Organisation mondiale de la santé (OMS) · Technical Documents

Seminar on Mental Health in Childhood, Sydney, Australia, 10-27 August 1953 : report

31 décembre 1953 Organisation mondiale de la santé

Le texte intégral est hébergé par l’organisation qui le publie. lawenc.com indexe les métadonnées et renvoie vers la source officielle.

Texte intégral

WORLD HEAIl1'H ORGANIZATION COMIolONWEALTH OF AUSTRALIA. IEPARTltlENT OF HSU/ffl

SEMINAR

.Q!! ME:NrAL HEAI1l'H IN CHILll:lOOD

held in S~r.dMy,

Australia,

10-27 August, 1953.

REPORT Compiled and Iasued by

The Institute of Child Health University Sydney.

,-.-----~~

VJG:~~"'~ ~. :.','~ ;'. :".

. . . . . ·. .

----~--.w...__._.c___"

I,:,.:

:~I'~r·~'}~~N , ",

. --..-

~ r ..., .- " r\ L ... ; ....

Lii's;':,'c,i I--------, ....._----,

TABIE OF CONTENTS!

•.... ~/".

page

• -.!'

FQreward AQlaIowledgementa Introduction Prel.iJJd.naryPlanning AooQ!!D'!!Odat1on Arrangements CaIlterenoe Event Session Organisation and Structure Steering Committee Conference Documents Observation V,Ud.,ts. and other Ev-ents Ubrary Filma Social Club Publicity ~

1 ;2

4 4 4-

5 5 5 6

7 "'--

THIi:ME

Y. -

THE CHILD AS .AN INDIVIDUAL, ~ ~

o£

~lity

Development.

Dr. Elwyn A. l&:>rey

2. The PosAble Relationship of Events and CoDdit i ocourring in the Pre"Natal Period Upon Persooa.lity tevelopment. Professor L. Dods

OD8

Some Events and Comditi.ons in the Post-Natal Life

of the Child which Might; Affeot Peraonality Development. Dr. Ronald Mac Keith'

"-.

The Childta Sooial Development. Dr. Irene Sebire

5. Psychoanalytical Theory of Early Personality tevelopment. Dr. Andrew Peto

31 37

6. SUDIIll.ry of

Main Points in Group DLsousaiona. Dr. C.H .Gundry

-. -~

1'HEME II. THE CHILD AND ITS RELATIONSHIP TO THE COMMUNI1'I. 1 .. Family Patterns and Child Care.

-'.

Professor Raymond Firth

Family Patterns in Western Culture. Miss Norma Barker

'3. The Child

and the Community in South East Asia.

51 4. Changes in Authority and Conformity of ChiJarell. Miss Gladys E. Pendred

Summary of Main Points in Group Discussions •. Professor Raymond Firth

THEME

ill 1.

MATERNAL DEPRIVATION. The Effects of Separation on Young Children.

nr-. 2. The Effects of Se~ration

Alan Jennings.

71 75

on Childhood.

nr-. 3.

Andrew Peto

Children in Hospital - Before, During and Afterwards.

nr-•. Ronald 4.

Mac Keith Meeting~.

Additional PointB Ra=.;::ed. in the Group .

.Dr.J~Williains THEME IV. BEHAVIO~

79 \

DISORDERS IN CHILDREN.

Some Typical Disturbances in Children and Their Meanings. Dr •. A.R.Phillips 80

Nervous Disorders in Children and an Approach to Therapy.

nr-; THEME V.

D.W.R.Arnott

Tl:":'T. PSYCHOLOGICAL PROBLEMS OF THE HANDICAPPED CHILD. Medical Aspects. Dr. Ronald Mac Keith

The Handicapped Child and.his PaJ;'ents, Mrs. Georgia M. Travis

""., ~

THEME VI.

