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VOLUME 26 OCTOBER 1960 NUMBER 4

The fostering of mental health during the early periods of childhood is an area in which the pediatrician plays a vital role. There are two parts which have particular relevance for the pediatrician. One has to do with counseling around a particular problem or symptom, and the other is concerned with helping parents to understand the various stages of child develop ment in order to prevent some of the diffi culties which might otherwise be encountered. These two aspects were considered in this presentation.

COUNSELING IN RESPECTTO A

CHILD'S BEHAVIOR

When a mother complains about her child's behavior, how can a pediatrician go about in vestigating it? What does one look for? And if emotional disturbances are uncovered, what can one do about them? In the field of child psychiatry there is no neat answer to every problem. A behavior problem is not a clinical syndrome any more than a symptom like fever or headache is a disease. Furthermore, the clinical syndromes in the field of child psy chiatry are not as yet very well defined. There

are variables among the determinants of most human behavior which are hard to identify and to evaluate, and usually there are some that are unknown. This leads to the necessity of tenta tiveness at first in planning for a child's treat ment, and uncertainty, often, as to prognosis. For anyone, the effectiveness of what is done depends greatly upon how adequate an under standing of the child's environmental back ground one is able to acquire. Such aspects of the environmental background as the emotional atmosphere of the home, the personalities and emotional adjustment of the parents, the feel ings of the parents toward the child and his be havior, and the feelings of the child about the people around him, are all important.

The physician, in his attempts to explore this emotional background, may often feel frus trated, and he may feel particularly baffled and irritated by the resistance which both the parents and the children display toward reveal ing their real feelings and thoughts. The more profoundly disturbed the family, usually, the greater is the resistance. Everyone working in the field of human feelings and interpersonal relationships has to deal with it. In child guid

Presented at the Annual Meeting of the American Academy of Pediatrics, Chicago, October 20 and 21, 1958.

Summary prepared by Dr. Robert M. Kugel.

ADDRESS:Clay and Webster Streets,San Francisco15, California.

PEDIATRIcs, October 1960

700

@ediuIrics

AMERICAN

ACADEMY

OF PEDIATRICS

PROCEEDINGS

EMOTIONAL AND BEHAVIOR PROBLEMS IN CHILDREN

Summary of a Round Table Discussion

Hale F. Shirley, M.D.

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AMERICAN ACADEMY OF PEDIATRICS—PROCEEDINGS

ance work one attempts to deal with this kind of resistance by being patient, tactful and ac cepting. One should be careful not to probe too fast, for too obvious curiosity or aggressiveness just increases the patient's anxiety and resist ance. Sometimes, it is many weeks or even months before patients will become really com fortable with the physician.

Besides giving parents the factual data they need to arrive at correct conclusions, one of the most helpful things which the pediatrician can do is to give parents and children an oppor tunity to explore and clarify their problems, thoughts, feelings and desires, if they wish. He, like the psychiatrist, can listen sympathetically and uncritically, postponing advice until he can be fairly sure of the wisdom of it, and also until he can feel that the parent or child can make constructive use of it. If the difficulties can soon be brought out into the open, and if the parents, with the advice and support of the physician, can come to constructive de cisions and carry them out, the pediatrician may be able to handle the situation to the satis faction of everyone.

Some of the points can be further illustrated in a case (to be presented and discussed at length later) where there is not extensive family psychopathology and sociopathology:

The patient herself was a little 3-year-old girl, who was the first and only child in the family at the time; physically healthy, intelli gent and attractive. The mother was an attrac tive, energetic, well-educated and conscientious young woman who was not handicapped in the least bit by an inability to verbalize. The father was not seen, but there was no reason for be lieving that he was not a very capable and promising young man. It is usually helpful to have both parents come into the interview, but this case illustrates that this is not always necessary.

The mother was seen 10 times and the child was also seen enough to obtain a good idea of what she was like. Altogether about 12 hours were spent with the family. From the practical standpoint, if one were charging $25 an hour, the treatment would have cost the family $300, not much more than any acute illness with a few days hospitalization would have cost. In a period of 3 or 4 months, results were obtained which were satisfying to the mother, and the family was helped over a crisis.

This, it would seem, is the kind of a situation

which a psychiatrically oriented pediatrician could handle. There is no implication that a pediatrician should do so, because each physi cian has to decide whether he has the capabil ity and can afford to devote sufficient time to such problems; but in this case no psychiatric techniques were used which are not appropri ate to pediatric practice.

The case illustrates how the development and dynamics of a behavior problem gradually unfold, how ever deeper layers of the etiology and ever more obscure maladjustments of the past have entered into the picture. At first, one is struck by the immediate emotional upheaval with which one must promptly deal. Then, one probes for the situations and incidents which have led up to the difficulty, first in the back ground of the child, and then in the back ground of the parents. As one goes on, one attempts to put the material together in such a way that it makes sense and provides a formu lation on which plans for treatment can be based. Furthermore, the case illustrates the fact that one never learns everything one might like to know about a situation, but ordinarily one attempts to uncover only what is necessary for satisfactory treatment.

Finally, the case well illustrates, when viewed retrospectively, how much could have been done from the standpoint of prevention before the child was ever brought to the guid ance clinic: what, for instance, could have been done to help the mother in her childhood; what could have been done during the prenatal period and in the infancy and earlier childhood of the little girl.

The problem which finally brought the mother of this 3-year-old girl to the clinic was that for about 2 months the youngster had been running away from home. She had run away from home six times. The mother was really in an anxiety state about it. There was no ques tion here that there was sufficient motive for getting help.

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S@)a11king was the best technique, just scolded her. After that, the mother tried to prevent the running away by “¿justclamping down on her― and not letting her out of her sight, but under this regimen Mary was able to give her mother “¿theslip―3 more times.

