The Mentally Unstable Child Jand its Needs
- Author:
Robert Hughes
M.B. (Lond.); M.P.C. School Medical Officer, Stoke-on-Trent. |L
Every medical officer, concerned with the duty of “ascertainment,” must, oftentimes, have met with children who are mentally abnormal in some way, but who are not embraced by any of the legal definitions relating to mentally defective children, and for who no special provision has been made.
These constitute a miscellaneous collection which includes almost everything from a slight degree of impulsiveness to conduct approaching that of the insane. To this ill defined and unclassified group, I have applied the designation, “mentally unstable,” though the use of this term in this connection is by no means free from objection and many will, doubtless, consider it should be restricted to those showing innate excess of general emotionality (the emotional common factor) ;* whereas a number of my cases cannot be placed in this category. All, I think, will agree, that the legal definition of a “feebleminded child” restricts this term to those suffering from mental defect which has existed, practically from birth and is of such quality as to interfere seriously and permanently* with ability to master the “three R’s,” and, consequently no child can be included under this heading who does not exhibit a serious degree of backward* Such is the meaning given to this term in an article entitled “The Definition and Diagnosis Mental Deficiency,” by Mr. Cyril Burt which appeared in this Journal, July and October, 1920.
t Whatever view may be held as to the significance of the absence of this word, 4 ‘permanently,” from the definition of a defective child in the 1899 Act, has been rendered nugatory by the words, “within the meaning of the Mental Deficiency Act 1913,” contained in Form 302 .M. As to whether, when applied to children, it signifies, “so long as these are legally children,” or “lifelong inability,” is another matter. ness in school subjects, no matter what other kind of mental inability it may show.
Some of my cases might be regarded as covered by the legal definition of a “moral imbecile.” Personally, I have the strongest objection to certifying any child as such, moreover the definition of this term in the Mental Deficiency Act 1913 refers to “persons” only, though the words “moral imbecile” contained in Form 302.M., seem to authorise its extension to include “children.”* Too much stress has been laid, hitherto, on ability to read, write and manipulate figures.
That proficiency in these matters is a factor making for social success, there can be no doubt. It is questionable, however, if, even in these days, it is essential to the maintenance of existence independently of supervision or external support, while ability to appreciate the effects of actions on self and others, to adopt means appropriate and proportionate to ends, and to regulate conduct in accordance with social requirements, undoubtedly is, and absence or defect of such ability constitutes a far greater menace to the welfare of the individual and of the community than any mere lack of scholastic attainments.
The late Dr Mercier was wont to lay great stress on disorder of conduct as an indication of mental unfitness ,f and disorder of conduct has been a notable feature of my cases, indeed natural law and positive law are so closely related, that the problem of mental instability is intimately connected with that of juvenile delinquency.
To attempt to review the psychological factors concerned with conduct and character formation, is to tread on delicate ground. I propose, therefore, to confine my remarks strictly to those aspects of the problem which have a direct bearing on the general line of treatment advocated.
There appears to be a tendency on the part of some to maintain that there is no distinction between instinctive action and intelligent action, no innate tendency natural to man beyond those connected with the animal instincts, and that conduct is conditioned by the activities of these tendencies and their correlated emotions, modified by influences, emotional in character, which spring from a feeling of the desirability of conforming to approved social conventions.
While admitting the profound influence of these factors, it is contended that man, in addition to the nature he shares with every other animal, has a nature which is intellective and rational, and which is so much higher than mere animal nature, that Aristotle and all the best ancient philosophers, held that man has in him something that is divine .J Consequently he is able, gradually, to subordinate animal impulses to a higher aim, nay to so enlist them in the service of his higher nature that, in this way, the fighter of boys may be transformed into the fighter of wrongs, and man’s natural attraction to physical beauty enlisted on behalf of attraction to moral and intellectual beauty, and so to absolute good and absolute beauty, by a process of ascent like that described by Plato in the Sym* To any inclined to certify a young child as a moral imbecile, I would recommend a careful perusal of the chapter dealing with moral imbecility in Dr Tredgold’s book “Mental Deficiency.” Baillifcre, Tindall & Cox.
I was informed a short time ago of a case in which a child of five had been diagnosed aa a moral imbecile solely on account of a certain sex habit.
