Child Guidance
- Author:
Moodi, M.D., M.R.C.P., D.P.M.
The term ” child guidance ” is comparatively new to this country but there is nothing fundamentally new in the conception for which it stands. As a term it is by no means perfect, since, on the one hand, it fails to convey adequately the range of its subject, while on the other, it gives rise to misconceptions as to its nature and scope. In many countries, however, it has come to be accepted as meaning in a general sense the sum total of the activ- ities directed towards the Mental Hygiene of the young and, in particular, the name is applied to a certain type of clinic which has been devised as a centre for these activities.
Many authors in the past have made studies of Child Development and the literature of all countries contains notable examples of this type of work. It was not, however, till near the end of the nineteenth century, when so many advances were being made, especially on the continent of Europe in regard to the normal and abnormal workings of the mind, that the observations of these older writers began to claim their just share of attention, and attempts were made to interpret their findings in the light of modern research.
It thus came to be recognised that all behaviour, from the simplest actions of the very young infant to the intricate and apparently irrational conduct of the insane, had a meaning and that, given the necessary data, all conduct could be traced back to its source and its causal factors explained. It was further observed that in the individual, as life goes on, the relation between cause and effect in conduct becomes progressively more obscure and so that relation is much more obvious in the young child than in the adult.
As a natural result of these observations, the study of the child gained an impetus which was greatly increased by the statement made by Clouston in 1906, that in almost every case of adult mental disorder the beginnings of the illness were present and could have been recognised during the childhood of the individual if we had the necessary skill and knowledge to do so.
During the years that followed, much was done by individual workers both in this country and abroad, in the study of child behaviour and simul- taneously great advances were made in the knowledge of psychology and its application to education, sociology and other sciences.
Then came the war, during which, though all everyday social problems were apparently dropped for the time being, scientific thought was by no means idle, and in the years of reconstruction which have followed, the accum- ulated knowledge has been co-ordinated and the present day ” child guidance clinic ” has come into being. England has been somewhat backward in following the lead so ably given by the United States and Germany, and not unnaturally so, since the principles involved in these other countries, though most excellently adapted to their own special needs, require a certain mod- ification for use in this country, that they may suit the prevailing social con- ditions.
Every individual is the resultant of two components, the mental equip- ment with which he was provided at birth, and the changes subsequently wrought upon it by environmental forces. The child is no exception to this rule, and any study of the child must necessarily include the consideration of both these factors. The possible variations in the mental equipment of a child are obviously very great, but the ramifications of his environment and the manner in which he reacts to it are even greater, so that the study of the in- dividual case at once becomes a laborious matter, entailing exploration of many sources of information.
Further, the aim of child guidance is usually to correct some abnormality of behaviour resulting from a maladjustment between the child and his en- vironment and here again a wide field for activity is presented. The Child Guidance Clinic as at present constituted has, in the majority of instances, assumed a definite form.
As has already been pointed out, the study of the child involves himself on the one hand, and his environment on the other, and each of these lines of investigation presents two aspects.
We may study the intellectual equipment and the educational attain- ments at any given time and we may observe their development over a period, but besides the gradual evolution which they undergo, sudden changes may occur in their observed values. These changes may be due to such intrinsic factors as emotional disturbances or physical causes. The two aspects of this study then, fall under the scope of the psychologist, who can estimate the value ?f the intellectual equipment, both innate and acquired, also frequently in- dicating the presence of disturbing factors, and the psychiatrist, who works out the specific nature of these factors, be they emotional or physical.
The two aspects of the environment are the home and the school. Between the ages of five and fourteen the child spends the major part of his waking hours in school and there he expends most of his intellectual energy and en- counters most of his difficulties. He has also to adapt himself to a standard environment. In the home, on the other hand, he leads his emotional life, and there circumstances tend to some extent to be modified to suit his particular wishes. It is not surprising that there is frequently a certain antagonism be- tween the school and the home, especially when it is remembered that the relative strength of these social institutions is tending to become reversed. Here- tofore, the home has been a stronger influence than the school, but it is doubt- ful how long this predominance will endure.