One time when Mary threatened to run away, her mother tried a different tactic. She said, “¿Okay,run away,―and so Mary packed her bag, went to the neighbors, and stayed for an hour or so. Meanwhile, the father came home from work. The neighbors invited the parents over and they had some cookies and chocolate. After a while the parents invited Mary to go home with them, whereupon she repacked her bag and returned, and nothing further was said about it.

However, running away was only one of several complaints about Mary. For about 2 months, also, she had been wetting her clothes in the daytime, something she had not done for about a year. There were also times when she would revert to infantile speech. But the thing which her mother said concerned her most was that Mary was constantly disobedient and de fiant. The defiance was in all areas: eating, the use of the toilet and at bedtime. Before going to sleep at bedtime, Mary would get up at least 10 times so that it was almost midnight before she would go to sleep.

It is often helpful in a situation like this, which seems to be getting more and more com plicated, to ask the mother to describe a typical day. This mother, in response to such a request, started at the noon feeding. Mary, she said, let the food run down her chin. Then she threw her vegetables on the floor. The mother, in anger, stopped the meal and sent Mary to her room. In her own room Mary took all of her freshly ironed dresses off their hangers and stuffed them into a small doll house. She then scattered some dress patterns on which her mother was working all over the room. She next stuffed toilet paper down the toilet bowl. Finally, she got some scissors and cut the bottoms off the shower curtains. By this time the mother said she had “¿abeautiful case of indigestion― and she could scarcely refrain from resorting to physical violence. The mother wound up her story by saying that she felt that what her child needed was discipline, but that she had tried everything and nothing had worked. She had tried reasoning, she had tried punishment; she just didn't know what to do,

and she added, she didn't want anyone to tell her that she could handle it, because she couldn't; experience having shown that she couldn't!

It would only be natural for a physician in experienced in the psychologic aspects of pediatric practice to believe that his first task in a situation of this kind would be to tell the mother that what she was doing was wrong and how she should manage her child. It is true that mothers sometimes come to the physician expecting criticism, if not a scolding. Some attempt to avoid the criticism by with holding information. Some attempt to forestall a scolding by promptly admitting their errors. Others are prepared to withstand the criticism, and occasionally one sees a mother whose feel ings of guilt and need for punishment is so great that she seems to seek criticism. This mother early expressed her concern about her loss of temper and her inability to carry through with a line which she believed was the proper one. Moreover, by emphasizing and attempting to prove the point that she had tried everything and nothing had worked, she was saying two things: first, that it could hardly be all her fault; and second, that she would have no confidence in an@' quick solu tions which might be proposed.

What this mother wanted and needed, her physician soon decided, was acceptance, sym pathetic understanding, and relief from emo tional tensions which were fast building up to a level beyond her capacity for tolerance. Un til she could obtain some emotional relief, it was felt she could neither deal with her child's difficulties objectively nor make effective use of suggestions in regard to her child's manage ment.

So the mother was just encouraged to talk. By his comments, her physician attempted to convey to her his appreciation of the difficul ties she faced without emphasizing the serious ness of her child's behavior. His responses to her statements implied that he felt she was sincere and doing her best to be a good mother.

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with Mary. Now it's pleasant to be told a thing like this, and the physician should enjoy it when it happens, but he shouldn't assume that such prompt improvement can be lasting. In this case it wasn't; when the mother returned the next time, she said that things were as bad or worse than they had ever been.

At the same time that the physician was giving his attention to the emotional reactions of the mother and attempting to lessen the emo tional tension between the mother and Mary, he was attempting to unravel the history of the development of the present difficulties. This mother, as is true of most mothers, was willing to talk freely of the development of her child. As she gained confidence in her status with the physician, she began to show more and more of a willingness to talk about herself and her own background.

Mary's mother and father were married soon after their graduation from college. Neither of them felt ready for the pregnancy when it oc curred, largely because of economic reasons. The father was quite upset about it. The mother said that she was shocked, but that she recovered more quickly than her husband did, and eventually she came to look forward to the coming of the baby with pleasure. However, throughout her pregnancy she felt continuously ill in one way or another. She was hurt by the fact that her husband and friends, for some time, thought that her complaints were on a neurotic basis. However, when her baby was about 8 months old, it was established that she was physically ill, and she was placed in a hos pital until her child was 18 months old.

While the mother was in the hospital, the maternal grandmother cared for the child and, according to the mother, this grandmother was very strict and demanding. When the mother returned home she felt that her little girl was terribly spoiled, and she was very much hurt because the child showed her no affection. At this time, the maternal grandmother left and the paternal grandmother moved into the home. She was extremely lenient and tolerant; what is more, she criticized every effort of the mother to discipline her child. The mother felt that she overdominated the household and finally forced her to leave. After the mother took over her role as a mother, the situation gradually im proved until 2 months before she came to the clinic, when Mary discovered that her mother was pregnant.

After this, Mary began to talk disparagingly about babies. She stole a nursing bottle from a neighbor's baby, hid it under her own bed, and the mother later caught her drinking from it. It was at about this time that she began to wet her clothes and to speak with baby talk. Some times, when she became angry, she would threaten to cut the baby's head off.

Here then was a second group of facts which might be clinically significant. The history sug gested that the pregnancy was unwanted at first, and was the source of considerable emo tional turmoil early in the marriage. Could it be that Mary was really an unwanted child, and that her mother's present solicitude merely covered up a feeling of rejection, which broke out in anger and excessive punishment during episodes of stress? Could it be that Mary felt this rejection, was reacting to it with resent ment and defiance, and was playing for atten tion by resorting to behavior inappropriately infantile for her age? And then there was the matter of Mary's separation from her mother from the age of 8 to 18 months. What did this do to the feelings of the mother and child toward each other? The mother said that when she was in the hospital, she longed intensively for her child, and she was deeply hurt when she returned home to find that Mary was per sistently indifferent to her. There was also to be considered the fact that Mary was exposed to two types of discipline by her two grand mothers. Would this have been confusing to Mary? And finally, there was the matter of the mother's present pregnancy. Obviously, Mary was already concerned about her position in the family and was jealous of the coming baby.

