In the Diageosis
- Author:
Earl, F.R.C.P.I., D.P.M.,
First Assistant Medical Officer, Caterham Mental Hospital
Modern psychology has laid stress upon die importance of the instinctive and emotional factors in human life, and it is now universally recognised that a normal emotional equipment is at least as important a determinant of success in life as is a normal degree of intelligence. Certain failures on the other hand, both of social adjustment and of specific ability, can be demon- strated as having their origin in the emotional sphere. It is justifiable to argue that emotional disturbance may produce behaviour reactions which closely simulate Mental Deficiency, especially when they occur in children of the lower grade of normal intelligence. Not only that, but we must hypothecate a certain low level of intellect, or conversely a high degree of emotional in- stability, at which the emotional factor may fairly be said to determine mental deficiency; whilst lastly, in the true intellectual defective, emotional factors may complicate the deficiency.
Consider first emotional reactions simulating mental defect. The be- haviour patterns of the child are more primitive, less firmly established, and more responsive to environmental influences than are those of the adult; and his emotional disturbances usually find expression, not in the fixed and highly symbolised psychoneuroses, but in the less definable form of behaviour disorders. There is a tendency to a similar reaction to physical illness. The naughtiness of the tired or sick child is proverbial, and the sequelae of Encephalitis Leth- argica in childhood include every variety of abnormal behaviour.
Broadly speaking, the causes of abnormal emotional reaction in children are, firstly the inherent instability of the child, and secondly stresses imposed by the environment; the final result depending upon the inter-relation of the two factors. Thus the inherently normal child may survive in a very difficult environment, whilst the inherently abnormal child may break down in a perfectly normal environment.
The normal unit of human society, the best environment in which to raise a child, is the family. The importance for the child from his first day of life, of the various emotional relationships within the family, cannot be over-estimated. And only if the parents are themselves normal can these emotional ties develop along normal lines. If the emotional adjustments of the parents are abnormal, their attitudes toward the child are abnormal, and the child becomes, as Kenworthy says, a pawn on the board of their unsatisfied instinctive and emotional strivings. Maladjustments between the parents, quarrels, parental separations, the introduction of a tactless step-parent; all these are fraught with psychological danger for the child.
Apart from purely psychological factors, an important though uncom- mon cause of trouble is physical defect in the child himself. Bodily deformity, speech difficulties, defects of special senses and so forth may cause difficulty in adaptation and set up emotional disturbance in a sensitive child.
To the possible variations in behaviour resulting from these disturbances there is of course no end, but those with which we are concerned can all be grouped under two heads?Regression Reactions and Insecurity Reactions. The regression reaction represents an attempt to escape from an intolerable situation, and to obtain satisfaction by the fixation upon, or reinstatement, of an infantile level of emotional reaction and of behaviour pattern. Such a child is babyish and dependent; he may become cnurctic, and may even insist upon infantile diet. He demands constant attention, and cannot join in games, or work with other children. He is emotionally barred from learning and is a school failure. He may appear emotionally apathetic but is more com- monly given to stormy weeping; and he is quite unable to face a difficulty. The insecurity reaction represents a failure to obtain complete emotional satisfaction, either normally or by regression; the result being constant emotional tension.
The insecure child is usually active and excitable, and a liar. He may be timid or by over-compensation he may be a bully; whichever he is, lie retreats from real difficulties lest his failure should increase his insecurity; unlike the regressed child who retreats to avoid advancing. Very briefly, these are the classical types; but it should be remembered that they rarely occur in their entirety and alone, and that sub-variants and mixed reactions arc the rule; regression tending to preponderate in younger and less intelligent children, whilst insecurity is commoner in the older and more intelligent.
We must next consider the differentiation between the behaviour dis- orders arising from true mental deficiency, and those arising from emotional disturbance. Quite obviously the diagnosis is exceedingly important; both for the child and for the community.
The first essential is careful case-taking, with special attention to develop- mental data, talking, walking, and the like; and above all a detailed investiga- tion of the home background. Descriptions of the child’s behaviour as obtained from parents or teachers should be evaluated with great discretion, inasmuch as the witness may herself play a part in the child’s disorder. It happens not infrequently that the parent’s story throws more light on her own maladjust- ments than on those of the child.
Physical condition is also important and it is not too much to say that the diagnosis of mental deficiency in childhood should never be made without complete physical examination. Such examination is compulsory in many American states. Really skilled mental testing is the best diagnostic weapon we have. Firstly of course everything must be done to ease any emotional strain ensuing from the test itself and to set the child completely at his ease. Testing should not be started until the examiner has to some degree made friends with the child, and parents and guardians should be rigidly excluded. Testing children in the Courthouse or in custody is manifestly unfair. Emotional strains removed, the mere difference between test results and outside behaviour may make the diagnosis clear. The following case illustrates this point well : ?
