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The 42st National Conference of Child and Adolescent Neurology and Psychiatry and Allied Professions with international participation


APPLICABILITY OF THE ‘PATTE NOIRE’ TEST IN ONCOLOGICAL CHILDREN WITH CHRONIC BLOOD DISORDERS

Autor: Speranța Popescu Camelia Stanciu Adina Mariș Luminița Cozlea
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This study aims to analyze the projection of the representation of psychic trauma that is determined by a serious illness during childhood and adolescence, like the onchological one, with great impact upon evolution of personality in comparison with children and adolescents without major suffering. Lot of subjects is represented by children between 4 and 17 years old, patients from the County Hospital, Department of Oncology, 70% are acute cases and 30% cases under medical treatment. Control group 2 is formed by healthy children from a Targu Mures general school. After applying the test „Patte Noire”, Louis Corman, analyzed the dynamic structure of personality from psychoanalitical perspective, adaptation and deffence mechanisms of „Self”, Oedipian conflict, latent conflict, regressive tendencies, dependence versus independence, in relation to present chronological state of psychic development. Identification of projective test of conflicts with negative impact, regarding evolution of children personality with serious illnes implies urgent begining of psychotherapeutical tratment associated to medical therapy.Psychological treatment is important as somatic treatment and has great impact upon physical healing.

Motto: “Always have to protect children, adults can take care of  themselves”.
(C.V., 17 years, early stage of abdominal tumor, under treatment)

 

 

Introduction

Childhood cancer remains a serious distress that deeply affects not only physic but also psychic in its evolution. Fortunately last years have seen a high rate of healing through therapeutic advancement made ​​in medicine.

If the body can be healed, we wonder about the echoes in the psychical life while struggling with this cruel disease, both the subject and his family. Rough and long treatment as the imminent threat of death can create significant traumatic sequelae in functioning and mental maturity of the child. Observing these subjects in the pediatric oncology department of County Emergency Clinical Hospital from Targu-Mures, and working to alleviate their emotional difficulties we found that: these children have something extra: a skill, a talent and they are wiser. Sometimes they are so mature that you feel like talking to an adult. And they are for us an example: we learn to have courage to fight when we find it hard, to know that powers dwell in us that we are aware and it’s worth fighting to the end, whatever the outcome.

Besides talent, maturity and strength, children with serious illnesses show some unstables (emotional, physical), changes in personality development, stagnation, even regression and pathological manifestations. All this due to side effects of treatment or  their „loss of patience”.

 

Objectives

In the present study we aimed to evaluate the psychological trauma of  disease represented in projection, following the quantitative and qualitative analysis of those aspects that influence the results of further organization of personality, such as cognitive and emotional ones revealed in persecutory scenarios, abandoniace, aggressive, regressive to pregenitale stages.

 

Materials and methods

Procedure  

The experimental method of evaluation used a projective test „Patte Noire„ by L.Corman. The test highlights the possibility of understanding pathological cases, each time putting into game theanalysis unconscious conflicts of the subject.

If we are guided by Freud’s Stages of Psychosexual Development, an unsolved conflict may indicate regression, stagnation or serious problems regarding the subject’s unconsciousness, they can be predictive for some disorders such as depression, personality disorders, disturbances in sexual development, and various deviant behaviors.

„Patte Noire” by L.Corman test consists of 18 drawings (frontispiece, drinking tank, kissing, beating, carriage, goat, leving, doubt, goose, dirty games, night, maternity, mother’s dream, father’s dream, breastfeeding 1, breastfeeding 2, den, tree, fairy) each board „hides” a type of latent conflict. Latent themes are:

  • aggression
  • sexuality
  • analitatea and orality
  • dependence versus independenta
  • Oedipus complex / reversed genders
  • fraternal rivalry and the desire to be only child
  • replacing the mother with an ideal mother and the orphan child
  • punitive behavior / punishment
  • emotional support (parental).

 

Applying the test we go through several stages:
  1. We ask the child to name the characters, to give them an age and to say something about them
  2. The child chooses from each picture one character he like and one he doesn’t
  3. The child chooses the images he like and images he doesn’t like
  4. He tells a little story using the images he liked
  5. The child enumerate the little pig’s wishes
  6. He tells a story about the pig’s drem and he draws it
  7. The question wich highlight the test is : ”What thinks the little pig about his spot?”

 

Subjects    

For the study we tested two groups of children:

  • an experimental group of 21 subjects aged between 4 and 17 years, made ​​up of children with hematological illnesses and different types of cancer
  • a group of 21 healthy children aged between 4 and 17 years.

