Child Guidance
- Author:
BARBOUR, F.R.C.P., D.P.M.
The study of the psychiatric problems of adults has shown that they mostly start in early life before the individual has reached school age. It is in the first five years of life that the emotional attitudes of a person are formed, his independence or sense of inferiority, his reaction to authority and to people of his own age. These are the .emotional patterns which determine neurosis in later life. When the importance of the child’s psychological problems was first realized, people shrank from using the word ” psychiatric ” to describe them, as that term was almost synonymous with ” mental ” or ” lunatic ” and instead the term ” Child Guidance ” was used, the word ” guidance ” emphasizing the natural growing powers of the child, who could be guided to grow aright.
All behaviour can be- regarded as the resultant of three sets of forces. There is first the inborn heredity and constitution, then early training and experiences, and finally present environment, both material and social. The same behavour, stealing, bed-wetting or nightmares, will be assessed very differently according to the contributory factors. An only child of university capacity, but with a broken home, who steals, is a very different problem from the tenth of twelve children who sits near the bottom of his class and whose only recreational facilities are the street or bombed-out site. In each case the relevant facts under these three different headings must be found out, a time consuming process but in the long run well worth while. It is possible for a single properly qualified individual to elicit all the facts but in clinics the custom has grown up of having a team of three, psychiatrist, psychologist and psychiatric social worker, though some clinics would add two other members to the team, paediatrician and play therapist.
Before seeing how the team works it is worth while considering where the child should be seen. Practice differs, at the one end there is the mental hospital out-patient clinic, at the other the individual interview at the child’s own school. The hospital staff stress the continuity of patient and symptoms with full facilities for laboratory investigation and in-patient treatment, while those who favour the interview in school, point out that the child is seen amid familiar surroundings, that he can be observed in the playground and that he does not even know that he is being thought of as a ” special case “, let alone a patient. Still somewhat opposed, but? less markedly, are the Child Guidance Centre and the psychological clinic at a Children’s Hospital. The latter may have unpleasant associations and arouse memories of injections, tonsils ; the word ” centre” is preferred by many educational psychologists as it is non-medical. In the middle comes the Child Guidance Clinic, usually psychiatric in its approach, but sometimes more broadly medical with a psychiatrist only consulting as required.
From the foregoing it can be seen that the emotional problems of children can be approached from two different angles, the medical and the educational. The same problem can be regarded as either retarded * This is the second article of a series concerning services of interest to the social worker, contributed by invitation.?Ed. development or as stunted growth ; the latter has a medical flavour, the former an educational. As will be seen later, it is not always obvious which member of the team should be the therapist.. It has been suggested that if several children could be ” trained ” together then it was an educational problem, but if individual attention was required then it was medical, but group therapy has made this distinction pointless. Legal requirements, as for instance, the signature on the Ministry form 2 H.P., make the doctor’s examination essential where any form of special educational treatment is required. It is very desirable that ” access ” to a clinic should be as easy as possible. Most referrals will come through educational or medical channels, but parents should be allowed to come direct. The problem may be one they do not wish discussed outside the home or they may be over-anxious, the latter at first sight might seem a waste of time but the over-anxious parent ” infects ” his child so that there is in fact a problem to be dealt with, even though it is 90 per cent, on the parent’s side. At a Child Guidance Centre or Clinic then one will expect to find a team of three. Usually it is the psychiatric social worker who takes the history from the parent, nineteen times out of twenty this is the mother. The history will cover material facts such as the living conditions and opportunities for play but it will deal also with the parents and other members of the family. The early development of the child, major events such as illnesses, evacuation or change of school are recorded. One is on the look-out for significant correlations such as symptoms starting after the birth of the next child, when father was demobilized or when mother started to go out to work. Of special importance is how the problem appeared to the parents and their reaction to it. While mother is being interviewed the psychologist may be seeing the child. An estimate of the intelligence will be made, his educational attainments measured. This is a standardized situation, rather like school and the child is asked set questions. By contrast, the interview with the psychiatrist is freer, there is more give and take so that the emotional problems are more easily seen. Usually some form of projection test is also used so that the child by his actions and words reveals his problems as he feels them, this is often in marked contrast to his actual words which may deny the problem that is too real to be voiced. A period of free activity, play or blackboard, follows and a physical examination with special attention to minor degrees of deafness, impaired vision, rounds off” the interview.
