Pathologic Transitional Object : A Case Report

A transitional object is the selection and binding to an object that reminds the child of the mother and helps deal with separation anxiety in situations where the child is separated from the mother. In reality, many children are observed to have transitional objects and no problems occur. In this case report, the transitional object became pathological. An only child, the boy was 3.5 years and wished to wear the pyjamas chosen as transitional object in all areas of life. According to anamnesis from the family, there was no socio-economic problem experienced. Additionally, the child’s developmental curves were normal and there was no physiological health problem. The child experienced problems in home and school life and this situation negatively affected the mother’s home and professional life, so the case was dealt with. The study applied a strategy developed based on a behavioral approach combined with an object relation approach. At the end of the four-week program completed with the parents and child’s teacher together, the problem was solved and follow-up one month later identified that this had not changed.


The Problem
The childhood period is a process with difficult and problematic experiences, in addition to good experiences.In the early childhood period, social and environmental factors directly affect the child's physical and mental development.As a result, negative experiences cause developmental arrest and problems (Bertan et al., 2009).While children are configuring the basic patterns of their personalities in the period from 0 to 6 years, they continue their development by encountering many events and problems.One of these involves children's relationships with objects.
The scattered experiences of children in terms of time and space in the first years of life form the core of their selfhood.In this period, mother-child relationships shape the child's experiences relating to their basic needs being met in timely and sufficient manner.Mothers who provide sympathetic responses to their children's needs will help the child to develop a consistent sense of self (Winnicott, 1998).In this process, the relationships between the parents and child, games and other experiences are important because according to object relations conceptualists humans internalize interpersonal relationships by transforming them into images (Gectan, 1993).
The object relations conceptualists of Melanie Klein, Donald Winnicott, Margaret Mahler and Heinz Kohut focused on the child's relationships with their surroundings.Children imprint trust-centred personality through the mediation of relationships with their mothers and fathers.They also reflect different situations through objects during times when the parents are not with them (Burger 2006).
One situation related to object relations in childhood is defined as a "transition object".The transition object concept was first explained by Winnicott.Accordingly, the child becomes aware of themselves as a separate individual from the mother.They choose an object to remind them of the mother and bond to it in an attempt to deal with separation anxiety.These include objects with long duration in the child's life like blankets, pillows and toys to which they bind excessively in problematic situations (Ongider 2013).

Importance of the Problem
This study investigates a pathological case related to a transition object.In this case, the transition object of the pyjamas transformed into a fetish object after some time.The roots of this situation are found in traumatic events occurring in the first months of childhood and disrupting self-integrity (Oguz and Uygur, 2005).Separations from the mother and anxiety before the phallic period play important roles in the development of a fetish object (Oguz & Uygur, 2005).
The case wore the pyjamas used as transition object everywhere (home, preschool, park, mall, etc.) and at all hours of the day.He experienced crying fits and anger seizures when they were removed.

Case
The case's mother was a formation student in teacher training at Ordu University Faculty of Education.She applied to the guidance service of the psychological counselling and guidance department seeking help.As the case was extraordinary, the mother was informed about ethical rules and written permission was obtained to publish this case study.The information from the preliminary interviews about the case were limited to information obtained from the mother.
The case was a 3.5-year-old male and the only child in the family.Born by caesarean, the child had not experienced any significant physiological health problems.The child began to walk at 1-year-old, was toilet-trained by 2.5 years and began to use single syllable words at 9 months.According to anamnesis information, the mother and father were university graduates, they lived together and had no socio-economic problems.The mother left work after the child was born and cared for him until preschool.
After the child began preschool, he wished to wear the same pyjamas at school, at home and in other places.He displayed an intense response when they were removed, entering crying seizures.When he was dressed in something else, he kept the pyjamas in his hands and looked unhappy.The mother stated the problem had lasted nearly 2 months, she had not been able to start work since this began and there were problems experienced in preschool.As a result, they had applied to a variety of mental health experts but no solution had been found.
During an interview with the family, the father, who was a banker, stated he came home late and tired, and the family had nearly no quality time spent as a family.The child's preschool was visited and observations made.Information was obtained from the teacher.Accordingly, the child displayed resistance to entering group dynamics, sat alone in the corner and observed the area with a sad and angry expression.He did not want to sleep at naptime.When the mother accompanied him, he wanted to play with her and wanted her to sit at the table with him.