The environment then, must be investigated by the psychologist, who should be thoroughly conversant with educational methods, and also by one specially skilled in obtaining information about the emotional life in the home. The modern Child Guidance Clinic has been evolved so that each of these separate departments in case investigation shall be handled by an expert. In other words, the ” team ” method is employed.
The usual team consists of a Psychiatrist, a Psychologist and a trained Social Worker.
The Psychiatrist is ” chief ” of the team. He is in full charge of the case and the other members of the team work under his direction.
The name Psychiatrist is a hard one to define. In days gone by it merely meant one who was experienced in the care of the insane, and the diagnosis of their ailments.
Those days are past, and psychiatry now embraces a much wider field, including the maintenance of mental health as well as the study of mental disease, and between these two extremes all degrees of variation from normal. It is coming more and more to be recognised that, although there is much to be learned from the study of definite mental disorders, there is infinitely more profit in the observation of those very minor variations from normal which occur in all of us from time to time.
The direct contribution which the psychiatrist makes towards the work of the team is a report on the physical and the mental constitution of the patient.
Many behaviour anomalies are found, on investigation, to arise from physical disease or illness. A slight degree of deafness, which is not evident in ordinary life, may cause a child to appear stupid, or the poisons being ab- sorbed from an unhealthy digestive system may render him irritable.
The physical examination of the child is an easy task compared to his mental examination, which demands the greatest care coupled with the utmost skill.
It is essential that investigation of the child mind be carried out without his being aware of it. Just as soon as the attention of the patient is directed towards his own mental working, an incalculable amount of harm has been done him?perhaps an irremediable harm. The work must be carried out rapidly because repeated interviews are very apt to make the child feel that he is the centre of the picture, and this is by no means helpful, especially in those cases, and they are many, where the conduct difficulty which we have been asked to treat, arises out of a frustrated desire for attention.
It is quite possible for the skilled observer to obtain all the information he requires from one or two informal conversations with the child?without ever asking a leading question or making a suggestion. Time spent in gain- ing the child’s confidence is not wasted, and after that point has been reached, it is only necessary to keep the conversation running as naturally as possible. To the Psychologist falls the task of carrying out such mental and per- formance tests as will render it possible to make an estimate of the child’s intellectual endowments and requirements. This can be done in the case of small children by observation of the use they make of standardised play materials, and in older children by the use of the well-known tests of Binet and Simon, or modifications of these.
Much used to be heard of the ” I. Q.,” or Intelligence Quotient, and many people seemed to think that if a number were affixed to the child, showing how much per cent, he was above or below normal, no more was required. Luckily, times have changed and an Intelligence Test now means more than this to us. The skilled psychologist can deduce much more than a quotient from the actual way in which the child tackles the various parts of the test and these deductions give invaluable pointers in the summing up of the case. Special aptitudes and specific learning disabilities can be recognised, and the presence of emotional blockings detected.
The psychologist can also assist by interpreting school reports and gain- ing information as to the behaviour of the child in the school environment. The function of the social worker is to investigate the home environment. The inclusion of specially trained social workers is probably the greatest advance which has been made in the constitution of the clinic team.
Many psychiatrists still retain a preference for carrying out their own in- vestigations into the environment of their patients. There are no doubt many valid arguments for so doing, but those who have experienced the value of the co-operation of really skilled workers are unanimous in saying that they derive the greatest possible help from them.
There is a not unnatural suspicion also, in the lay mind in this country, in regard to the employment of social workers in the investigation of cases. There is a feeling that these workers will force their way into the homes of patients and pry into their private affairs. This is far from the truth, and in fact the properly trained worker pursues her investigations in such a way that no such situation is created. Besides being specially trained, she is chosen for her tact and suitability for the work. She approaches the home in such a way as to inspire confidence and instil the feeling that she is desirous of rendering all the help she can. She becomes the trusted friend of the family and once she has attained to this position she can observe at first hand the circumstances obtaining in the home.
There is no doubt that she can render a much truer account of the home environmental factors than a psychiatrist can ever obtain from the parents over his consulting-room table.