PLANNING TO MEET THE PSYCHOScx::.IAL NEEDS OF CHILDREN. Methods of Mass Communication in Mental Health PrillCiples. Dr. Elwyn A.Morey

100

Ways and Means of Ioplementing the Findings of the Seminar. Dr. J.F .Bulsara

104-

Summaries of Conclusions of Discussions on Planning to Meet the Psychosocial Needs of Children. Principles Emerging out of the Seminar.

107 112

4. The Concept of Mental Health and Some Basic

EVALUATION OF THE SEMIN.AR BY THE MEMBERS EVALUATION OF THE SEMINiill. BY THE FACULTY APPENDIX

114 116

Time Table List of Members of the Seminar Circular letter No.3. sent to participants before the Seminar •

APPENDIX II. .APPENDIX

ill.

•

SEMINAR ON MENTAL HEALTH IN CHILDHOOD.

FOREWARD. Herein is submitted a report of the first Seminar on "Mental If.ealth in Childhood" of the Western Paoific Region of th& World Health Orgat)j.,ation held in SydneY9 Australia, from 10-21 August 1953. Proposals for holding a seminar in Australia were first put forward in

1951 and arose out of successful oonduot of Mental Health Seminars in Europe. Arising out of these disoussions a recommendation was forwarded from the Division of Organisation of Health Servioes at Headquarters of WHO to the Regional Direotor, Western Paoifio Region, and the proposal was listed on the Agenda for the Seoond Session of the Regional Committee at Manila in 1951. The Australian delegation at the Seoond Session formally invited iVHO to assist the Australian Government to oonduot this seminar. The Seoond Session of the Regional Committee agreed to the proposal and reoommended that the invitation should be accepted. The projeot was listed in the proposed programme for 1953 under Interoountry Programmes and provision for the expenditure of $16.200 was made in the proposed budget. This item was included in the programme adopted by the Fifth World Health Assembly. The purposes of and arrangements for the seminar were stated in the following terms: "To help develop an informed professional opl.nl.on on mental health problems and to emphasize the mental hygiene'aspects of general public health praotice it is proposed to hold a regional seminar in 1953. A short-torm consultant will be provided in the regular budget, and short-term regional fellowships will be given, so that Member Governments oan send seleoted oandid.ates to attend the seminar. As in the oase of the nutrition seminar ment:j;oned in the following paragraphs small quanti ties of essential technical literature and speoial teaching equipment and supplies will be furnished".

ACKNOWLEDGEMENTS. Sinoere acknowledgement is due to The Master, Wesley Coll~e, and the Principal, Women's College, The University of Sydney, for providing residential aooommodation for the members of the. seminar, and to the Principal, Women's College, for making available many rooms in the College for the business sessions of the seminar. Our thanks go to the members of the faoulty, particularly the Australian members of the faoulty who, in addition to contributing to the teohnioal discussions assisted in the planning of the seminar. The members of the seminar expressed their appreciation to the numerous Commonweal th Government Officials who assiSted in making the seminar a success.

Appreciation was expressed of the valuable assistance rendered by

Mr. John Minter9 and his staff.

- 2 -

INTRODUCTION. The 8eminar on ''Mental Health in Childhood" was held at Sydney University, Australia, from 10th to 27th August, 1953, at the invitation of the Australian Government. It was organised by the Institute of Child Health, the Uftiversi ty of Sydney, at the request of the Commonwealth Department of Health. The objectives of ibis seminar were to bring together workers in the field of .child health, education and child welfare from the countries of the Western Paoifio Region of II.H.O. In addition, invitations were issued by ,the Regional Director, South East Asian Region, W.H.O., to the oountries of that region to send one or more participants to the seminar. It was agreed that the majority of the faoulty members would be Australians, for whose expenses the Australian Government would accept responsibility. W.H.C. agreed to secure four overseas lecturers for subjeots for which suitable Australians were not available. There were, all told, 15 members of the fa.oulty. Forty-seven participants took part from, Australia, Eurma, China,(Taiwan) Hong Kong, Indonesia, Japan, Malaya, New Guinea, New Zealand, Philippines, Sarawak, Singapore, Thailand. In addition, Dr. Massal, Executive Member for Health of the South Paoific Commission, was able to attend a number of the sessions. 'Dr. F.W. Clements, Institute of Child Health, was Direotor of the seminar; he was assisted by an administrative staff, by members of the Western Pacific Regional Office of W.H.O., and by the Liaison Officer and his staff of the Uni ted,Nations Teohnical Assistance Eoard, Sydney. . . ).