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BEHAVIOR PROBLEMS

uncertainty and inadequacy. Throughout the early interviews, she was reassured that Mary was a healthy girl of normal intelligence, who was reacting in a very understandable way to her present situation, and that with her co operation there was no reason to believe that the situation needed to remain so uncomfor table. She discussed what was said in her inter views with her husband and was pleased at his interest and willingness to share the problems by devoting more time to Mary. The mother, at our suggestion, enrolled Mary in a nursery school. The social worker who had seen Mary felt that she was ready for it, needed it, and would react to it satisfactorily, which she did. Now what did helping this mother consist of during this period? Probably just teffing about these things released a great deal of emotional tension which the mother no longer directed toward the child. Probably the mother got some insight into the reasons the child was be having as she did, and she was able, therefore, to decide what it was this little girl needed. Also, the early experience that the child's be havior could improve increased her confidence in her ability to be a good mother. There were a number of aspects of the situation which were explored at considerable length. One was what the mother could do to prevent the increase of the jealousy, particularly after the baby was born. Another one was what the mother could tell the child about the matters of sex that were coming up. The subject was rather embarras sing to the mother, although she wanted to do the right thing. And finally, one bit of advice was given: that she be enrolled in a nursery school.

After seven interviews, the mother suddenly asked her physician whether, now that Mary's problems seemed to be pretty well settled, he would be interested in helping her and her husband, principally herself. She then dis cussed her lack of satisfaction in the marital relationship with her husband. She said that she had been troubled with this ever since their marriage. She felt that it was not fair to her husband, who was really a very fine husband, father and person. She said she felt very guilty about it, hated herself because of it, and wished it were different.

She said that she had always harbored a great deal of hate towards her own mother, describing her mother as a “¿coldfish―and a strict disciplinarian. She had always had the

feeling that her mother. was always right, and yet she resented it. She also expressed a great deal of disrespect and hate for her father, emphasizing particularly her feelings toward him in her early childhood when he was an alcoholic. In her childhood she blamed him for all the family difficulties, siding with her mother in that view.

Here, then, was the third collection of infor mation which might contribute to a more corn plete understanding of the problem and which also needed evaluation. It now appeared that the mother in her childhood felt unloved and rejected. One began to wonder just how capa ble this mother was of warm, loving feelings, and it soon became clear that she was still struggling (though she was still able to keep them pretty well hidden) with neurotic con flicts extending back to all of the early stages of her childhood. She told at considerable length of her jealousy toward her younger sistcr, which was so severe that at one time, in a fit of jealousy, she ran away from home and had to be brought back from a neighboring city 200 or 300 miles away.

At the beginning of the tenth interview she asked if it were all right to discontinue inter views, temporarily at least. She said that the interviews had served the purpose of “¿breaking the ice―as far as her sexual difficulties were concerned. She had been talking these things over with her husband and had been quite surprised at his reaction. Although she had ex pected him to be hurt and angry, he was kind, sympathetic and interested. She and her hus band decided that they wanted to see if they could work it out together. She was assured that this was their privilege, and that if her physician could be of any further help to them, he would most certainly want to be so.

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AMERICAN ACADEMY OF PEDIATRICS—PROCEEDINGS

mother's abdomen. The mother told her that she was going to have another baby. We asked the mother what it was that she wanted of us this time, and she said that all she wanted was assurance that she should handle the problems as she did the previous time. We told her that, as far as we could see, this was the thing to do.

COUNSELING PARENTS

This case described illustrates many points. From the standpoint of the functions of the pediatrician attempting to deal with behavior problems of children, some points in regard to the parents are worth further elaboration and emphasis.

First, while the physician is attempting to determine from the parents' complaints the nature, extent and seriousness of the child's behavioral difficulties, he should also be at tempting to evaluate the emotional components of the situation of which he has become a part. When parents seek help in regard to the be havior problems of their children, it is usually because they are driven to do so by their own anxieties. The anxiety may be quite obvious, even disconcertingly so, or it may be covered up with rigid formality, poise or display of a keen sense of humor; but it is wise for the physician to expect it, to be alert to the extent of it, and to be prepared to deal with it con structively.

In all probability, in addition to being anxious, the mother, in particular, feels guilty. She likely feels that she must be to blame for her child's trouble, that she must be doing something wrong, or that she is inadequate as a parent. She may, in addition, feel frustrated and angry—angry at her child because he will not respond to her efforts, and angry with her self because she cannot make him behave; she has tried and tried, and nothing has worked. The mother may early reveal these feelings directly or indirectly, or she may hide them, perhaps displaying a more or less disguised, defensive attitude. But as long as such feelings are intense and dominating, it will be difficult for her to consider her child's problems ob jectively, to accept suggestions which may be contrary to her feelings, or to change her methods of handling the child when this seems indicated. It would, of course, be unrealistic and futile to attempt to allay anxieties which are warranted by a dangerous situation or to overdo the act of reassurance by allaying the

parents' anxiety to the point where they no longer seek the help which they really need; such measures usually only “¿backfire.―More over, as most pediatricians have learned by repeated experience, merely telling parents not to worry about something does not always allay their worries and is often anything but helpful to them. Nevertheless, by his own self assurance, his sympathetic interest, his willing ness to listen, his sharing of responsibility for the solution of the problems, and his contribu tion of information, the pediatrician may be able to ameliorate emotional tensions which in themselves are a source of disturbance in the parent-child relationship. Even though such a measure does not entirely solve the problem, or at least for long, it lays the groundwork for, and encourages the mother to continue with, further therapeutic efforts.