II happen to have by me a back number of the “Journal of Mental Science” dated January 18C6, in which Dr Mercier states (p.12.):?”It is now fourteen years since I submitted to the Journal of Mental Science the doctrine that disorder of conduct should enter as an integral part of our conception of what insanity is.” Dr Mercier was here describing a case in which disorder of conduct was the only indication of insanity.
J Aristotle appears to have meant that man, in contemplation, (decopia) being capable of attaining to ideals, and ideals, being divine things, must have in himself something that is divine. Ethics. Book. X. Ch. VIII. posium. This natural tendency in man towards the “summum bonum” is a definite conation, an urge, and is known by the name of “rational desire.” Although the good of the higher must always take precedence, it is not contended that the good of the lower nature merits no consideration. The Stoic rule “naturae convenienter vivere,” to live according to nature, is perfectly sound, So long as the word, nature, be taken to signify whole nature, and not merely part of it.
The young child is incapable of discerning, clearly, the ultimate objects of either animal desire (preservation of self and species), or of rational desire (attainment to perfection); while, however, at least the proximate objects of the former are presented to consciousness in concrete form, food, drink, &c., that of the latter can only be presented, imperfectly, in the form of a graduated series cf ideals,” chosen by the self for the self, but which become more and more perfected as age advances, and more and more firmly organised in the sentiments, and, hence, more and more effective as a power making for self control, and for giving reason and consistency to conduct. Now it appears to me that the salient feature about the mentally unstable consists of a disproportionate intensity of certain animal tendencies and a defective formation of this habit of rational control. Even the “man in the street” will describe such people as “governed by their emotions and not by their reason.”
Weakness of rational control and the substitution for it of a process of emotional repression of a tendency striving to express itself in conduct, is liable to cause that tendency to become “bottled up,” shut off from consciousness altogether, and to express itself in other ways by the setting up of a species of automatism, so that the mentally unstable, besides exhibiting a number of mannerisms, and other instances of the “psychopathology of everyday life,” are specially liable to disorders of conduct or even a definite neurosis, such as stammering.*
Another way in which this deficiency of rational control is shown by these cases, is their inability to observe, what Aristotle in his famous definition of moral virtue termed, the “golden mean.” They are as immoderat2 in the demonstration of their affection as of their antipathy, they are as fickle as a weather cock, and the means taken are, often, not only abnormal, but out of all proportion to the end in view. One of my cases, a boy of eleven, forged his father’s signature to a cheque for ?’20 because he was short of sixpence to pay for his admission to “the pictures.”
The following brief account affords a good instance of defective rational control:?Boys age 9, E.Q., 100, I.Q. (Binet), 104. An inveterate liar and thief. Injures himself as often as other people. Has sustained several injuries through darting, impulsively, in front of horses and carts. Sustained severe incised wound of thigh through playing with a scythe. Admitted hospital. One day tore all dressings off his wound for no apparent reason. On another threw a book at the chaplain’s head while the latter was holding a service in the ward.
Some of my delinquency cases have been instances of what I have been accus* I am indebted to Rev. V. Moncel, S.J., Professor of Psychology, Stonyhurst, for many of my ideas as to the relationship of the “new psychology,” to the old and to philosophy, ancient, mediaeval and modern, The “summum bonum” of philosophers is, of course, identified by theologians with God. The following passage occurring (p. 100) in such an “ultra-Freudian” publication as Dr Hug-Hellmuth’s “Mental Life of the Child,” is remarkable:?”To see God in all His glory?that is the constant longing of the child mind … it was out of such agitating desires as these, felt in his own childhood, that Hebbel’s genius created the poem “Butensonntag.” Dr Putnam states, in the translator’s preface:?”Psychoanalysis studies a certain portion of the influences, mainly in the form of passions and cravings but, in the opinion of the writer of this preface, other influences still more important are at work as well.” tomed to call a “three cornered” mental conflict.* In these, the repression is essentially emotional, and based, in my own cases, on a wrong emotional attitude towards the sex question .f I have rather a striking case illustrating the influence of the condition known as “introversion” on school progress. This was a boy of twelve, for five years incapable of anything beyond standard one work. He took no interest in lessons or in play, often sat aimlessly in school long after the bell had rung, and I am informed, behaved in much the same way at home.
The introversion had been set up by adverse home conditions of long duration. An attempt to divert attention and interest from internal phantasies to external realities by nature study, organised games, and a healthy open air life in the simple, well ordered environment of our residential open air school in the country, succeeded far beyond expectation, and, after little more than six months’ residence, he is now doing work almost equivalent to that of standard four, an utterly impossible advance had there been any real innate defect of intelligence. He was well nourished and, apparently, in good bodily health.