Diagnostics:

  • Acute lymphoblastic leukemia
  • Granulocytic leukemia
  • Abdominal tumor in early stage and stage III
  • Tumor in the spine and cephalic hyperhidrosis with shunt
  • Testicular cancer
  • Hodgkin Lymphoma
  • Haemophilia A and B
  • ITP (idiopathic thrombocytopenic purpura)
  • Different kinds of anemia

Almost all cases were acute (70%) and the rest are under maintenance therapy (30%).

 

Specific diseases (short description):

1. Acute lymphoblastic leukemia is caused by increased or decreased lymphocytes and is manifested by leg pain, fatigue, decreased immune system and other related diseases (child gets sick more easily and make complications). The child has psychological depression, not accept the disease, sometimes feels anger, behavioral changes, becomes irritable, difficult, sometimes lethargic, with slowed mental function due to treatment side effects on the central nervous system.

2. Granulocirara Leukemia is a milder form of leukemia that would affect the number of granulocytes in the blood and can be treated at home with treatment lasting several years. The psychological impact in children with this diagnosis  with is high, they show a hidden depression (sadness and behavioral disorder plus mood swings) and the family is involved in the control of the child’s treatment set at specific hours and observing the diet and a very restricted lifestyle.

3. Abdominal tumor is a common diagnosis, especially in girls between 8 and 15 ani. The cause is unknown. After initial treatment for tumor reduction, and then the removing surgery the child continues his treatment for stoping the progression of the disease, going into remission. If he has a restricted lifestyle he can lead a normal life and the disease does not recur.

4. Tumor in the spine and cephalic hyperhidrosis with shunt. These illnesses associated are extremely severe and affects the child’s language and intellect. Child has feelings of faintness, tired quickly, can not maintain attention, any activity he carries with obstacles and interruptions, motivation and willingness are affected, is hypersensitive emotional, affection crises manifestations, hysteria, mood swings, learning difficult, understanding and learning n econcepts is difficult. Often these children are in a coma for a while, usually after surgery or accidental cases.

5. Testicular cancer treatment requires surgery and relatively easy treatment compared to other cancers and has a good prognosis. In recent years there have been several cases of testicular cancer compared to the years 2000-2010.

6. Hodgkin Lymphoma  is common among teenage girls, is a mild form of cancer (lymphatic cancer) and requires a relatively easy treatment and shorter than the leukemia. The prognosis is good and rarely children do relapse, in which case, there is a transplant or autotransplant.

7. Haemophilias are genetic diseases passed from mother to male child and  manifests itself at boys, girls are only carriers. It is a serious disease because these children have greater restrictions both nutritional and lifestyle and due to this they experience more frustration. However, children with hemophilia have normal intellect and usually above average to compensate the lack of physical movement and „childhood living” with study. They are interested in study, reading, arithmetic and have patience in meticulous activities. There have been cases in which the three brothers boys, all showed disease. Hemophilia is due to lack of factor VIII from blod and is usually followed by bleedings which do not stop. Emergency treatment is injected), the child is brought to hospital where he is treated. Often children have bruising that occur without an external factor on the body or they swollen feet and hands painful joints with movement problems. Haemophilia is a disease „for life”, is untreatable you can only keep it under control,so the emotional impact in children and their families is very high, they have a preferential “treatment” at school so they often feel „different”. Every year are organized camps for those children where they can socialize and carry out activities together.

8. The ITP is a chronic blood disorder that consists in shortage of  platelets (with a role in blood clotting and hemostasis) and is manifested by hard-to-stop bleedings, and haematomas. Treated with corticosteroids, ese having harsh side effects on the physical body and central nervous system and thus on behavior. Drug treatment is long and gradually removing because it can cause withdrawal syndrome. If drug therapy is unsuccessful, the spleen it’s removde. Like any chronic disease, the whole family is affected by a preferential treatment of the child and change of the normal of life. Problems: accepting the disease, parents self blaming („I didn’t know to take care of my child”), depression, anxiety, conflicts between family members, conflict and brothers rivality („you love him more because he is ill”), lack of hope and parents concern, the child can become naughty because of frustrations.

9. Anemia of various forms is a decreased hemoglobin level and lead to pallor, fatigue, nervozitate. Its treated with iron supplement and appropriate treatment to the type of anemia. If it is severe and untreated, can lead to leukemia.

 

RESULTS

These conflicts are unconscious complex whatever the provided stimulation by the drawings highlights the same dominant theme and in this game image and fantasies (stories) follows a general scheme of trends that dominate the subject’s personality.

Children suffering from cancer expressed dominant themes related to oral stage, aggressive, sexuality, dependence /independence compared with healthy children in these conflicts have been much less emphasized.

 

Edifying latent content

Boards responsible for oral stage: Breastfeeding 1, Breastfeeding 2, The goat, Newborns, Doubt /Indecision.