The pediatrician can do more than this. By assuming the importance of the mother in the resolution of the difficulties, by respecting her ideas and efforts, and by supporting her in whatever remedial steps she feels she can take (when he feels that they are appropriate), he builds up the morther's confidence in herself as a mother. This is of fundamental importance. In the case that was presented, the mother, in working through a complicated situation, ap parently obtained enough feeling of self-confi dence as well as guidance that later when she was faced with a similar situation she felt, with a minimum of reassurance, that she could tackle it on her own.

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facilitated if she can be made to feel that the physician-parent relationship is a collaborative one. The physician, because of his objectivity, as well as his knowledge and understanding, may be a catalytic factor in the resolution of the difficulties, but what the mother and father have to contribute is of no less importance. The mother, after all, is usually the one who has most closely observed the child's development, and she is most familiar with the child's reac lions. She and her husband are also most aware of the characteristics of their home atmosphere and of their feelings toward each other and the children. More likely than not, the parent has some pretty good theories or even considerable understanding of what is wrong. Moreover, they, better than anyone else, usually can de cide what they can or cannot do to change the emotional atmosphere of the home and their attitudes toward the child or their child-rearing practices. So what the physician can accom plish depends greatly upon the co-operative attitude he can inspire in the parents and upon the assets and positive resources which they can bring into the therapeutic process.

As the physician, indirectly through history taking and more directly through his encourage ment of the parents to discuss freely their ideas and feelings, attempts to acquire an under standing of the etiology of the presenting prob lem and the dynamics of the home background, he obtains some insight into the feelings of the parents toward the child and his behavior. Child-rearing practices and philosophies, whether inherited by tradition or acquired by conscious effort, are of significance in the analysis of the disturbed situation; but in the long run, child-management techniques are likely to reflect parental feelings; and, more over, they are likely to be permanently effective only as they do reflect broad, pervasive and reasonably consistent parental attitudes.

As conversation with the mother (or father) proceeds the physician begins to form an im pression as to her (or his) attitude toward the child and his behavior. Thus, he may soon come to feel that the mother is a warm person, basically accepting of her child and profoundly interested in the child's welfare, even though she may be confused and upset. In this case, he may properly feel that there is a sound basis for entertaining much therapeutic hopefulness. Or, because of the extent and nature of the complaints against the child, the criticalness and vindictiveness of the mother's attitude, or

an extreme and unreasonable oversolicitude which alternates with periodic outbursts of rage against the child, the physician may sus pect that the mother's basic feeling is one of rejection, which may vary in degree from one of intense dislike to one of mere preoccupation with unacceptable behavior. The physician may further gain some impression as to whether the mother values the child as an ex pression of her own maternal feelings, either because of his accomplishments or because he serves her neurotic needs; also, whether she underrates or overrates his capacities. And, finally he may gain some idea as to the amount of dominance which she exerts upon the child: whether she is indifferent, overpermissive, over submissive, or is unable to be positive and firm or is overdemanding and overcontrolling.

Along with the evaluation of the parental attitudes the physician must appraise the ex tent and nature of both the psychopathology in the personality of the parents, if any, and the sociopathology in the home. Frank mental ill ness in the parents and grossly inadequate or disturbed home environments are usually easy to uncover, but much more commonly to be dealt with in a pediatric practice are the ubiquitous and more or less normal frailties of human personality and the ordinary and extra ordinary stresses of daily living, complicated frequently with marked degrees of personality deviations and neurotic conflicts which are often difficult to define and evaluate without skilled and sometimes prolonged study.

From these impressions the pediatrician

must decide what he feelshe can do to be

helpful. There is no simple answer as to what a pediatrician should and should not, or can and cannot, do. It depends, in addition to the extent and depth of the psychopathology and sociopathology in the case, upon the training which he has obtained in the psychologic aspects of medical practice, upon the interest which he has in working with the behavior problems of children, upon whether or not he has or can afford the time, and also, upon whether he has learned to make use of child guidance personnel for help with the diagnos tic and treatment procedures which need special training.

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can be acquired through practice, nonpsychia trically-oriented pediatric training will leave many young pediatricians feeling confused, inadequate and frustrated when dealing with emotional disturbances. It is the author's ex perience that it takes the equivalent of about a year of training and work with the emotional and behavior problems of childhood before the pediatric resident can integrate basic psychi atric concepts into pediatric practice, and deal with the rank and file of the behavior problems with a satisfying degree of self-confidence and effectiveness.

However, the pediatrician, and the general practitioner who engages in pediatrics, have an area and function in the field of mental health which is peculiarly their own. They are in the best position to educate parents in regard to the nature and needs of their children and to provide guidance and support to the parents in the appropriate management of the common emotional disturbances and behavior problems associated with normal social development that are inherent in the ordinary stresses of home, school and community living. They are in the best position to forestall or to minimize the emotional trauma resulting from illness. Fur thermore, in their assumption of responsibility for the health of children, mental as well as physical, they can play a fundamentally im portant role in their support of the develop ment of adequately staffed and qualified psy chiatric facilities for children, which are no where adequate in number or size to meet the recognized need.

CRUCIAL STAGES IN THE EMOTIONAL AND SOCIAL DEVELOPMENT

OF CHILDHOOD

From the standpoint of personality develop ment, childhood can be divided into six de velopmental stages. The child's personality in each period is built upon the foundations acquired in the previous periods. No child can skip a stage, nor can any child ‘¿besuccessfully hurried from one stage to the next. Each child has his own individual rate of emotional and social, as well as physical and intellectual, de velopment. One of the most helpful services a physician can perform for a child is to help the parents understand the kind of behavior for which the child is ready.

