The Neurotic School Child
- Auhtor:
Cyril Burt.
Psychologist to the London County Council (Education Department.) A neurosis* is commonly defined as a functional nervous disorder, that is, a nervous affection unattended by any gross or demonstrable change in the organic structure of the nerves or nervous system. In this group of diseases (if they can be called diseases) both the symptoms and the causes appear to be predominantly mental. Such a definition and description are certainly vague and indefinite.
What particular disorders are to be comprehended under the general term will become sufficiently evident from the subsequent discussion of the specific types. Most neuroses, as recent investigation has shown, have their ultimate origin, not in adult life, but during childhood; and, as a rule, the neurosis in the grownup person is continuous with the neurosis of the child. During childhood itself a nervous affection of this kind may hinder mental growth and hamper normal education; it may even, if undetected, turn the child into a dunce or a delinquent. Many children, brought by parents or teachers for special examination as suspected cases of mental defect, prove upon enquiry to be suffering from what is merely or mainly a neurosis. Many young criminals are highly neurotic; and their crimes and naughtiness are often either symptoms of, or substitutes for, one of the more generally recognised forms of functional disorder.
To obtain precise figures for the prevalence of neurotic conditions among children of school age is by no means easy. Such conditions require for accurate diagnosis something more than one brief interview; and merge in their milder forms so gradually into normal health that it is extremely hard to offer any clearcut standard of subnormality, or to draw any definite line of demarcation. According to Terman’s estimate, “at least 5 per cent, of our school children are neurotics, in the sense that they are more than ordinarily predisposed to the development of mental complexes unfavourable to the healthy and co-ordinated functioning of intellect, emotions, and will. “I In the survey of backward children, carried out jointly by Dr B. R. Lloyd and myself for the Birmingham Education Committee, 6 per cent, of the normal children, and 12 per cent, of the backward, were found to be suffering from defective nervous conditions.t In a recent analysis of the causes of juvenile delinquency I found symptoms of mental instability, with marked repression, in 19 per cent, of the delinquents, and in 6 per cent, of the normal control-group, the condition being in either group nearly twice as prevalent among girls as among boys. If, however, the term neurosis be restricted to more definite maladies, and reserved for such graver conditions as from their character can be ascertainably classified under one of the recognised heads, and by their severity are sufficient to retard the child’s school progress, and to require special and immediate treatment, then, beyond question, the foregoing percentages would need to be greatly reduced. The figure for the popula* I use the briefer generic term to cover what are called ‘psycho-neuroses’ as well as those which are sometimes distinguished as ‘actual neuroses.’
t Hygiene of the School Child, p. 290. t Report of an Investigation upon BacKucard Children in Birmingham, p. 13. tion of the ordinary elementary school would probably drop to less than one per cent.
In what follows I shall have space to attempt only a classificationf and description of the chief neurotic conditions observable among school children. Causes and treatment I shall not venture to discuss. Neurasthenia.
Of all the neuroses recognisable during childhood the one which most commonly produces educational backwardness and simulates congenital dullness is neurasthenia. Neurasthenia is a term most loosely used. There is, indeed, a tendency to apply it to almost every kind of neurosis that is not conspicuously hysterical. By the more accurate writers, the word is kept specifically to denote a primary fatigue neurosis. It signifies, that is to say, a functional nervous disorder, which is not merely an incidental after-effect of some other previous illness, but is itself apparently fundamental, and is essentially marked by an unusual susceptibility to fatigue. Neurasthenic children are by no means as dull as they appear. In educational attainments, it is true, they are at times exceedingly retarded; and in the classroom they sit listless, irresponsive, and inert. These are the young sorrowfuls whose teachers constantly complain that they were 4 ‘born tired.’’ Nevertheless, they have often deep and genuine intellectual interests; they are sincerely eager to make headway in their school work; and repeated failure and exhaustion afflicts their sensitive minds with the acutest misery and distress. It is characteristic of them that with brief conversational tests, such as those that make up the Binet-Simon Scale, they do well. When an appropriate appeal is made, their spontaneous attention may for the moment be ready and intense. But with voluntary attention it is different. The effort of will so easily induces weariness, and is itself so easily destroyed by fatigue, that all continued application is beyond them. Lack of sustained concentration is thus their gravest and most evident failing.
Memory depends upon voluntary attention. Consequently, the inability to attend carries with it an inability to memorise and learn. Wherever school work requires memorisation, in getting by rote the multiplication table, in learning the rules and irregularities of spelling or grammar, there the neurasthenic seems for ever at a standstill. The liability to brain fag, as it is familiarly called, manifests itself incidentally in perpetual inaccuracy and seeming carelessness. The child’s paper work is all scribbled, blotted, and erased; and any unusual strain or stress is likely to reduce him to silent tears.