Boards responsible for Sexuality: The kiss, The birth, The night, Mother’s dream, Father’s dream

Boards responsible for Aggression: The drake, The battle, Dirty games, the carriage, the pit

Boards responsible for Dependence /Independence: Leaving, the pit

 

Example for Oral stage:

Children suffering from cancer

“The goose caught the little piggy because it wanted to eat him.”

“Father with a little pig drink water, a pig drinks milk and a pig watchs them surprised at them drinking as pigs (rude ones!!).”

“He was with his son and father was in the garden.

– Will you take me to the garden ?

– Well, son, you will.

And they ate and then went home and the pig said to his brothersbrothers:

– Father showed me where the good grass is and we had fun. Let’s us, three brothers go. “

Healthy kids 

H.D., 12 years: “A pig is dreaming that he is with its family, and people are feeding them, being hungry he enters in the food, then he eates it.”

N.M., 7 years: “One day some pigs rested, when they woke up they drank milk from the goat, then he went home. At home he drinked milk with the others brother, then he went to bed. When he awoke he drank some more milk. “

 

Example for Sexuality:

Children suffering from cancer 

“The pig gave birth to three little pigs and one of the people puts hay for the little pigs to be more comfortable and one of them offers food. The rest don’t like that the little omnes are because they are no longer the spoiled then.”

“The little looks that mother and father are kissing and the others are sleeping.”

“They loved each other. Dad kisses mom.”

Healthy Kids 

C.T., 14 years: “The two parents love each other little pigy is spying”

L.A., 7 years: “At night one is sleeping, then there was dark and he looked and got scared.”

B.D., 5 years: “They loved each other and gave him a kiss”

 

Example of Aggression

Children suffering fromcancer 

“There was a thief who came to steal the smart pigs. Father and mother saw the man puting the pigs in the cart. On was hit by the cart, the wheel passed over him. When they reached the cart, the farmer came and caught the thief. He bounded and beaten him, then called the police. “

“The goose is pinching his tail and sister and his sister is watching and she is afraid of not going through the same.”

Healthy Kids 

S.A., 11 years: “Once there were five pigs, one had a spot and hwas despised by the others, after they played and them there was a fight”

B.D., 5 years: “It was once two pigs, one saw dark and then eat a pig. “

R.C., 5 years: “Pigs went home to do something, and large and small pigs and the big ones aet and they bit on the hardworking”

 

Example Dependence / Independence:

Children suffering from cancer

“It was a river and the water was very high. Little pigs says:

– I do not want to die, Lord, I want to stay near my parents.

– Well, this time I will help you.

There was a road and the road brought up to his parents and God said:

– I come to keep you not geting hurt.

And there was a way that bought him to his brothers and the brothers were very happy. The parents came:

– Hey, son, where were you?

– I saw grass and went to eat and it was actually a high water and prayed to God, who said that will helps me.

– From now on don’t go until I go with you.

– From now I will listen to you. “

“A pig goes on a path to the mountains. On this way were taken his brothers with the car and he goes to rescue them.”

Healthy Kids

S.A., 11 years: “He was mad and he left, but he began to miss his family”

R.C., 5 years: “He went for a walk alone”

S.C., 14 years: “It was a family with three children, the youngest one goes to the barn”

 

Preferred drawings are those in which identifing with  the situation and / or characters or corresponds to situations or emotions most powerful ones faced in real life of the subject.

Self considered an essential court of adaptation for the subject and emphasized in every situation (story) of how a solution was found through a compromise acceptable of trend and defense. Thematic analysis revealed that children suffering from cancer have indicators in graphic demonstrates the existence of a weak Self wich hardly stand or do not bear frustration, while the group of healthy children obtained evidence regarding the situation of an flexibel self, namely a good adaptation to life situations and appears also indicators concerning an rigid self of subjects which involves taking life situations in a manner that involvement remains low.

 

The chart regardin regression shows results in the group of children suffering from cancer presenting difficulties of adaptation to higher stages according to chronological age in personality remaining fixed points on the lower stages like: oral, often expressing regression in child in a moment of immaturety of its existence since that this fixation is expressed as oral confusement of affection and food in the maternal protection, protection without which the baby is doomed to be lost, only that this fixation can have a negative influence on subsequent mental development. From this test we learned that subjects who have hemes wich emphasizes regression to pregenitale stages give to the characters in the ages wich check with chronological age (1-2 years).

This sign of the protagonist’s Black Spot crystallize depresive trends of the subject when is happening that what realy happened in the group of children suffering fromcancer, black spot was seen as a sign wich makes a negative difference between him and the other characters. Stigmatized aspect of the spot, seen symbolically as a mark of impurity.

 

Healthy children

Example of response to the question: “How little pig feels about his spot?”