The child who is ready to adopt a more mature way of behaving can be expected to

provide the cues which signify these strategic points in his development. His interest in the new behavior can then be encouraged and he can be shown how to do it. Failures and errors, which are inevitable at times in the learning process, can best be ignored and successes should be approved. The thrill of achievement and of exercising his newfound powers, coupled with the social approval which success affords him, provides the child with the satisfaction necessary for the continuance of the more mature behavior.

It should be emphasized that personality de velopment is not always continuously advanc ing. Within every child there are three ten dencies competing with each other in regard to the direction of emotional and behavioral de velopment. First, there is the drive toward maturity; in the over-all picture this is nor mally predominant. Second, there is the need at times to remain static in order to enjoy the satisfactions of a resting point and to consoli date the gains already made. Third, there is the desire, at times, especially when the going gets tough, to revert to the satisfactions of the more immature stages. Such fixations and re gressions are usually quite temporary and should be no cause for alarm. If, however, the child fails to make a comeback, the cause for such failure should be investigated.

Only the first four of the following six age periods will be considered.

2) Late infancy 3) Early childhood

(“preschool―)

4) Late childhood (“schoolage―) 5) Early adolescence 6) Late adolescence

Age Range

The first year or 15

Early Infancy and the “¿Senseof Trust―

One of the most important developmental tasks of infancy and early childhood is to acquire a basic feeling of confidence in the self and in the world in which the child finds himself, which has also been called a “¿senseof trust.―°In the first years of life this feeling comes from the establishment of a satisfying

0 Erikson, Erik H.: Childhood and Society. New York, Norton, 1950.

Periods

1) Early infancy

months

15 months to 3 years :3to 6 years

6 years to puberty

Puberty to 17 or 18 years 17 or 18 years to matur

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BEHAVIOR PROBLEMS

dependency upon the mother. The mother child relationship, especially the first year or two, is a symbiotic one, and the infant, if necessary, will struggle desperately to maintain a close, satisfying and supportive relationship with the person who plays the mother role.

From the mother-child relationship, pri manly, comes the foundation for the develop ment of the child's feelings about himself, about people and about the world in general. The first year or two is the decisive stage for the acquisition of this feeling. If the mother child relationship is a satisfying one, the child acquires a feeling of his own worth and ade quacy and a feeling that his world is a pleasant, giving and rewarding place. To the extent that the mother-child relationship is not a satisfying one, however, the infant feels a discomfort. He becomes anxious and angry. His emotional tension may become manifest in such symptoms as tenseness, restlessness, fretfulness, whining, crying, clinging, persistence of infantile be havior, substitute satisfactions, loss of interest in people, and visceral dysfunctions. He begins to view the world as hostile and he becomes defensive. Resentment may be expressed in negativistic, resistive, overly-aggressive or hos tile behavior.

The physician's task, therefore, is to help the mother and infant—and the father too—to be as comfortable with each other as possible. It is becoming increasingly recognized that the emotional state of the mother and her feelings toward the child are more important in the development of a healthy mother-child relation ship than are the methods and techniques of infant care.

From the standpoint of the child, in the de velopment of a healthy relationship with his mother, the pediatrician plays a primary role in his fostering of the physical health of the child. Illnesses are likely to undermine a com fortable parent-child relationship without the understanding help of the physician. The rela tionship is also facilitated when feeding sched ules are kept flexible to meet the individual and changing hunger rhythms and nutritional needs of the infant. The prevention of un necessary conflict over eating is one area iii which pediatricians in recent years have been highly successful.

It should not be lost sight of, in one's con cern for the infant's welfare, that parents also have needs and schedules. Parents are also

human, and being human means that there are infantile experiences and needs at the core of their personalities.

There are three situations in infancy and early childhood which may undermine the child's sense of security and which are worthy of special consideration. The most common of these is the anxiety and resentment which the small child feels when he discovers that he must share his parents' love with a newly arrived sibling. Such feelings of jealousy probably cannot be entirely prevented, but if the parents can be helped to recognize the symptoms and to accept the feelings, even though they may have to restrain some hostile behavior, the seriousness of the emotional dis turbance may be minimized.

Another important factor in the normal per sonality development and socialization of the child is a continuous relationship with one per son—the mother figure—in infancy. Deprivation of “¿mothering―or prolonged separation from the mother in certain instances interferes with both mental and emotional development. This ma produce what has been called an “¿affec tionless character.― Such a child is lacking in capacity for feelings of affection and thus lacks motivation for socialization.

According to Dr. Bowlby,° a baby or small child separated from his mother goes through three stages of reaction. The first he designates a “¿frettingstage― or a “¿stageof protest.― Dur ing this period the child is very unhappy and miserable; he cries, fusses, and makes every effort to get his parents to be with him. Then comes a transitional period of varying length, which he terms the “¿periodof despair.―And finally there develops a period which he calls the “¿settled-inperiod,―which is characterized by the defense mechanism of denial (probably really repression) and in which the child ad justs to the new situation, but he loses interest in his own parents.

The seriousness and permanency of this type of reaction to separation from the mother apparently depends upon a number of factors. An attempt is being made to clarify the rela tive importance of these factors. One, quite clearly is the age of the child. Probably it

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AMERICAN ACADEMY OF PEDIATRICS—PROCEEDINGS

months of age, when a child begins to cry at night he may need soothing, but he may need to “¿cryit out,―which will probably not be in jurious to him. By 2 years of age, he may have trouble getting to sleep, and here the parents should be helped to realize that the anxiety is real. Frequently, if the mother will sit in the room with the child until he falls asleep, the problem may be over in 1 to 2 weeks.