The essential condition may be detected by one of the many tests for fatigue. Perhaps the simplest is the Kraepelin addition test. Here the child adds pairs of one-place figures printed in columns : the number correctly added in each period of ten seconds is computed; and the diminution in amount measures the susceptibility to fatigue. Such a test may be applied quite easily as a group-test to a number of pupils working together in class. The normal child, as he warms * So far as my own brief enquiries have gone, the proportions vary enormously from school to school. In certain departments, it is alleged, the repressive discipline and the rigid methods of teaching actually favour the development of neurosis ; and some writers have sweepingly spoken of neurosis among children as nothing but a school-made disease. In other departments, where each child’s interests are given free expression, where the atmosphere and tone are homely and sympathetic, where manual, practical, and concrete work take the place of purely abstract subjects and of formal and mechanical drill, no more than the milder degrees of common nervousness is discoverable.
There is a further difficulty in making such statistical assessments. Acute and transitory conditions, even if relapsing or recurrent, are sufficiently obscure and rare to be almost wholly missed. Hence, the investigator discovers only obvious and chronic cases, together with cases reported or supervised for some other subnormality?such as backwardness or delinquency?in which the previous history or subsequent supervision is thorough enough to reveal neurotic complications.
f Most medical textbooks recognise only two forms of neurosis?hysteria and neurasthenia. The French school haj split the latter into two distinct conditions?neurasthenia proper and psychasthenia. The Austrian school again subdivides each of these into, firstly, neurasthenia and anxiety-neurosis, and secondly, anxiety-hysteria and compulsion-neurosis. The latter classification seems to fit the symptom-groups distinguishable among children the most exactly. The few writers who deal specifically with neurosis among children appear usually to confuse very different states: and fail to distinguish what is due to normal lack of development, and what is assignable to dullness, backwardness, or deficiency, from what is genuinely a neurotic condition. The most thorough of them, L.G. Guthrie (Functional Nervous Disorders in Childhood’. Oxford Medical Publications, 1909) devotes only a few scattered pages to neurasthenia and hysteria; and, for the rest, discusses in successive chapters, either such wide-spread symptoms as fears, fretting, moral failings, and disorders of sleep, or such special maladies as epilepsy, asthma, and chorea, which hardly belong to the group as above defined. to his work and reaps the benefit of adaptation and practice, shows at first a discernible improvement. Fatigue may not appear for several seconds or even minutes, the time varying considerably with the age and ability of the examinee and with the special conditions of the experiment. The neurasthenic, however, shows the symptoms of exhaustion from the very start; his output begins instantly to decline; and continues to fall at a far more rapid rate than the normal; before the exercise is over, flushing, flurry, and confusion give evidence of emotional strain and an impending collapse.
Neurasthenia is generally attended by distinctive bodily symptoms. Without any manifest illness being present, the child nevertheless seldom seems well. He is intolerant of cold; and often looks as chilly as he feels. His pale face and puffy eyes wear the expression of one who is thoroughly tired, depressed, and unhappy. All his muscles appear limp and relaxed; and his whole being is wanting in physical and moral tone.
The feelings of fatigue are often localised in definite parts of the body. The child, when sympathetically questioned, admits that he continually suffers from aches and pains in his head, in his back, or in his legs and arms. A common feature is the so-called irritable eye. The eyelids are heavy and sore. Both the retina and the smaller and larger muscles of the eye are quickly fatigued, even where only the slightest errors of refraction are discoverable, or perhaps none whatever. The child prefers to work in a good light; and yet suffers easily from glare. Reading, writing, and needlework can thus be continued orly under great difficulties. Sleeplessness is almost an invariable complaint. Sleep-walking, sleep-talking, and nightmares are not common; nor is the insomnia severe; but the child finds it difficult to get to sleep during the first hours of the night; and often dozes on until late in the morning. Bad sex habits are frequently discoverable, and may perhaps be intimately connected with the child’s condition.
Many common ailments are accompanied or followed by similar states of nervous debility. A condition of high fatiguability is a common sequel to influenzal attacks, and a frequent concomitant of chronic gastro-intestinal catarrh. Thus it seems legitimate to recognise a secondary as well as a primary form of neurasthenia. But, whether manifestly secondary or presumably primary, neurasthenia is, in the opinion of most writers, attributable predominantly to a physical cause,?the favourite suggestion being derangement or exhaustion of the sympathetic nervous system either by auto-intoxication or by disturbances of internal secretion. It is here that the assistance of the medical man is most necessary, since he may be able to detect and deal with some underlying physical factor. As a rule, the disorder rests upon a vicious circle; the mental trouble aggravates the physical, and this in turn reacts upon the mental. Anxiety States.