Each of these interviews will take on the average, an hour. A conference of the team follows, each contributing their side of the picture.
At the Bristol Clinic we see eight or nine new cases each week, the following six cases were all seen within one week, the three others were an enuretic, another ” care and protection ” case, and a stammerer.
(1) Boy, aged 9years, referred by speech therapist at request of headmaster who was concerned about his educational backwardness and wondered how far it was due to his left-handedness.
An only child, his father in the R.A.F. was posted as ” missing, presumed killed ” in 1942 ; five years later, two years after the end of the war, this boy had still not been told that his father would never come back. His mother, tense, with an artificial laugh, was in half-time work. They both lived with her parents.
His early development showed he was slow in learning to talk, toilet training was completed by two years. He was always a poor sleeper. Physical examination showed a healthy lad, left-handed and left-eyed. His finger nails were bitten, his speech showed little hesitation but he could not pronounce ” sc ” as in school or skate. His intelligence quotient was 93, he was twelve months retarded in his educational work. He was excessively polite, asked permission before doing anything, unless occupied his fingers were continually intertwining. He was on the verge of tears when talking about his father and again when talking about his pet dog which had been destroyed. Three wishes of the boy in the story completion test were to have (1) some friends, (2) friends to play with him, (3) friends every day. The picture is a complex one, constitutional handicaps in his left-handedness and speech difficulty, environmental in the all-adult house in which he lives and in the past the lack of a clear explanation about his father’s death.
(2) Boy, aged 16f years, referred by the magistrates on account of stealing clothes from his father, which he then sold.
The youngest by six years of four children. His father is a metal polisher. His mother has gone to work as the parents could not rely on this boy earning regularly.
His early development was normal. His mother thought she might have spoiled him. He had a good school report, was considered trustworthy and for a time was class monitor. He held his first job for nine months, but left on medical advice as he was getting skin trouble, thereafter he was in a series of jobs usually leaving for trivial reasons, or being sacked for inefficiency.
He was before the court once for playing on the railway line, but otherwise his record seemed to be good until six months prior to his present offence. Later it became clear that in fact there had been problems, staying away from work half:a-day, breaking into the electric meter, but these were not disclosed by his parents. During the last six months he had ” gone to pieces “, staying out at night, twice taking clothes from home and selling them. He played cards, used his pay to go horseriding and was said to keep bad company, to wit an army deserter.
His intelligence quotient was 80?his reading age 2 years behind his mental age, his arithmetic at the adult level.
Physical examination showed a left-handed lanky lad, who held himself poorly.
The basic problem was the mother’s attitude? originally a “good boy” he did well while a scaffolding was provided, and he had an adequate series of outlets, but left to himself his desire for excitement and to have a good time, soon got him into difficulty.
(3) Girl, aged 5f years, referred by School Medical Department on account of fears, being shy and frightened.
The third of five children, the sixth born soon after her, died at four months. The father a dustman, was discharged from the army on account of psycho-neurosis. The mother, rough-and-ready, works in a factory.
It was a normal pregnancy but when a year old the child was removed to the fever hospital with measles. Walking and talking were late, speech is backward.
Intelligence quotient 94, would not be separated from her mother during the test and turned to her for help.
Physical examination showed a saddle-shaped nose with rhinorrhoea.
A week after the referral and before the child had been seen, she was in hospital for 48 hours for tonsillectomy. This aggravated all the symptoms. In this case the attitude of the mother, the low state of health of the child, the traumatic effect of the operation seemed to be the main factors. (4) Boy, aged 5? years, referred by School Medical Department on account of enuresis.
The elder of two children, father is only at home at week-ends. Mother irritated by her children? ” such a tie “.
A wanted baby, but he cried ” night and day Talking was slow, walking normal, ” resisted the pot “. Was dry at 2? years, but enuresis started at 3^ years, shortly after the birth of his sister. Now he ” wants attention “, ” likes mucking about “. Is still put to bed with napkins on.
Physical examination was negative.