The separation that occurs in the case of working mothers need not be a problem, if the mother assumes the role of a mother when at home. Sometimes there is a conffict between grandmother and mother and here the physi. cian may need to help the mother to tesolve the problem. A child will be confused, however, by confficting and changing philosophies. Although it is generally preferable to have the mother with the child until he is 4 to 5 years old, it may be that the mother has great need to be out of the home sooner.

A third situation which may adversely affect the socialization of the child, is that in which the mother is unable to feel affection for her child. In the attempt to understand a mother's reactions to her child, one must investigate such factors as: the emotional relationship she had with her own parents and how they managed her as a child; the development of her feelings toward her own siblings; the degree to which she accepts or rejects her own femininity; the satisfaction she experiences in her marriage relationship; the motives she has or does not have for wanting a child; her conscious and unconscious expectations for the child; the experience she has had in taking care of infants and small children; and the quality of help she can obtain during the ambivalent feelings and anxieties she experiences in her new role in life.

Late Infancy and the “¿Senseof Autonomy―

From about 1 to 3 years of age is the crucial period in the child's life for the development of what has ‘¿beentermed a “¿senseof autonomy.― He becomes aware of himself as an individual. He is inclined to be uninhibited and curious and to be into everything. His judgment is poor, yet he resists limitation and domination. So this is the decisive stage in the development in the child's feelings of being an independent in dividual, on the one hand, and of being able to accept the guidance and help of others, on the other.

doesn't matter who takes care of the child or whether he is separated from his mother before the age of 3 months or possibly 6 months, but by 9 months the child's dependence upon his mother is becoming a profound one, reaching its peak at about the age of 2 years. After that, it gradually decreases, and the effect of separa tion from the mother (or the person playing the mother role) after 5 or 6 years becomes of less importance from the standpoint of the distor tion of basic personality development.

Another factor determining the child's reac tion to separation is the quality of the relation ship that existed between the child and the mother before the separation. If this has ‘¿been very satisfactory to the child, deprivation of the mother's care is felt as a great loss. If the relationship has been highly unsatisfying to the child, separation causes little additional dep rivation.

The length of the separation is also an im portant factor. If the separation is for only a few days or during the “¿periodof protest,― al though the emotional upheaval may be great, the process is quite reversible. If the child returns to the parent during the transitional period, the result may or may not be reversible, depending much upon the parent's reaction. If after the separation, the mother is understand ing and accepting and permits the child with out censure to be clinging and overly dependent for awhile, the condition seems to be reversible; if the mother is coldly rejecting of the child's emotional distrubance, it may not be. After a year or two of separation, the child may not be able to recover. Dr. Bowlby has stated that he followed some of these children for several years and the emotional defect persists.

The completeness of the separation is an other factor determining the seriousness of the child's reaction. If the child is in a hospital and his parents visit him frequently, there is less likelihood of emotional harm. The availability and quality of a substitute relationship may be another crucial factor. A warm mother-figure may eventually be a satisfying substitute for the absence of the mother. If a child must be in a hospital for a long time, it may be better for one person to have a close relationship with him than for many to give him relatively impersonal care, even though their attitudes are kindly.

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It is to a great extent during this period that the child's basic attitudes toward authority are acquired. The wise parent wants to encourage normal aggressiveness and curiosity and yet, be cause of the lack of knowledge, experience and judgment in the child of this age, and for his own protection as well as for tolerable home living, limits of acceptable behavior must be set.

The limitations that the parents set in early childhood, and the attitudes which they display toward different kinds of behavior, eventually become a part of the child's personality and later, more or less automatically, restrain un desirable behavior from within. When limits are not set, the child does not learn the basic elements of self-discipline and continues to step frequently over the bounds of the socially toler able; this keeps the child in trouble, confused and anxious, and eventually results in parental explosions or frustration and resentment. But if the limits which the parents set are to be effective and are to result in a healthy, well socialized “¿conscience,―they must be appro priate to the age and stage of maturity of the child. To attempt to hold children of all ages rigidly to adult standards, can result in nothing but constant friction between the parents and the child, emotional upheaval in the child, and frustration for the parents. In the socialization of the child during this period—when his inner drives are powerful, when he has little control over his feelings, and when his ability to “¿rea son―is very rudimentary—it is hardly possible for parents to avoid all friction and heat or out bursts of anger at times. Fortunately, when they make mistakes (as all parents must at times) serious harm will not result, if the parent child relationship is basically a healthy one.

Parents frequently ask the physician how to handle temper tantrums. In homes in which all family members frequently and freely give vent to their hostilities, temper tantrums in the small child may not be considered a problem; he is

merely fitting into the pattern of family living

which is held up to him. In most families, how ever, even if the parents cannot handle their own hostilities well, violent temper outbursts on the part of the child undermine the confi dence of the parents.

The physician may be able to help the par ents handle such episodes in a constructive manner. First, the parents must realize that

when the child is angry, there is some reason for it. If he is chronically angry, he and his par ents are probably headed for trouble, and the emotional atmosphere of the home needs inves tigation. In any case, causes may be found that are unnecessary and removable. Second, the parents should know that when anger once has become mobilized, it must dissi pate itself in one way or another. It may be that when the anger has accumulated to the limit of the child's tolerance it is healthier for the energy to become discharged in a fit of anger than to let it seethe within at the expense of normal visceral functioning. Third, the par ents should be supported in their effort to teach the child that he cannot utilize his anger to get his way or to dominate the household. Often it is best to ignore the temper. When this cannot be done, it may be best, at times, to send the child to some appropriate place where he can have it out. Then, when he has gotten over his anger, he is received back promptly into the good graces of the family. Fourth, the child should not be made to feel that he is inhuman, abnormal, bad or criminally inclined because he becomes angry at times. It is better for him to be able to look upon his feelings as normal and human even though one cannot approve of them or leave them uncurbed, for otherwise the child has to deal with feelings of guilt and anxiety superimposed upon his resentment; when intense such feelings may lead to patho logic symptoms.