Tommy was brought to the London Child Guidance Clinic in custody following his second conviction for housebreaking at the age of 11. He was seen for a few minutes in the presence of the officer who brought him. He shook hands with his left hand, he identified a clockwork model of the racing car Blue Bird as ” The Golden Arrow he was unable to tell the time by the clock, and his drawing of a man barely scored 5 years on the Goodenough scale. His general manner was strongly suggestive of defect. Mental testing the same afternoon but without the presence of the officer showed an obvious insecurity reaction but an intelligence quotient of 118. Full investigation related his misconduct closely to his emotional disturbance.
Such cases as this are relatively rare. The numerical result of the tests is usually of value chiefly in so far as irregularity of distribution of success and failure constitutes evidence of instability, and for this reason testing should be as wide as possible in range. The Binet scale alone is insufficient, while the practice of ” asking just a few questions ” out of this or any other scale is simply criminal.
Goodenough’s ” drawing a man ” test, and in older children Binet’s 6o word test, or the Kent Rosanoff word association test, are partly dependent upon emotional factors and give valuable evidence.
More important than any of these is the observation of the child’s be- haviour under test. His attitude to his mother or whoever brings him in, his attitude to the examiner, to the situation as a whole, to the test material, to success and failure, his economy or extravagance of movement, his ability to attend, to stick to his work, to correct errors?a hundred and one tiny details combine to give a picture of his mind. That a child fails in a test means little; how he fails may mean everything. Two children fail at a memory test; one may have grasped the sense of it and the other not. Billy and Jack both fail at a block design test; Billy a defective may be amused and unaware of his failure, Jack a regressed child may cry and say ” I can’t do it,” whilst Tommy with an insecurity reaction may do splendidly till he makes his first error, and then promptly becomes upset, makes wild moves and shows signs of panic. Insecure children may refuse a test lest they should fail at it. Regression cases may refuse to try, because they never try anything. Defective children may refuse because they cannot understand or attend to the instructions. Only close observation and extensive experience will enable the distinction to be made.
Sammy, aged 8|, was said to be violent, excitable and unteachable. His father was dead. During life he had been very excitable and violent in temper. The father’s mother was insane. Sammy had had meningitis in infancy. He had been sent to a strict private school where drastic discipline had been tried without result.
On interview he was friendly, excitable, and very childish. He drew a very crude attempt at a man. He counted on his fingers. He jabbered on so fast as to suggest a manic type. He was unable to concentrate at all.
On test his mental age on Terman was 6 years 2 months, I.Q. 73. On the Merrill Palmer scale of performance he scored only 5 years. He was handicapped by (1) The visual defect, (2) The fear of failure which made him refuse tests altogether or give them up without trying, (3) He was unable to concentrate.
His behaviour showed gross insecurity and he was rated as dull normal. Phychiatric treatment and careful handling justified the diagnosis and he improved very markedly.
Dickie, aged 5, was sent from school. He was violent tempered and stupid, and could not keep up in work or play. He was enuretic by night and day and at times was dirty.
On interview he spoke little and was judged defective. On test he showed an intelligence quotient of 67 in the Merrill Palmer scale. The Binet could not be applied.
Motor control was poor, and his answers to questions were largely unintelligible.
Investigation of the home showed that he was grossly over-protected, and treated like a baby. He was far more babyish at home than in school and was a finger sucker. With alteration of the home he improved, but in school was still restless and difficult and showed signs of insecurity.
Re-examined a year later his intelligence quotient had risen one point only but he was now measurable in the Binet scale, showing an intelligence quotient equal to his Merrill Palmer I.Q. His random answering was now obviously an attempt to retreat from difficulties, and his whole reaction suggested emotional rather than intellectual failure. He was graded as dull normal and eventually made a good adjustment at home and in school.
Consider next, emotion as a determinant of defect. There is a fairly large group of high grade defectives whose purely cognitive ability is enough to allow them to earn a living, but whose emotional disabilities render survival in other than a protected atmosphere impossible. If the least strain is put upon these people their emotional instability combines with their low intelli- gence to cause some folly or delinquency bringing them swiftly to the work- house or the court. It is fair to say of such cases that it is the emotional factor which determines their defect.