Of the children reported by teachers as “nervous” by far the majority are suffering from what may be broadly named anxiety-states. The examiner’s first impression is that the child is labouring under an extreme liability to the instinct of fear, that he is living, almost chronically, in a mood of apprehension. Often the symptoms exhibit so long a history, and prove so stubborn and persistent, that it is hard to withstand the inference that the timidity is hereditary or inborn.* The mother will usually relate that, even as an infant in arms, the child would start, tremble, and scream, at everything new or unfamiliar. In almost every case the child’s sleep is disturbed. Between the ages of three and eight he may have been subject to night-terrors; jater on, he probably complains of nightmares and alarming dreams, or he may awake suddenly 1n the night, with all the symptoms of panic, but without recollecting any terrifying dream. The commonest stimuli that provoke the emotion of fear are loud and sudden noises; hence, throughout life, such an individual will suffer from what is termed (not quite accurately) an auditory hyperaesthesia; for him, as for Carlyle, “the dog’s harsh note, the cock’s shrill clarion, the melody of wheel-barrows and wooden clogs upon the street, and that hollow triviality of the present age, the piano, will torture the ear and set the nerves on edge.” As he develops from a baby into a child, his fears become prone to excitation, not only by outer stimuli, such as strange sights and sudden sounds, but also by internal ideas and thoughts. He worries; and his life grows to be one perpetual state of pessimistic expectation.
When he is older still and his intelligence is well advanced, he may realise that his alarms are usually groundless, and his worries seldom justified and fulfilled. The manifestations of fear become in consequence somewhat restricted and localised; and, though the child now finds existence less of a torture, he begins to exhibit signs that strike the observer as even more irrational and morbid. The limitation may follow two directions; and, according to its nature, gives rise to two different neuroses, anxiety-neurosis and anxiety-hysteria, respectively. For convenience, the two conditions may be considered as separate and distinct; but, as will presently be noticed, it is usual to find symptoms belonging to one accompanving the symptoms of the other.
Anxiety-Neurosis. —————–In some cases?generally (though by no means exclusively) among the duller and the younger children?it is the physical symptoms that become the more pronounced. These physi* In some of these instances a more careful analysis will reveal the operation of some exciting shock or situation about the second or third year. cal’symptoms are largely paroxysmal. They often appear for the first time after some severe shock or fright, or some prolonged tension or strain. Afterwards they tend to recur; and are easily re-aroused by a milder crisis or excitement. During the war an anxiety-neurosis was a frequent consequence of air-raids. But the precipitating shock is not necessarily a shock of terror. The sudden introduction of young boys or girls to sexual knowledge?particularly where some temptation is provoked, to which the child does not give way?is often followed by similar neurotic manifestations.
Generally the action of the heart is disturbed. The most usual and most characteristic symptoms are attacks of palpitation, tachycardia, and feelings of faintness. Disturbances of respiration are almost as common. The child wakes up in the middle of the night with a sense of suffocation, gasping rapidly for breath. Perspiration may be profuse; and in these fits the child trembles, shakes, and shivers. Not infrequently there may be some gastro-intestinal disturbance, and perhaps spells of diarrhoea, or precipitate micturition. Of these physical disturbances almost all, it will be noted, are exaggerations of the normal expression of the instinct of fear. Often, however, the reaction is 60 strictly localised, so completely confined to some particular organ or system, that the physician is apt to suspect some organic disease of heart or stomach or lung.
Anxiety-Hysteria. —————-In the preceding cases it would seem as if the child had developed some mechanism whereby his excessive fear could vent itself directly in bodily reactions, without any of the accumulated tension which is perhaps needed to generate the more painful and more intimate experience that forms the subjective emotion. Older and brighter children avoid the arousal of such emotions by a different process. They carefully shun all objects or situations that are likely to set up the reaction of fright. Thus certain specific fears or phobias are progressively evolved.