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AMERICAN ACADEMY OF PEDIATRICS—PROCEEDINGS

first comes to the child in a highly significant way in relationship to toilet training. We live in a society in which cleanliness is highly valued. The sight and odor of the infant's feces is disgusting to many parents; they want to get over the toilet-training period as soon as pos sible, if not sooner. This too often results in a prolonged feud or a “¿knock-downand dragout fight―which adversely affects the development of the child's feelings about cleanliness, elimi native and sexual functions, aggressiveness and authority in general, or results in defeat for the

parents.

There are a number of possible solutions to the child's dilemma. The socially desirable re action is for him to adopt the adult behavior patterns. The healthy child can be expected eventually to do this, if he feels secure in the love and approval of his parents; if his satis factions in living have not ‘¿beenotherwise Un dermined; if too many demands have not al ready been made upon him; if he is not, during the training period, in an emotional crisis over such matters as weaning, the birth of a sibling or starting to nursery school; and if his parents are patient and tolerant of accidents until he has acquired reliable control. Sometimes during this period the child may have a period of fecal smearing. Here parents need to know that this is not a catastrophe, but the child must also be helped to see that this cannot go on.

In addition to conforming, he may take over his parents' feelings in regard to the dirtiness and smelliness of defecation. If parental pres sure has been great, he may become anxious about possible accidents and, sometimes, preoc cupied in regard to matters of cleanliness and overcontrolled to the degree of compulsiveness. Or even though conforming, he may continue to harbor anger and resentment, which often, to the parents' bewilderment, finds expression in negativistic or hostile behavior. Occasionally a child refuses to become “¿broken,―continuing to soil to the age when such behavior is labelled as encopresis.

Ordinarily, toilet training will not be much, if any, delayed if the parents are willing to wait until the child provides cues in regard to his readiness for it, i.e., interest in his bowel functioning and a desire to do what he sees adults doing, or at least until the child is able to walk and run well, which is a good indica tion of cerebral control over the reflex centers ing to the parent's emotional burden.

In clinical experience of dealing with fami lies, one encounters many conflicting opinions as to the value of punishment. There are par ents who believe that regular spankings, analo gous to daily vitamins, are good for the child's mental health. Then, there are those parents who believe that there may be better methods of punishment than physical trauma, but they sometimes exhaust all their other resources and just do not know what else to do. Then there are those parents who, whether or not they ap prove of physical punishment intellectually, find that an occasional spanking is a good outlet for their own accumulated hostility, and they hope it serves the same purpose for the child. There are also parents who believe that their children need punishment, but they cannot bring them selves to administer it. Finally, there are par ents who are confident that they are able to control their children adequately without pun ishment.

The physician dealing with this matter must be careful lest his own feelings, rather than an objective evaluation of the situation, determine his course of action. For instance, if he identi fies strongly with the parent against the “¿bad― child, he may fail to understand the meaning of the child's behavior. Conversely, if he identi fies with the child, feeling that the child is being abused by a hostile, punitive mother (which may or may not ‘¿betrue), there is dan ger of his not being able to understand the problems and difficulties of the mother and thus, of his not being able to help her and, through her, the child. But physical punish ment, especially if frequently and severely ap plied, is likely to backfire, arousing feelings of anxiety, hostility and guilt in the child, which only adds to his emotional disturbance. Ordi narily, in child guidance work, as the parents gain understanding of their children and of their own emotional relationship to their chil dren, punishment, particularly corporal pun ishment, becomes less and less of an issue; bet ter and more effective measures can usually be found. In any case, punishment is never the es sential aspect of discipline. Well-socialized be havior comes piimarily from being loved and learning to love in return. It comes also from the child's need and constant effort, in spite of many failures, to become like his parents.

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of the lower region of the spinal cord. When parents are unwilling or unable to do this and want to help hurry things along, the physician

may still be of help to them, if, while out lining a procedure of putting the child on the potty, etc., he emphasizes the importance of not making an issue of failures and ac cidents.

The Preschool Child and the “¿Senseof Initiative―

The preschool child is still self-centered, parent-oriented and emotionally dependent upon his parents, but he is becoming increas ingly independent physically. At the same time that the child is learning the rudiments of family living through his relationship with his parents, he is acquiring the capacities and ex pen 3nces necessary to get along with other children. If he has siblings, he has the oppor tunity at home to work through his social prob lems with them, or if he has none, a nursery school may be of help to him in his social de velopment. This is the period when he needs to acquire a socially acceptable balance be tween aggressiveness and restraint. One wants him to acquire and maintain an initiative in satisfying his basic needs and a confidence in his ability to do so. At the same time one wants him to learn the value of co-operative activity and the disadvantages of fighting, in spite of the importance of being willing to fight if ne cessary.

During the preschool period the child not only continues to develop his concept of him self as an individual, but becomes increasingly aware of his own sexuality. This is the decisive stage for acquiring healthy attitudes toward sex. It is quite generally recognized now that the emotional foundations for sexuality are ac quired during the first 6 years of life. However, contrary to popular belief, sex education or training does not consist only of the impart ing of the “¿factsof life―at the appropriate time—important as such teaching is. Sex edu cation begins in early infancy with the de velopment of feelings the individual acquires in regard to his bodily functions, also the feel ings he acquires—and the development of these feelings as he proceeds through infancy and early childhood—toward his parents and, to a lesser extent, toward his siblings. The impor tant aspect of sex training is the development of the child's capacity for receiving and giving

love, and this, as has already been pointed out, is bound up with the development of the parent-child relationship and the satisfactions which the child obtains from parental care and training.