He had an intelligence quotient of 116, his work was very imaginative but egocentric. (5) Boy, aged 14 years, referred by Juvenile Court as ” exposed to moral danger, having parents not exercising proper care and guardianship “. The second of six children, he lived in London for 6 years, going to hospital with his sister for some skin condition ; he did not return home but was sent to a cottage home from which his parents reclaimed him 6? years later ; during the period they neither visited nor wrote to him. Shortly after his return home he began to take bread and cakes, for this he was soundly thrashed. Later a 10s. note disappeared at home and this boy was taken to the police station, but nothing was proved, the boy maintaining he knew nothing about it. He was locked in his bedroom and given only scraps of food ” to teach him “. The maltreatment was so obvious that an aunt took pity on him and he went to live with her, but she got crowded out, with a son being demobilized, so the boy was returned to his home, he ran away, took a cigarette case from a parked car and eventually was picked up by the police. Father refused to go bail. Physical examination was non-contributory. His intelligence quotient was 81, his educational work only some six months retarded.
The boy himself presented rather a pathetic spectacle, like a ” fish out of water no social contacts and longing to get back to the cottage home where he had spent the happiestyears of his life. (6) Boy, aged 8 years, referred for advice re placement.
Illegitimate. Sent, aged 2 years, to a residential nursery as he was reported to be backward, defiant, aggressive and moody. Aged 6years, had improved considerably and foster-home placement was suggested, this occurred when he was 7 years. Within two months the foster father got a job in the north of England and the family moved. Was placed in another foster-home, but he did not fit in, so transferred to small home school. But after six months was considered to be too babyish and the foster-mother had been offered more attractive children so he was again moved; by now he was enuretic and occasionally soiled.
His intelligence quotient was 87, but his behaviour and general attitude to life suggested a much lower figure.
Physical examination showed him to be shortsighted, the glasses prescription had last been known of nine months previously.
The stated reason for referral may be physical, psychological or social ; asthma, ” faints headaches?fears of the dark, jealousy, loneliness? truanting, sex offences, stealing, but no matter in which sphere the main problem is, there are bound to be repercussions in the others. The commoner reasons for referral are those which are more of a nuisance to the grown-ups, as some adult has to consider the child a problem before it is referred. ” Naughty ” children are sent more readily than timid children. The larger the class at school, the greater the chance of referral. The staffing and siting of the clinic or centre also influences the type of referral. At a children’s hospital, enuretics, asthmas, feeding problems, will predominate. At a psychological centre, backwardness, day-dreaming, stealing, destructiveness will be more prevalent. From the above cases it is easily realized that much child guidance is, in fact, parent guidance. As a rough-and-ready rule one may say that with the under-fives three-quarters of the work is with the parents ; from five to eleven it is fifty-fifty ; over the age of eleven it is the work with the child that is of greater importance.
Treatment has to be considered from the two sides, parent and child. Once again one has to stress the fact, that treatment of fathers is, in most clinics, conspicuous by its absence. Treatment of mothers may be in part educational and suggestive, and in part cathartic. The former deals chiefly with the child, methods of meeting and avoiding problems, explaining what is usual at certain ages, that independence, prized by adults, is uncommonly like obstinacy when at work in the nursery. The latter is more truly psychotherapeutic, if anyone feels frustrated, tense or inhibited, they are less able to give affection and they are more likely to give vent to other feelings when checked or irritated by a, to them, less overpowering member of society ; the clerk told off by his employer, takes it out on the office boy ; the daughter frustrated by her own mother is likely to expect too much of her own child. Friction between parents makes for nailbiting among their children. If a mother will unburden herself, and the greater the feeling, the greater the relief, then she is able to return to her home better able to cope with her children and the everyday problems of life.
Owing to a child’s limited vocabulary and lack of understanding of abstract ideas, discussion plays little part in treatment, instead one makes use of the child’s natural form of self-expression?play. In suitable cases play-therapy may be combined with other measures such as medicine, speechtherapy or specific tuition. To the grown-up, play is apt to signify something unimportant, a way of idling away the time, but to the child it is real work and is as expressive of the individual as any other form of creative work. A bedroom or study can tell us much about the owner, so the play-world can reveal to us a great deal about the child. How a child plays, his selection of toys, impulsive or thoughtful, the actual things chosen, their arrangement, what happens to them during the play, is of significance. There is the child who never gets down to actual play but spends the whole session arranging the pieces, the child who never chooses people but only animals. When arranging a battle, one boy will divide the soldiers equally, an insecure lad will see that he has the larger force. The way the ” dangerous” things, crocodiles, guns, soldiers, face, whether towards the child or away, is of importance. One notes whether the wild animals are carefully fenced in or whether they roam at large. Then the fate which overtakes the toys, the male figure who is always being run over, the child who gets accidentally (?) buried, may show one the emotional problems that are occupying the child’s mind.