As with every mood or emotion, a free floating fund of anxiety is apt to attach itself to definite ideas or objects. The child thus ceases to be, or perhaps never lias been, generally timid; but begins to betray an irrational dread of particular classes of things. In the initial stages, the things he fears may be those general objects or situations which normally provoke fear in all members of the human race,?solitude, darkness, thunder and lightning, strange men, large and noisy animals, and even dangerous creatures seldom met with in a civilised city, as cannibals, serpents, and bears. At a later stage, the situations feared and avoided are those that, as found by experience, are most liable to precipitate the attack of anxiety; for example, crossing a wide and open street, or being left alone in a room with a closed door. Sometimes one phobia will generate another; and eventually, upon a series of fears, 6omethirg like a compulsion neurosis will be eventually built up. The attacks of palpitation in the night may suggest to the child that he is liable to sudden illness. The fear of illness may create a dread of germs and dirt. The dread of dirt may generate a washing-mania; and the child washes its hands so perpetually that the skin is always chapped and sore. In extreme cases, the disproportion between a neurotic child’s fears is sometimes astounding. I have seen a girl of thirteen, who would sit calmly, night after night, tnrough aerial bombardments, nevertheless fly into a panic of terror because she had found a speck of soot upon her plate, and spend the whole afternoon worrying because there might be similar smuts upon her hands or clothes. In most instances, however, the morbid fears of young children are less easy to fix upon than those of adults ; from his very childishness, inexperience, and inferior size and strength, a greater measure of timidity is looked upon as normal in the child. As a rule, too, in children, if not in adults, anxietyhysteria and anxiety-neurosis are found in combination; and the distinction with them must be largely theoretical.
A pure anxiety-neurosis is usually connected with current conflicts, or with unrelieved excitement springing from some contemporary situation existing at home or at school; to solve the conflict, to remove the child from the disturbing situation, is often sufficient to abolish, at any rate temporarily, most of the physical manifestations. With anxiety-hysteria, on the other hand, the roots of the disorder reach far back into the child’s mental past. Such cases are by no means infrequent among children in whom the fear-instinct itself does not seemjabnormally strong; some other emotion, in fact, lies at the bottom of the disturbance. The horror of solitude, for example, may prove to be really a desire for the absent mother, who hitherto has always been present to protect or console it. The horror of the dark may actually be based upon an expectation of ghosts; and the expectation of ghosts in turn may prove to be the outcome of a secret hope or desire for the reappearance of some beloved relative now dead. Again, the fear of strange persons, and even of strange animals, is often associated with a hidden fear which the child has developed towards its own father; and this fear itself may be motivated by some halfrealised jealousy, or by a guilty sense that some prohibition that the father once enjoined has been furtively transgressed. In most of the anxiety-states that are usually attributed to overpressure at school, the actual trouble is not intellectual over-work, but emotional conflict and strain; and the disturbing elements are often to be looked for not at school but at home, residing perhaps not in the present but in the past. It follows that it is difficult to make an exact diagnosis, and to distinguish anxiety-hysteria from an anxiety-neurosis or from anxiety-states of a vaguer sort, until some deeper analysis has been conducted.
Compulsion Neurosis. ——————-In children, compulsion neuroses are rarer than the conditions so far enumerated. They show much the same underlying mechanism as those already described for anxiety-hysteria, only the mechanism is usually more elaborate still. The child seems to suffer from some uncontrollable impulse to certain irrational actions?to touch certain posts or articles of furniture (like Dr Johnson), to utter certain improper words or phrases on the most embarrassing occasions (like John Bunyan), to count everything he comes across (like Napoleon), or to carry out a most elaborate ritual when he washes himself or goes to bed. It will be observed that the genius suffers almost as frequently as the dullard. Occasionally the impulse is a criminal one; and the few instances of genuine kleptomania, pvromania, and so forth, are instances of a neurotic obsession?of an involuntary compulsion to steal, to set things on fire, and even sometimes to wound or kill.
The simplest cases are those of so-called tics and habit-spasms. The child, after having been chafed by some article of clothing, or irritated by some transitory inflammation, still continues to make the movement which the irritation originally provoked. He blinks his eyes as though they were still sore; he twists his neck as though his collar were still hurting him; he spasmodically shrugs his shoulder, even when undressed, as though his braces were too tight, or his woollen vest was tickling his skin.
Unlike the cases of anxiety-neurosis and anxiety-hysteria, the obsessions seem in no way connected with specific or general fears; and there is no persistent background of apprehension or worry. Indeed, the child, so far from being of a timid or a bashful nature, is usually aggressive and masterful. It is the instinct of anger or of self-assertion that is most intensely developed, rather than the instincts of submissiveness, tenderness, or fear. Once more, a thorough casehistory, or careful mental analysis, will usually disclose the presence of some so-called complex or conflict arising from this abnormal propensity, and dating back to the earliest years. Perhaps the child’s first acts of aggression have called forth some warning or threat; and the movements that the child now makes, the actions that he is impelled to commit, can be shown to have some associative connection with the penalties he believes he is still deserving, or with some penance or other compensation that he feels himself bound co carry out.