Inability to progress at school owing to the existence of an “unconscious wish” not to learn and the consequent unconscious creation of difficulties which should not exist, is alluded to in text books dealing with psychoanalysis in relation to education 4
Beyond the elementary procedure of ascertaining the existence and nature of a “three cornered” mental conflict alluded to above (if such procedure can be dignified by being included in the term at all), psychoanalysis has been undertaken at our children’s psychiatric clinic so recently, that I am unable to express any opinion on this matter from my own observation. The history obtained in some cases, coupled with the disproportionate results obtained from purely educational tests, Dr Ballard’s, to those obtained from tests such as the Porteus tests, in which the influence of school training is reduced to a minimum, and the absence of any irregularity of school attendance, is, however, suggestive, though innate defect confined to the factor, “general educational ability,” might, of course, be the explanation.?
All intellectual operations, being so closely interwoven with those which are sensory and motor, it is probable that an act which is purely intellectual never occurs in man. It is, therefore, easy to appreciate the extent to which abnormal cerebral conditions may influence intellectual operations. The influence of physical abnormality on mentality, however, may be indirect. Anyone with experience of cripples must have met with cases where an abnormal mental state has been due, not to any direct lesion of the cerebro-spinal axis, but to the indirect influence of the “feeling of inferiority” set up by the physical disability.
I was recently consulted about a crippled boy of about sixteen, who had definite delusions of reference, apparently set up in this way. * Dr Healy gives a detailed account of several cases in Ch. X. of his book: ‘ ‘The Individual Delinquent.” Heinemann.
t I have found the little pamphlet by Dr Mary Scharlieb: “What Mothers must tell their Children” of great service in the treatment of these cases. Published by the N.C.C.V.D. J For example:?Sect. 4’Transference and Identification,” pp. 270?271 in “The Child’s Unconscious Mind,” by Dr Wilfred Lay. ? Apart from these cases, the correlations obtained between E.Q’s and I.Q’s and between Binet and Porteus I.Q’s work out at a lower figure than was anticipated: Binet and E.Q’s?r= .51; p.e.= .031. Porteus &E.Q’s?r= .47; p.e.= .065. Porteus and Binet?r= .56; p.e.= .051. My cases, however, contain a large number of backward and mentally defective children. Results obtained from a fair sample of the general school population might give very different results. Disproportinate development is characteristic of mental deficiency.
The commonest physical contributory factors I have met with are excessive tea drinking, excessive juvenile smoking, especially of “fag ends,” measles, chorea, adenoids, tuberculosis, hyperpituitrism, malnutrition, congenital syphilis and constitutional physical inferiority.*
Certain families in my district tell me that they “never take in any milk,” but drink strong tea without any milk at every meal. One case, a girl of ten, a typical one of excessive general emotionality, a veritable imp of mischief and a perfect nuisance in school and out, was said to have been quite normal until she had ‘ ‘mealses and brain fever” at the age of six. Permanent damage to the supra granular layer of the cerebral cortex may be accountable for her condition.
The influence of the endocrine glands on mentality generally, is also a very promising subject for further investigation. The influence of the physiological crises, puberty and adolescence, is too well known to need further consideration, while the most important factors of all are, undoubtedly, heredity and home environment, especially early home environment, and defective early training.
Apart altogether from the pernicious influence of bad precept and bad example, parents are slow to realize that correction by punishment is of less importance than appreciation on the part of the child of why it has merited punishment at all. This is often quite as hazy as that of the little boy who was heard to sob out:? “they told me to try and be a man and when I said damn I got spanked.”
A child who is punished continually, but no pains taken to insure that it appreciates why, will soon develop the rudiments of an anti-social grudge, which, later on, may have very far reaching effects.
Some of my cases have been rendered much worse through the application of the “give a dog a bad name and hang him principle.” The general aim of treatment consists of an endeavour to instil into the mind of the child a series of definite “ideals,” suited to mental and moral age (both very different things to chronological age), and so to substitute rational for emotional control, drain off superfluous emotional energy by means of muscular exertion, correct such faulty habits as may exist, both moral and intellectual, and train the child to “express itself” in conduct which is consistent and reasonable. In some cases a thorough exploration of the whole emotional life by means of psychoanalysis is advisable.