PRELIMINARY PLAlfNING. Unfortunately, the length of time availr.ble for pre-seminar planning was too short to enable an exohange of ideas between the partioipants and those responsible for the planning on the content of the seminar. MUch of the ." preliminary planning had, for this rea.son, to be made by those members of the. faculty resident in Sydney, although a lively correspondence was maintained betweon the administrative headquarters and all members of the fap.ulty. W_H.O~ secured the services of Dr. C.H.Gundry, Director, Mental Hygie)1.e Programme, Vancouver, B.C., to a,ssist the Director with tho:teohnical aspects of the programme. He arrived in Australia early in June, when a series of meetings with all Austral'ian members of the faculty was held. (Unfortunately the other 'three overseas members of the fa.oulty oould not !'~rive in Sydney untii the week preceding the seminar.) At thGse meetings the general outline of the programme was deVeloped, and the introduotory talks allooated to speakers.

As soon as W.H.O.a.dvised the Director. of th€ SeDiina.r, of the names of the participants, a series 6f oircular letterswa.s sent to :each. These 'letters gave deta.ils about the seminar, and.one posed.a series ofquEistions which, it was reQuested, the partici'pants might study beforo leaving their oym oountry. A oopy of this. ciroular letter (No.3) is reprinted in the appendix. Due to the late selection of some participants they had little or no time on which to oonsider the oontents of this circuln.r letter. They found this a handicap_, The letters of invitation to'Governments suggested that the oriteria of selection should be: (a) that the partioipants are in M,.9.dministrative position in ei ther Hee.l th, Child Welf.r>.re, or Educa.tion and are in a position to implement,tho lessons of the seminar

(b)

- 3 That the participants are teachers of medical graduates or undergraduates, public health nurses, or the equivalent, social workers etc.,

The result was that there were representations from at least seven disciplines in the total membership of the seminar, as the following figures showl Psychiatrists.oo.ooo •••• oo • • • • • • • • • • • • 14 Pedi'a tricians co • 10 Ma~ernal & Child Health Services ••••...••••••••• 7 Soc,ial workers, Social scientists.... 7. Psy~hologists ••••••••••••••• o • • • o • • • • 6 Ntlrses ••••••••• lit...... .. . . . .. ... . .... 6, 0 •••

<> 0

•

•••

\10

•••

\10

•••

•

\10

Edu~ationalists

••••••

ooo • • • • • • • • • • • • •

5 3. 2, 1 1

Public Health Administrators ••••••••• School of Medical Service •••••••••••• Teachers of Public Health •••••••••••• Cultural Anthropologist ••••••••••••••

The multi-disciplinary character of the seminar was probably the moat important single factor in creating the stimulating atmosphere experienced by the members. •

---

ACCOMMODATION

ARRANGEMENTS~

Experience of similar international seminars oonducted by WHO has emphasised the value of members of the sQ~inar living in the same hotel or hostel during the meeting. This arrangement allows for the maximum exchange of ideas outside the scheduled meetings and helps to develop a good social spirit. Through the willing co-operation of the authorities it was possible to make arrangements for the women to reside in the Women's College, and the men in Wesley College. !he colleges adjoin one another in the grounds of the University of Sydney. By a happy arrangement it was possible for men and women to take lunch and dinner at either college. This provided the maximum opportunity for informal discussions. With the exception of the formal Opening and four plenary sessions, to be referred to later, all meetings were held in the Women'~ College. THE CONFERENCE EVENT. Opening Session: The seminar was formally opened by the Rt. Hon. Sir Earle Page, Minister ef State for Health, Commonwealth of Australia, and was attended by the Deputy Chancellor, University of Sydney, Officials of the Governments of AUstralia, and New South Wales, representatives from the Embassies and Consul~tes of the Governments of the countries from which participants had come, members of the medical profession, press, and others. Addresses of welcome were made by the Minister for Health, and the Deputy Chancellor, University of Sydney. Dr. Gan, representing the Regional Direotor, Western Pacific Region, read a message from Dr. I.C.Fang,. and responded on behalf of WHO.