D.B., 9 years: “He is the most beautiful pig”

T.P., 10 years: “He thinks he isthe only one with a spot, he and his father, and he feels so good”

S.C., 14 years: “Piggy must think he is unique”

 

In terms of highlighting psychopathology problems with the help of this projectiv test, it may through the obtained results in projection of the subject, to highlight an unconscious complication, a difficult conflict of identifing in an interview or an application of a questionnaire. And in the valences of the test and that in the present study it was possible to be shown a psychological echo of serious disturbances in the organic sphere. The studied groups, meaning the group of children suffering from cancer could ighlight two important aspects of psychological difficulties:

 

  1. regressive stages, with sn impact such as cessation or slowing of the psychological development of the subject with to possible effects in cognitive, emotional and behavioral field
  2. depression, expressed by the lack of dynamism, sense of inferiority, failure which can lead to failures in real life.

 

CONCLUSIONS AND DISCUTIONS

For the group of healthy children, trends appear normal and conflicts resolved. They do not cross the traumatic effects of the disease and live a normal life. Sometimes their development stage is small slowdown, according to the child’s home environment and degree of exposure to stimuli / trauma, but these little slowdowns are recoverable.

In children with cancer and chronic diseases occur gaps between healthy children as they cross a very traumatic just when their psychological development and their maturity is in progress. Oncological disease has a great impact on their psyche and their families and jams all psychological instances. They have a very faint self, dominated by Superego, they censor thier manifestations of frustration. Self is more powerful, these children are very egocentric, sometimes selfish, jealous, children eager to be unique. Between Ego-ID-Superego there is a gap, and the 3 courts are not in balance, but in conflict. Events that occur:

 

  • depression and anxiety;
  • behavioral disorders and personality changes;
  • conflicts with others, outbursts, bouts of emotion in children (over 8 years);
  • separation anxiety in children of 16-17 years;
  • conflicts with mother, which increase in intensity, wanting her mother to be replaced to an ideal mother

 

Oedipus complex is unsolved or greatly slowed. Oral, anal and genital stages sometimes remain unsolved or in pending. Sometimes children sufering from cancer feel a like an “orphan child”, especially those who are alone in the hospital. They grow mature quickly, as evidenced by the high degree of independence that they assume sometimes at an early age. Little children still feel addicted to thier mother and don’t have the courage to assume independence. Some feel guilty for their disease and manifests a punitive behavior. All children in this group had a high degree of aggression, the accumulation of frustration due to bursting as tantrums, self / aggression, “hard” words, negativism. Brother’s jealousy is shown or regarding other children from home from or hospital. This jealousy was also found in children of 16-17 years whose mother was taking care of children aged 4-5 who were alone in the hospital.

In general, all the group of children show declining trends at all levels of their development: affection, behavior, memory, communication.

The causes of these results are:

  • Diagnosis, causing „shock” and denial;
  • Long period of hospitalization;
  • Specific of disease;
  • Lack of parents and family;
  • Frustrations related to medical procedures, pain;
  • Waiting to return home;
  • „Shattered hopes” and disappointment („I can’t go home today because my tests weren’t good”);
  • Projection of a black future („I will not live, I will not get better”);
  • Feeling of saturation („I’m tired, I can not stand”);
  • Feelings of guilt and autodevalorizare („I am not the same I used to be”).

 

Fairy wishes reflect the wishes of children. For all the group of children, the three wishes appear:
  • desire about orality or possession (to have food / grass / more apples / palace / a car);
  • desire linked to the presence of parents and family (mother and father to be with him, to play with his brothers);
  • desire of projections of his future or related to presence in another place (to grow big, to be the fairy, to be far away);
  • sometimes wish that the “spot” to disappear.

Ill kids project the “black spot” of the pig as a disease. They chose “black spot” as something “extra”, something “not like”, that should “disappear” and “ashamed of it.” As such, they do not feel good in their skin, not pleased with themselves and “have something on their mind, a spot” (emotional injury).

In conclusion, sick children are more sensitive than healthy ones and need attention, guidance, emotional support and early establishment of psychotherapy.

 

BIBLIOGRAPHY

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  7. POPESCU, S., STANCIU,C.,(2011), Practica testelor proiective, Risoprint,Cluj-Napoca
  8. POPESCU, S., MORARU, A., STANCIU, C., MOLDOVAN, T., & SABAU, D. (2010), Quality of Life and other related factors in cancer patients, p.44, 24th Annual Conference of the European Health Psychology Society, Cluj-Napoca, Romania.

 

Correspondence to:
Faculty of Psychology and Educational Sciences, Dimitrie Cantemir University, Targu Mures, 3-5 Bodoni Sandor street, Tel.: +40-365-401.127; +40-365-401.129, Fax: +40-365-401.125 Email: speranta.psy@gmail.com, stanciu_cameli74@yahoo.com, adinamaris1975@yahoo.com, cozlealuminita@yahoo.com