Diagnosis
A diagnosis was made of pathologic bonding with the pyjamas used as transition object.The pyjamas had transformed into a fetish object after some time.The child wore the pyjamas not to discharge stress but to gain from the object (Gectan, 1993).
The anxiety forming as a result of the mother leaving the child at preschool was compensated by the pyjamas.This is because the transition object (pyjamas) corresponds with the attributes of the mother (Winnicott, 1953).

Strategy
During the problem determination and strategy formation stages in the study, the object relations concept was used.A strategy based on the behavioural approach was applied in solving the problem.Morgan and McMillan stated that behavioural techniques may be integrated with object relations and attachment concepts and they reported successful results in the literature increasing support for this approach (Corey, 2005).

Application
The necessity for quality time to be spent between parents and child was stated and a weekly behavior activity plan was made.In line with this, the following recommendations were made;

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In the preschool period, the child's relationships with the mother-father are important (Knauth, 2000).In line with this, spending time with the child in entertaining activities (reading, singing, cuddling, etc.) will positively affect the well-being of the child and family integration (Ozmert, 2006).As a result, games appropriate to developmental age involving all members of the family with the child given an active role were planned (doctor set, kitchen set, Lego etc.)

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Touching plays an effective role in trust, love and acceptance (Erkan, 1988(Erkan, -1990)).Parents abundantly touching, hugging, smiling and talking with the child have an important place in development (Wickelgren, 1999).Physical contact is reported to be effective in development of positive self-esteem (Culbertson et al, 2003).The parents were asked to hug the child frequently and hugging games were explained and planned.The necessity of continuing contact until the child does not want to be touched anymore and pushes them away (with touching left for a while afterwards) was explained.
• One of the methods related to ending negative behaviour in the child is ignoring it (Basar, 1999).Nothing was said about the child wearing the pyjamas with neutral behaviour displayed; in other words, ignoring the behaviour was applied.

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The child was given a daily responsibility that they could complete (bringing bread or spoons to the table, taking them away after eating) (Ozen, 2015).

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Information was given about responsibility such as the child organizing their own bed and closet, collecting toys and dressing themselves alone.Recommendations were provided about making this easier in accordance with the development of the child (e.g., buying elasticated trousers, practical bed covers that can easily be arranged, etc.) The following recommendations were made to the preschool teacher; • Similar to the recommendations to the parents, nothing was to be said about the child wearing pyjamas with neutral behaviour displayed.
• Before naptime, the child should be accompanied to the sleeping area and simple organizations made, with the child given responsibilities in this process.

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The teacher was requested to include the child in an active role in meeting all basic needs (toilet, eating, water, etc.) and to ask the child frequently if they needed anything.