.;. 4 Organisation and structure. The work of the ,~eminar was oonduc·t'e'din both plenary and group meetings; of the forme!' there were two kinds, those held in the daytime, and restricted to the members of the seminar, and four meetings held in the evening to which .. about 100 doctors, sooial workers, psychologists and educationalists in Sydney were invited, These four meetings were an experiment 'designed for the dual purpose of reporting back to the members of the seminar the salient points in the discussions which had taken plaoe in the group meetings, and of satisfying a strong demand from a large group in Srdney for some participation in the seminar. (The value of these meetings is discussed fully in the section on evaluation). ,

The devise of using one speaker to summarize and "report back" to a plenary meeting the group discussions was an eEPerimental attempt to present this material in a concise form. Each plenary meeting restricted to members e-f -ihe seminar, was an information session at which a member of the faoulty provided some background information as a basis for the subsequent discussions. Six groups, each multi-cultural and multi-disciplinary, were formed. Two faculty members, (one of whoqi. had some skill in discussion methods) were assigned to each group. Two sessions were held each day, either in the morning, afternoon or evening. When an evening session was planned the afternoon was free. The general arrangement was that each plenary meeting was 'followed by a brief reoess and a group meeting of about one In addition one meeting was held of eight and a half hours duration. professional groups to discuss various aspects of "Planning to meet the Psyoh4l-social needs of Children". The indiVidual members of each of these groups found this meeting most satisfying. Each group appointed a reporter who prepared reports for the faculty members responsible for summarizing the group meeting to a plenary session, or, gave them directly to a plenary session. Steering Committee. Interspersed with the foregoing activities were meetings of .the steering committee. One of the main funotions of this committee was to evolve the day-to-day plans of the seminar. This committee consisted of a representative from each of the six groups, elected by the groups, a representative of the faculty ~nd the director. As the seminar progressed this committee was called upon to mnke decisions regarding changes in the programme plan and other arrangements. In evaluating this committee, the opinion was expressed by some that it could have been used more. ~

On arrival each member was given a folder containing:-

( a)

the seminar directory (which gave information about seminar, and non-seminar topiCS of importance) a who's who of members

the working library list maps of Sydney and the University grounds tourist literaturo a prOVisional time-table

(e) (f)

- 5 In "rder that each member might have a reoord of the talks fo~ reference in the group discussion meetill8s, each speaker Was asked to prepare a fairly fUll. summary of his, or her, talk. At first these were distributed after the talk was given, but £ollow1ng. a request from those- who found it·.difficult to follew all tha.t -was tlaid, tb.ese talks. were given. ~ut half a day preceding the talk. Observation Visits and Other Events. By delibera.te decision visits to' institutions etc., were not included as part of the programme of the seminar as it was considered that the limited time available could be more profitably spent in the consideration of principles. However, a number of Visits and excursions were arranged for the week-ends, and free periods. One feature of the seminar was n dinner attended by all members of the seminar followed by a social evening on the last but one night. This. proved to be most successful and was enjoyed by all. The easy friendly atmosphere this evening was an expression of the friendly spirit which prevailed throughout the seminar. Libra:r:z:... Portion of the library of the Women's College was set aside for the seminnr library. A list of books and relevant scientifio articles in periodicals, was prepared by members of the faculty. Copies of the books, representative samples of periodicals dealing with the various aspects of the subject, and in so fnr as was possible photostat copies of the scientific articles were assembled in the library. .> •