Conversion Hysteria .* ——————-Hysteria in the true sense of the word is rarely seer, before puberty Most of the younger children reported as hysterical are hysterical only ir the popular meaning of the word; they are cases of excessive general emotionality, of constitutional liability to unrestrained excitement in every form; they are, in fact, not so much hysterical as unstable. In a few cases the fits of excitement may be so convulsive, so intense, and so peculiar, that the child is mistakenly supposed to suffer from mania or epilepsy. But even here the usual stigmata of typical hysteria are always hard to demonstrate during the period of elementary school life.
During these earlier years the few examples of true conversion-hysteria that I have seen were associated with some preceding or concurrent disorder of a physical or organic kind. A child, who has broken his thigh may still, when the fracture is quite healed and the leg quite strong, declare that it is unable to walk or stai d4 The child, who has suffered from some ocular defect, and perhaps had its eye shaded or bandaged for several days or weeks, may still, when the defect has been cured and the shade or bandage removed, complain that it cannot see clearly, or even that it cannot see at all, with the eye that was previously affected. In my experience most of these instances occur among children of a somewhat dull intelligence. The bright, imaginative, supernormal child is by no means exempt from hvsteria; but the hysteria generally assumes some other form.
At a later age, in secondary schools for girls and in training colleges for young women, especially where the strain of examinations coincides with the crisis of puberty or the trials of first love, typical hysteria is more frequently met with; and, with these persons, premonitory symptoms, of the same order but occurring during earlier years, are sometimes recalled by the relatives.
With all such cases, analysis will reveal a predominantly psychical origin for the functional disorder. Most of them fall under the well known formula that the symptom is the expression * The term “conversion-hysteria” (Freud) or 4’substitution-neurosis” (Rivers) is used to distinguish the familiar type of hysteria in which physical manifestations predominate over, and seem to be substituted for, mental manifestations?the latter being, by the processes of association and habit formation, “converted” into the former.
tin children conversion-hysteria tends usually to a spontaneous cure. Hence, apart from those that relapse early and often, it is possible that many transitory cases exist in elementary schools that never come before a specialist.
$In one of my cases the child was at first supposed to be suffering from hip-disease. He was ?eventually discharged from the hospital as cured. He suffered, however, from several relapses; and in the last the disability suddenly changed from the right to the left leg of a fear or wish that is more or less repressed. The physical disability, thus mentally produced, is a mode of unconscious self-defence. For example, the child, who has first been for many years spoilt and indulged as the only child of the family, and has then become jealous of a newly-born brother or sister, but has later, during illness or convalescence, recovered his original privileges as the chief focus of family interest and attention, may endeavour almost automatically to maintain this ego-centric situation by prolonging his earlier infirmities. It is, of course, important to realise that both the wish and the device are nearly, if not quite, unconscious. The child is not deliberately simulating or malingering.
Such, then, are the commonest types of neurosis to be encountered among school-children. With special modifications, simplifying or complicating them, they are, it will be seen, closely analogous to those described as obtaining among adults. The prevalent notions that hysteria is a disease of young women, and neurasthenia a disease of elderly men, are wholly misleading. Neurosis disables the child in the classroom quite as often as it incapacitates the adult in the office or the home.
Except where the nervous disorders are accompanied by evident physical symptoms, or culminate in troublesome outbreaks of crime or wild behaviour, little or no attention is paid to these cases at the younger ages. Yet, if we may rely upon recent psychological doctrines, it seems clear that a proper application, during the school period, of the principles of mental hygiene, would avert during after-life many of the most serious disorders of the mind. Under existing conditions the detection and treatment of these young neurotics must rest, not with the school medical officer, but primarily with the parent or the teacher. Medical assistance is invaluable where it can be obtained, both for preliminary diagnosis, and for broad recommendations as to treatment and training;* but, as a rule, all that the milder cases most urgently need?and, unfortunately all that even the graver cases will usually obtain?is not intensive medical treatment, but prolonged educational training upon sound psychological lines.
*In certain circles, at the present time, there is a tendency, by no means unsound, to emphasise the essential importance of mental processes in the production of functional disorders. This, of course, must not lead the layman to suppose that a smattering of general psychology, or an acquaintance with books on psycho-analysis, will qualify him to discover or treat neuroses in children. Ideally, indeed, every case should be seen by a medical man; and the failure first to rule out the possibility of organic illness may obviously lead to fatal errors in cases rashly diagnosed as hysterical.
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