The commoner problems are excessive aggression or drive for power ; a feeling of guilt or sense of inferiority, usually the consequence of past aggression felt or put into practice ; lack of affection by parents, with resultant insecurity and inability to love others. Needless to say the child has no insight into his problems, he quite fails to appreciate that his dawdling over meals is one way of getting more attention from mother.
If the problem is at a more primitive level, then play is more elementary, sand, water, squirting water into holes, making a mess, letting the water get on the floor (and watching the adults’ reaction). Hammering, cutting, sawing, can all help a child who is uncertain as to how much scope may be given to his destructive impulses.
Older children can use puppets or dressing-up games to act out their feelings.
Play-therapy is by no means standardized. Some therapists think it wisest to act merely as passive observers, although even by their presence and noninterference they must be classed as beneficent grown-ups. Others take a more active role. Most consider that at some stage the problems must be allowed to enter consciousness, that the aggression and fears should be linked to the objects causing them. At present, most play-therapists are selftaught, or, at best, have watched other playtherapists at work, but the need for a more definite type of training is recognized. The emotions of a child are not lightly to be played with, the potential aggression is great and if proper channels are not provided then the destructive effect may be much greater than expected. Provided the personality is stable and the individual has insight into his own problems and is willing to proceed slowly then probably any member of the team can develop into an efficient therapist. The training of the mental hospital psychiatrist in this respect gives him little advantage over that of the educational psychologist, neither of them has had specific training in emotional problems while both of them may have made full use of their practical experience and learned from it, the same applies equally to the psychiatric social worker.
Treatment occasionally requires residence away from home, but at present, adequate in-patient accommodation in colony, hospital, or hostel, is extremely limited. Even facilities for residential observation are practically non-existent. Prior to the war there was a flourishing register of fosterhomes, but lack of houses, the general strain of queues and post-war shopping, together with the experiences of war-time billeting, has caused a dearth of willing foster-mothers.
One should not lose sight of the fact that the child is developing and that a proper “leading forth ” (e-duco) of his assets may be as important as the solving of his problem. For this reason seeing a child at the same hour each week may be a mistake, if as a result, he always misses the same class. Child guidance is an expanding subject and certain aspects of it are receiving special attention at present. At the organic level studies with the electro-encephalogram show that in certain children their ” physiological age “, to coin a phrase, lags behind their chronological age, the records are atypical for their age though possibly within normal limits for a younger child. The certainty regarding the intelligence quotient is much less than it used to be, it is still true that the intelligence quotient is fixed ” provided the child is doing its best “, but temperamental factors which influence the result are now receiving an attention that they seldom had before. Various attempts are being made to estimate the ” emotional age ” of the child. One speaks also now of “social quotients this being the ratio of the child’s social achievement compared with his chronological age. Vocational guidance is a new service which will expand greatly once it is better standardized. Group Therapy is being investigated. It is no new thing for a therapist to take one or two children together, often partly to save time, it also provides a chance of seeing difficult children playing together, but now it is coming into its own as a specific form of therapy. So much for the plan ; in fact, however, the tale is at present rather different. There are many areas without clinics, of those open many cannot get fully trained workers for each department. Waiting lists are long and the number of unwanted children does not grow shorter. Every clinic has its group of post-evacuation cases where the child has had no settled home but lived in a series of hostels. It is therefore of increasing importance that as much preventive work be done as early as possible, that screening be as efficient as possible. Educational psychologists, school medical officers, paediatricians, social workers are the first line of defence. Their training should enable them to deal with simpler problems but in every case a follow-up should be made after six months, and if the improvement is not maintained then the case should be sent on for fuller exploration and treatment. Only in this way can the best use be made of the limited services available at present.
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