Frequently, a question is raised about the best time for doing an elective circumcision. During the 3 to 6-year-old period is espe cially bad, because the child is apt to view this as punishment and to regard it as an attack upon himself. As it is difficult to explain this to him, it is best to postpone circumcision until after 6 years of age.

Some parents may need to be cautioned not to overwhelm their child with facts which he is not yet ready to understand or to use con structively, yet if a child is old enough to ask a question, he is old enough for a factual an swer. Certainly, as soon as children discover the anatomic sex differences, they should be assured of their own normality. Even informa tion concerning sexual intercourse should not be withheld when the children seek such in formation.

Perhaps more important than the factual an swers the child receives to his questions, is the attitude towards sex to which the child is ex posed—the manner in which the parents deal with the sexual material. If the child can learn

to feelthe naturalnessof sexualityas well as

what is socially acceptable and what is not, he will be able to deal with his later thoughts and feelings much more realistically. It is particu larly important in the interest of later mental health that the child (as a result of scoldings, threats, and punishments) does not acquire feel ings of dirtiness, badness and shame in connec tion with his normal sexual feelings. The child, as has been mentioned, must learn what society expects of each individual in regard to sexual conduct, but he also needs to learn of the con structiveness both of love in social living and the role of sex in family living. By helping the parents to deal more comfortably with these sexual problems, the physician is helping to in culcate into the child sound emotional attitudes for later successful sexual adjustments.

(14)

always to be solved the problems of satisfying his own needs, of keeping in the good graces of his family, of avoiding punishment, and of growing up and adjusting to an intriguing, but strange, sometimes threatening, and ever-ex panding world. The point of significance is not so much whether there are behavior problems

or not, but rather whether the child, with the help of his parents, is successfully working at their solution. In many children there will be more of less persistence of infantile patterns during this period as well as reversions to in fantile behavior at times when there are diffi culties. There will, also, at times be symptoms of anxiety and signs of frustration and hostility. Usually, patience, tolerance, humor, under standing and sympathy on the part of the par emits will be more helpful to the child in over coming such immature and emotionally driven behavior than criticism, scolding or punish ment, even though the latter may be indicated at times. If, however, in spite of all the physi cian and parents can do, unsolved emotional problems amid the behavior characteristics of one stage of development persist into the later stages, psychiatric study is indicated.

Enuresis is a problem often encountered by the pediatrician. Certainly there is no one @va@ to handle it, but it is important to establish that there is no organic basis, as is true in most instances. Often this is but one of mans' s\mp toms which the child has. When this is the case, it is likely that psychiatric help is in order. Although there is often a familial pattern in enuresis, genetic heredity seems difficult to prove. It is perhaps more a question of “¿social― inheritance.

Many techniques have been advocated for the control of enuresis, such as drugs and wak ing-up devices. In some instances they are suc cessful, but frequently making a great issue of the matter only rivets the child's attention to the problem. In general, bed wetting should not be considered pathologic unless it continues beyond 3 to 4 years of age. If parents consider it a problem at an earlier age, reassurance is usually indicated.

Although encopresis is only one tenth as

common as enuresis, the emotional impact is

usually greater. It usually indicates a greater degree of disturbance on the part of the child, and will usually require psychiatric help.

The question of the use of tranquilizing drugs is timely. They may be helpful in a van

ety of situations, especially because they pro duce less cortical sedation. It is important to realize that one is treating a symptom only and therefore the use of a drug alone is generally not the treatment of choice. If used in conjunc tion with the child guidance approach, there may be considerable benefit.

The School Age and the “¿Senseof Duty and Accomplishment―

The active interest of the pediatrician in well-child care should continue well into the school-age period, for developmental tasks es sential to communal socialization now emerge from the accomplishments in the elementary and domestic socialization of the infantile and preschool periods. The child not only continues to grow up, he “¿growsout,― for during this period, on his was' to community living, his interests and activities become centered about school life, both academic and social. During this period, he must free himself from primary emotional dependence upon his parents, join peer groups, give as well as receive love, identify with contemporaries of his own sex, learn more social rules and morality, use lan guage to exchange ideas and influence people, and develop a scientific approach in his think ing.

Starting to school, then, is a crucial point in the social development of the child, although nursery and kindergarten experiences help make the transition easy for many children. For some children this first step into com munity living means entering an environment in which the expectations, demands and emo tional atmosphere, and even the ethical stand ards, social values and cultural patterns, are different from those in the home to which they have learned to adjust. For all children, the change means learning to adapt to a group of children with needs like their own. In an at mosphere of security and acceptance (which the understanding, kindliness and permissive ness that the teacher, as a substitute parent, at first brings into the situation) the child can

gradually learn to satisfy his own needs through his own efforts and to work and play in harmony with others whose needs are en titled to the same consideration and satisfaction as his own.

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the adjustment necessary the first 3 or 4 years of school life. Successful adjustment depends upon several groups of factors. First, the pre school home care must provide the child with the emotional and social readiness and the ele mentary and domestic socialization which are basic requisites to the developmental tasks of school life. Certainly, behavior problems are inevitable at first if the child brings to the school, for projection upon his teachers and classmates, chronic and dominating anxieties and hostilities which have been unresolved in relationship to his parents and siblings at home. Second, the school atmosphere must be accept ing, understanding, tolerant and flexible, even though firm, until the transition has taken place. Third, the child must be intellectually, as well as physically, emotionally and socially,

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1960;26;700

Pediatrics

Hale F. Shirley

Round Table Discussion

EMOTIONAL AND BEHAVIOR PROBLEMS IN CHILDREN: Summary of a

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1960;26;700

Pediatrics

Hale F. Shirley

Round Table Discussion

EMOTIONAL AND BEHAVIOR PROBLEMS IN CHILDREN: Summary of a

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