This general outline of treatment is much the same as that advocated many years ago by the late Sir Thomas Clouston, if not for mental instability generally, at least for a specific manifestation of it. In the 1892 edition of his work, ‘ ‘Mental Diseases” he writes:?”Cultivate enthusiasm about ideals, find ideal outlets for the affective and social faculties, eat only non-stimulating and fattening food be much in the open air and work hard. Finally, so fill up and systematize the time that none is left for day dreaming.’’ The italics are mine. The prognosis depends largely on the age at which treatment is commenced, the degree of general intelligence and the degree of instability shown by the patient.
In these days of “strictest economy,” it would be futile to advocate the provision of any new type of institution, moreover, some of these cases may be treated successfully at home under general guidance from the psychiatric clinic.
There are numbers, however, whose presence in an ordinary school is distinctly “detrimental to the interests of other children” who, on account of school attainments, are not “feebleminded within the meaning of the Mental Deficiency Act 1913” and, therefore, cannot be certified and dealt with as such. These require special treatment at a residential school, as do a fair number of delinquent children at present 4 ‘on probation.’’
Epilepsy is omitted as epileptic children are already legally provided for.
As stated elsewhere,* I have found our residential open-air school in the country of great service in this respect. Few such schools, however, exist; and those that do, our own included, are intended for the treatment of quite different conditions.
A type of residential school already existent, which seems to me to be eminently suitable, is the Industrial School, that is, if the industrial school I visited recently may be taken as a fair sample of the rest.
At this school, the Industrial School for Boys, Werrington, Stoke-onTrent, every child is graded and “placed” according to “mental age” as ascertained by the Stanford revision of the Binet-Simon tests, the “free system” is used as much as possible, there is an excellent series of workshops, and one of the “shows” of the school is a huge map of the district drawn to scale by the boys which coincides closely with the official ordnance map. Land surveying, indeed, appears to be a favourite occupation at this school.
Most important of all, every endeavour is made to cultivate a “class spirit” and a sense of social obligation by means of organised games in which the interests of the individual become merged in those of the “side.” Waterloo is by no means the only battle which has been won on school playing fields. There are also two excellent brass bands.
Thanks to the courtesy of the Head Master, Mr. Johnstone, I was able to spend an entire day at this school and was much impressed by the good behaviour of the boys. Sullen looks were conspicuous by their absence and there was none of that flattening against walls and endeavouring to look as small as possible on the approach of a master, one has seen at some residential schools. Masters and boys are clearly on the best of terms.
The classes of children “liable to be sent to an industrial school” are defined in section 58 of the Children Act 1908 and include:?those, apparently under the age of fourteen years, who have been found begging, wandering, destitute, truanting, under care of criminal or immoral parents, frequenting the company of a reputed thief, living in an immoral home, and children whose parents or guardians declare to be beyond their control.
This category obviously includes a number falling within the class I have termed “mentally unstable,” although it does not include all of these who are in need of special provision.
The great drawback to the use of these schools, for the mentally unstable generally, is the stigma attached to a child by reason of existing methods of securing admission by order of a Court of Petty Sessions. For the same reason a change of the name given to these schools would be desirable.
A scheme for the transference of these schools from the general supervision of the Home Office to that of the Board of Education, and of the means of securing admission thereto from the Court of Petty Sessions to the Local Education Authority, although involving a number of details requiring careful consideration, should present no problem which cannot be solved by the collective wisdom of the Central Association for Mental Welfare.
The time has also, surely, now come for placing all work connected with the mental condition of children and young persons in the hands of an expert able to devote his whole time to these duties. At present, such work of this kind as is carried out at all, is done either by the School Medical Officer, or where this official is also Medical Officer of Health, by the Senior School Medical Inspector, and is one of so many other duties, that the time available is totally inadequate.
*”The Psychiatric Clinic for Children.”
The Child, Vol. XI. No. 12. The appointment of a psychological expert by the Birmingham Justices was a move in the right direction, and the work of Dr W. A. Potts demonstrates the urgent need of the services of an expert of this kind if the problem of Juvenile Delinquency is ever to be solved successfully.
Unfortunately, in many cases in which an attempt has been made to follow the lead of Birmingham in this matter, this work has been handed over to an already overburdened official, whose activities have consequently been restricted to ascertaining whether the delinquent is certifiable as mentally defective. In many places one whole-time expert could act as mental specialist to the Local Control Authority, the Local Education Authority and the Local Justices.
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