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The teacher was asked to frequently hug the child, and that contact should continue until the child pushed away (with touching left for a while afterwards).
• For timid and shy children, structured games and activities with low stress levels may be beneficial (Ozmert, 2006).In line with this, the child was called each time after preparation for group games.However, there was to be no insistence if he did not come.
The items listed above were recommendations in line with preparing an environment where the child can move from an immobilizing strategy of secondary bonding with the teacher to a hyperactive strategy (Calısır, 2009).
Parents and teacher were requested to fulfil these recommendations for one week and note any problematic situations with explanations.An appointment was made for one week later.
At the first appointment, the parents stated the child did not get tired of hugging and the duration of contact continuously lengthened.At this point, they were requested to continue contact games and to increase hugging further.There were no clear problems experienced with completing the other parental recommendations.
At the first appointment, the teacher stated the problem continued.However, after two days of not taking an active role in sleep area organization, the child began to happily fulfil his tasks.The homework related to hugging involved some problems due to work intensity.As a result, there was not too much hugging.The teacher was asked to continue with the recommendations, to lengthen the process of arranging the sleeping area and to use verbal reinforcement about the child's duties.Reinforcement is effective in ensuring continuation of behaviour (Babayigit & Erkus, 2016).Praising the child immediately after positive behaviour plays a role in discipline (Larsen & Tentis, 2003).
At the second appointment, parents stated the child sometimes got tired of hugging and wanted to play alone.In this situation, the role of secure attachment was explained and recommendations were renewed.The parents said the child was very happy and enthusiastically went to school.At the second appointment the teacher said the child happily sat at the table and ate his food and happily completed his sleeping area duties.
At the third appointment, the parents stated the child was very happy, hugging was at normal levels and crying fits had stopped.At this stage the premack principle was used (Mitchell & Stoffelmayr, 1973).The mother was asked to give him the responsibility of collecting dirty clothes for washing with the condition that they will play his favourite game after the dirty washing was collected.Here, it was predicted the child would bring his dirty pyjamas.Neutral behaviour was requested whether the child brought the pyjamas or not.
The teacher was requested to act neutrally on the first day the child attended school without the pyjamas.On other days, they were asked to tell the child how his clothes suited him.Additionally, they were asked to request that the child help them in bringing the other students to the sleeping area and in keeping them quiet before naptime.During this process, the child will want to play the sleep game with the other children and the dominant role is given to the child.Later, after moving to the sleep area and the children sleeping, the teacher was asked to use verbal reinforcement with the child.In the evening, the child was to explain what they had done related to sleeping to the mother and father and the child was to be rewarded with a toy.On other days, similarly the child was to be included in suitable games and inserted into the group dynamics.
At the fourth appointment, the parent and teacher stated the problem had ended and that the child was happy.Information was given about child development and they were requested to contact the counsellor if there were any problems.One month later, there were no problems experienced according to information from the parent.

Discussion
When determining the problem, the starting point was in line with the transition object concept.A transition object is defined as orientation toward an object associated with the primary carer (mother or childminder) to compensate for or ease anxiety as a result of long term separation of the child from the carer (Winnicott, 1953).In this case, the mother looked after the child at home until he began preschool and as the father could not spend time the child due to his work intensity and excessive stress, a pathologic attachment was observed between the mother and child.
The mother wished to start work after the child reached preschool age (3.5 years) and the child's reactive behaviour began as a problem with a pathologic transition object.However, some researchers have not observed the transition object as a problem.The study by Lehman et al. (1992) identified that children with transition objects develop more secure attachment.Hobara (2003) found the rate of transition objects was 30-70% among children and that there was no concrete evidence of whether or not there was a psychopathologic problem with attachment in the presence or absence of transition object.In this case, the transition object was pyjamas and the child wished to wear them at all times, and resisted with anger fits when the pyjamas were removed, so it was assessed as psychopathologic.The child experienced problems in school and conflict with the parents related to the transition object and this situation caused unhappiness.
The study followed a strategy to create a quality parent-child relationship, because the parent child relationship is effective in psychological development (Burger, 2006).The case was a 3.5-year-old child and the parent child relationship is very important from 0-6 years (Knauth, 2000).Additionally, according to anamnesis obtained from the parents, the father's relationship with the child was at low levels due to work intensity and stressful living conditions.In reality, an interested father plays an important role in creating fewer behaviour problems in the child (act.Ongider, 2013).It was also determined that activities with the father contribute greatly to secure attachment formation (Bowey, 1995).In line with this, a structured program was applied involving quality time spends with the mother and father.Increasing the quality of the parent-child relationship by active involvement of the father will end the pathologic attachment between the mother and child.Over time it is assumed the child will make an effort towards autonomous behaviour.Additionally, gaining skills about taking responsibility at home and in school and completing duties were added to this strategy.Thus, it was considered the happiness and self-confidence gained would contribute to the child's autonomy.This is because responsibility secures a child's feeling of confidence, sharing contributes to learning, success provides pleasure and contributes to taking initiative and organization skills (Ozen, 2015).Variations in line with the strategic targets were observed in the case both at home and at school.With the child's rapid gain of autonomy skills, the need for a pathologic transition object reduced.Later, negative behaviour ended.
In this study it was concluded that in cases with pathologic transition object, behavioural techniques together with strategic applications based on object relations concepts were effective in solving the problem.