently the devotion of the child to doctor or nurse becomes very marked on the days after the distress caused by a painful medical procedure has been experienced.
(iv) Reaction to pain as a diagnostic factor. - With young boys in the oedipal stage, their reaction to bodily pain provides a useful key to the differential diagnosis between genuine phallic masculinity and the misleading manifestations of reactive overstressed phallic behavior designed to ward off passive feminine castration ideas. The masculine boy is contemptuous of bodily pain which means little to him. The boy who has to defend himself against passive leanings cannot tolerate even slight amounts of pain without major distress.
(i) Changes in libido distribution. - The casual observer, while following with his attention the loud, manifest reactions to anxiety and pain, nursing procedures and restrictions, is in danger of disregarding another process which, silent and under the surface, is responsible for most important alterations during illness: i. e., the heightened demand of the ill body for libidinal cathexis. Some observant mothers know the mental signs heralding his state and are able to diagnose from them the onset of disease even before any significant bodily symptoms have appeared.
There are two ways for the patient to react to this demand from the side of the body. Many children who, when healthy, are in good contact with their surroundings, full of interest in their toys and occupations, are in the happenings of everyday life, begin their sicknesses by withdrawing from their environment, lying down on the floor or curling up in a corner, listless and bored.8 At the height of the illness they lie in bed without moving, their faces turned to the wall, refusing toys, food as well as any affectionate advances made to them. Though these reactions occur in certain children regularly, even with harmless sore throats, stomach upsets, raised temperatures, and the most common infectious children's diseases, the impression given by such a child in a state of withdrawal is that of a seriously ill person. Anxious mothers are terrified by this complete reversal in their child's behavior and feel him to be in grave danger. In reality the manifestation is not a physiological one but a psychological one and not commensurate with the severity of the illness. It is a change in libido distribution during which cathexis is withdrawn from the object world and concentrated on the body and its needs. Despite its frightening suggestion of malignancy this process is a beneficial one, serving the purpose of recovery.
There are other children who, for some unknown reason rooted in their individual libido economy, use a different manner to achieve the same result. Unable to give their own ill body the additional narcissistic cathexis which it demands from them, they claim this surplus of love and attention from their mothers who nurse them through the illness, i. e. they become demanding, exacting, clinging far beyond their years. In doing so they make use of a natural process dating back to the first year of life, when the mother's libidinal cathexis of the infant's body is the main influence in protecting it from harm, destruction and self-injury. (Hoffer, 1950). For the surface observer children are extremely "fussy" when ill, those of the former type are undemanding.
In both cases the gradual return to health is accompanied by a gradual regularization of these movements of libido, though not without difficulties and reversals during which the child appears "cranky." Occasionally the abnormal distribution of libido proves irreversible for a certain length of time and produce some of the puzzling personality changes after illness which have been pointed out above.
(ii) The child's body as the mother's property. Hypochondria. - Some mothers find it difficult to resign themselves to the fact that their children, even after the toddler stage, cannot really be trusted to take care of their own bodies and to observe the rules serving health and hygiene. Whenever a mother reports with pride that her child washes hands before eating without being told to do so, analytic exploration will reveal that the child in question is a severe obsessional and his apparently sensible cleanliness a compulsive and magical defense against imaginary, dangerous contacts. Children who protect themselves against colds and drafts ward off fears of death; those who choose their foods carefully do so on the basis of fears of being poisoned; those who refrain from eating too much or too many nourishing foods are obsessed by anxieties concerning pregnancy. The average, normal child will observe none of these precautionary measures; he will eat with dirty hands, stuff himself, brave wet and cold weather, eat green apples and other unripe fruits unless forced, urged or prevented by his mother. In illness he will at best co-operate with her; at worst he will fight the care taken of him and proceed to use his own body as he pleases. So far as health, hygiene and nursing care are concerned, the mother's ownership of the child's body extends from earliest infancy, when the mother-child unity is an important factor in the libido economy of both, through all of the phases of childhood into adolescence. At this last stage, before independence is finally reached, recklessness in matters of health provide one of the most familiar battlegrounds for bitter struggles between the adolescent and the mother.
It is interesting to observe that this state of affairs is reversed more or less completely when motherless, orphaned and institutional children are concerned, even in those cases where competent professional nursing care is provided. Far from enjoying the freedom from anxious motherly supervision (as the observer might expect from the mothered child's revolt against her care) motherless children proceed to care for their bodies in an unexpected manner. In an institution known to the author it was difficult sometimes to prevail upon the child to shed his sweater or overcoat in hot weather; his answer was that he "might catch cold." Rubber boots and galoshes were asked for and conscientiously worn by others so as"not to get their feet wet." Some children watched the length of their sleep anxiously, others the adequacy of their food. The impression gained was that all the bogeys concerning the child's health which had troubled their mother's minds in the past had been taken over by the young children themselves after separation or bereavement, and activated their behavior. In identification with the temporarily or permanently lost mother, they substituted themselves for her by perpetuating the bodily care received from her.9
When watching the behavior of such children toward their bodies we are struck by with the similarity of their attitudes to that of the adult hypochondriac, to which it perhaps provides a clue. The child actually deprived of the mother's care, adopts the mother's role in health matters, thus playing "mother and child" with his own body. The adult hypochondriac who withdraws cathexis from the object world and places it on his body is in a similar position. It is the overcharging of certain body areas with libido (loving care) which makes the ego of the individual hypersensitive to any changes which occur in them. With children analytic study seems to make it clear that in the staging of the mother-child relationship, they themselves identify with the lost mother, while the body represents the child (more exactly the infant in the mother's care). It would be worth investigating whether the hypochondriacal phase which precedes many psychotic disorders corresponds similarly to a regression to and re-establishment of his earliest stage of the mother-child relationship.
In carrying further the author's and other writers' studies of separation anxiety (hospitalization) this paper surveys the other factors which play a part in the child's reaction to bodily illness. The effects of the various nursing medical and surgical procedures which are open to modification are distinguished from those elements which are inherent in the process of illness itself, such as the effects of pain and the inevitable changes of libido distribution. Lastly, a comparison is drawn between the state of deprived children who care for their bodies in identification with their lost mothers and the adult hypochondriac who overcathects his body with libido after it has been withdrawn from the object world.
In summarizing these factors which play an important role in very normal development the author wishes once more to stress how serious a measure hospitalization is, separating the the child from the rightful owner of his body when his body is threatened by dangers from inside as well as from the environment.
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