Parents are frequently quite unconscious of the reasons behind many of their attitudes towards their children. This is quite natural, since these atti- tudes are often the result of distorted recollections of the treatment which they themselves as children received from their parents. It is unlikely, therefore, that they will be capable, however willing they are, of giving a dispassionate account of their own parental attitudes. The trained social worker can, how- ever, observe in the home what actually happens?this the psychiatrist, at least the clinic psychiatrist, can never do.
As will be seen later, the social worker is also a very valuable adjunct in treatment.
As soon as the three members of the ” team ” have made their observa- tions, the psychiatrist calls a conference of the team, and their individual reports are read and considered.
As a general rule, the conference is not limited to members of the actual team, but other workers in the clinic and any interested professional person? the physician or teacher or social worker who referred the case, may be invited to attend. In this way all available help is concentrated on the case, and it is viewed from every angle and in the light of all obtainable evidence. The psychiatrist acts as ” chairman,” and upon him falls the duty of summing up and deciding future policy in regard to the case.
In addition to their immediate function, case conferences may be very useful educationally. If necessary, the case may be disguised, the patient’s identity being rendered unrecognisable by the alteration of identifying data, and the conference given before large batches of students. It need hardly be said that no actual child is ever shown, even at a private conference of the team?to do so would be contrary to all the principles of Child Guidance. The team method as above described, appears at first sight to be somewhat complicated, but in actual practice it is not found to be unnecessarily so. The whole team, of course, only collaborate when a full study of the case is required. When it is obvious that the report of one member will suffice, that report only is taken, but the usual custom is to examine the reports on every case, even if only a partial study has been made, at a Case Conference. When a case is under treatment, further conferences are held from time to time as occasion arises, to report progress and regulate further treatment. Treatment consists, as a rule, in modifying the environment rather than in any attempt to influence directly the child’s conduct by psychotherapy, though the latter method must occasionally be employed in the case of older children.
It should be clearly understood that no attempt is made to modify the environment in such a way as to pander to the whims of the child patient. Rather does one seek to produce only such modifications as will give him situations of average difficulty to contend with and, especially, to provide him with opportunities for developing any special aptitudes with which he may be endowed. It is of supreme importance to foster and not to frustrate tend- cncies such as self-restraint and a feeling of personal responsibility, without which no child can ever become a good citizen.
In this work of environmental modification, the psychologist and the social worker each take a part. The psychologist, being in touch with the educational situation, can discuss with the teacher the encouragement of special aptitudes by alterations in the curriculum, or by giving extra facilities for physical exercise. The social worker, in virtue of her standing in the home* can suggest the adoption there of attitudes suitable to the special needs of the case.
She can, moreover, observe the results of her suggestions, and modify them as need may be.
The types of cases dealt with in a Child Guidance Clinic are many and varied. As a rule the patients are of school age, but many clinics deal also with pre-school children and adolescents.
The problems presented fall, broadly, into two groups. Firstly, there are the problem children?those whose behaviour is in some respects obviously abnormal, and secondly, there are those who, though their behaviour abnorm- ality is not apparent in the ordinary way, are causing anxiety to their parents or teachers by reason of some almost concealed nervousness, timidity, or what not, which, it is feared, may be only a slight indication of some deeply hidden emotional imbalance.
In actual practice it is found, as might be expected, that parents’ attitudes determine, much more than anything else, what the effect of the environment will be, and those occupied in the work of Child Guidance are coming to see, more and more, that parental education, given at the proper time and con- ducted on proper lines, would go a long way in eradicating the problem child.
With the object of supplying this very necessary type of instruction, ante- natal and mothercraft centres exist in connection with many Child Guidance Clinics abroad, and are found to fill a very valuable role in the field of Mental Hygiene.
The results obtained in Child Guidance Clinics where the intensive ” team method ” is employed, have hitherto been very satisfactory. It has been found that though the time and labour expended appear at first sight to be ex- cessive, this expenditure is more than warranted by the increased efficiency obtained.
There is no doubt that these Clinics, with their allied activities, will soon be considered a necessary part of the Public Health organisation, and that, if adequately staffed with trained workers, they will well justify their existence.
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