Apart from cases of this type is a group?fortunately not large?who are far more difficult. The condition cannot be defined as a clinical entity but amongst the border-line psychotics, psychopathic personalities, recidivists and social ineffectives, one finds cases displaying very severe emotional abnorm- ality rather of the childish type, in that it finds expression in behaviour dis- orders, usually markedly anti-social; and showing on test as subnormal, dull normal, occasionally normal, and in quite exceptional cases high normal intelligence. These people are definitely unable to adapt to normal society, or to manage their affairs with ordinary prudence; their disorder appears in adolescence?in that it resists any known treatment it seems to be permanently installed. For all these reasons they are said?and quite rightly from the social standpoint?to be mentally deficient. Whether they are so in fact is more than doubtful?probably many of them are not. The distinction is im- portant because it seems likely that a number of these people represent severe types of emotional disturbance, complicated by the chronic failure, by the adult physiological make-up, and in the great majority of cases by rather low intelli- gence. If this is so, whilst little or nothing can be done for the present genera- tion, it seems certain that with the increasing interest in psychology and the establishment of Child Guidance Clinics, the evidence obtained from the mal- adjusted child of to-day will throw light upon the origin, treatment, and even the prevention of the so-called moral defective of to-morrow. This can per- haps be best illustrated by quoting the case of a boy not a typical moral defective but whose true allocation is still uncertain.
Peter started stealing at the age of six. When he was nine he was sent to a Home Office School as ” unmanageable.” After his discharge eighteen months later, he was ranked as impossible at home and in school, and was finally excluded from the latter after organising a mutiny. He tried his hand at every form of crime from shooting his enemies with an air-gun to stealing a cur and pocket-picking. He tried to commit suicide, and planned to commit murder. House-breaking was his favourite sport, and for this he was arrested at the age of fourteen.
Investigation showed that he was illegitimate, and had a poorly repressed knowledge of the fact. His father, who had deserted, was a blackguard, and his mother was markedly psychopathic. His emotional environment must have been simply appalling from the day of his birth.
Mental testing showed an intelligence quotient of 98. He was negativistic and showed signs of severe emotional disturbance. A word association test showed a worse result than the writer has seen outside a mental hospital.
After some psychotherapy Peter was sent to a reformatory school managed by a genius. The immediate improvement was amazing and a year later he was still doing very well, had had a fortnight’s home leave and had behaved admirably.
How are we to classify such a boy? On first sight, despite his normal intellect, he is as typical a moral defective as one could wish, yet with skilled handling he improves beyond belief. What the end result will be no one can tell. Cases even more difficult are not wanting; whether the condition is a form of defect, whether it is mainly congenital or mainly acquired, whether it can be cured or modified by treatment are the questions for the future. For the present, the law deals with these people as best it can, as moral defectives, criminals and the rest. The psychiatrist can do no more than label them ” pathological delinquents.”
So much for diagnosis. A brief reference to treatment of emotional factors complicating defect can now be made. The defective, like the child, is very responsive to his environment?moreover he is often very unstable. The defective boy or girl admitted to an institution fresh from the troubles and failures in society is frequently violent, excitable, resentful, and a nuisance to himself and to everybody else. Yet in a few months with wise handling in the protection of an institution, the same boy or girl may settle down com- pletely, becoming quiet, happy, docile and trustworthy, and may improve not only in stability, but in apparent intelligence. The degree of improve- ment of course depends largely upon the institution. Unfortunately in this country the legal and custodial views tend to prevail over the psychological; and custodial institutions are apt to be too mechanical, whereby the affective psychology of the individual patient is only too frequently crushed in the administrative machine.
In some of the American states where the psychiatrist has a free hand, and where plenty of skilled assistance is available, far better results are obtained; and those of us in England who have had an opportunity of working in circumstances in any way comparable to such standards, can vouch for their value.
Here is a case which will illustrate the point:? John was in a large institution from his tenth to his nineteenth year. After a year on licence he stole some money from his employer and was re-committed to an institution of a fairly strict type and under lay management. There he was at first violent, obscene and abusive, but settled down in a year or so to the ordinary routine of the place. Interviewed for rough testing in the presence of the superintendent he did badly at simple block design tests, and appeared to be below the trainable standard. His manner was a little anxious, but very civil, and it was obvious that he hated his superintendent?to whom he was almost nauseatingly polite.
He was re-tested after two weeks’ handling by up-to-date methods. His Binet age was then one year higher than that obtained on committal and his block design ability was two years above that obtained in the presence of the recent overlord.
He is now reported as a good worker and exceedingly well-behaved, though emotionally somewhat unstable.
The case illustrates the essential fact that the proper person to handle a defective is not a lawyer, not a reformatory master, not a kindly old lady (of either sex) but a skilled psychiatrist. The proper person to train him is not a nurse, not a tradesman, but a trainer: the training should be selected and supervised by some person with expert knowledge of amentia, and its aim should be not merely the production of goods, nor even merely the teaching of a trade, but the stabilisation of emotion and the attainment of a condition as near to normality as possible.
The writer is indebted to Dr Wm. Moodie, Medical Director of the London Child Guidance Clinic, for permission to publish particulars of cases attending this Clinic.
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