A working library list was prepared and a copy distributed to all members of the seminar. A librarian was in attendance in the library during meal breaks and all unscheduled time up to 10 p.m at night. The place of the library in a seminar of this nature is discussed in the section on evaluation. Films. A wide range of films dealing with various aspects of child development was assembled, and some were screened in the late aftern~on. This did not appear to be a thoroughly satisfactory arrangement. In addition, a small group interested in the making of films for research purposes had an opportunity to discuss this subject with a guest to the seminar (Dr. Michaelis) who has had wide experience in this field. THE SOCIAL CLUB.

In order to provide an apportunity for the members of the seminar to get together informally in the late afternoon and evenings, a social club was crganised. This meeting took place in one of the rooms at the Women's College. It proved most popular and was regularly frequented by most of the members of the seminar.

. ....

- 6 PUBLICITY. ""

An',:enoouragingfeature of the seminar \vas the interest shown "by'the'press. Some (1f 'the technioal aspects were .given prominent 'press notioes,. and the reports of the inteJ,"Views with overseas members a.ppea.redin"d.ai~y.newspapers, and weekly periodioals. In addition, at least twenty members' of the' seminar gave broadcast talks which were used on both· Australian programmes arid oh,,' short-wave programmes direoted to the home oountries of the speakers. The interestsilown by sections of the public' in'the seminar was qui:te oonsidera.ble.

. \

-7AN ORIEnTATION LECTURE by C. H. GUNDRY.

The purposes of this seminar are to examine the early development of personality with particular reference to factors that make for good or poor health and to consider how a knowledge of that subject can be applied in programmes of child welfare, child health and education. Per'sonal i ty is a term of many meanings but it is obviously important that in our discussions we agree to stick to one definition. Let us say that we shall mean by personality the whole person, each person being unique and the development of his interacting somatic, psychological and sociological systems tending towards integration. ( The W.H.O. has defined Health as a state of complete physical mental and social well being, and not merely the absence of disease or infirmity. It is to be noted that that definition of "positive health" agrees with out definition of "per'sonali ty" in that it unites the physical mental and social aspects. Although we must not lose sight of the ideal of "positive' health" it is still true that in our habits of thinking as well as in most of our daily work and our attempts to evaluate our problems we are often concerned with disease. Whatever his profession each of us will encounter various ideas about the nature of disease. Amongst the public, he will find beliefs, active or vestigial, that diseases are due to magical or supernatural influences.' Displacing these oln ideas are the common current theories which are derived from laboratory science. In this second type of thinking the implication is that there is a number of disease entities, each with its specific cause and treatment. This approach has, of course, made possible the great advances of Western medicine in the past century. However, it is inadequate in illnesses that are due less to a failure of any organ or part, of the patient, and more to a failure in his functional organisation. The third type of theory, which is coming back into j.ts own after having been overshadowedfcr a while by narrowly scientific thinking, emphasizes the importance of the -·-----patient's constitution and personality. It holdsthat there are no ready-£'lade:==: disease entities, but only sick people. If we leave out of consideration the primitive and religious ccnceptions of disease the two current ways of thinking can be called respectively mechanical and biological. Mechanically, the human organism is likened to a machine made up of a number of parts and illness is considered to be a breakdown of one of the parts. From. the biological point of view the concern of medicine is with an individual's reactions to various influences in his environment. In psychiatry, it has been caUed the psychobiological point of view. . A disease is a condition of an individual when his "normal" adjustment is disturbed by excessive stimulation. The relationship :between "norma.l" and "disease"is illustrated by that between normal anxiety and anxiety neurosis, between normal discomfort and heat stroke, between resistance in response to a smali infection and disease in response to a large infection.

'-.;.

There is no case of sickness in which one cannot find more than one causative factor if one takes a broad view. In many cases of course one factor outweighs others in importance. It is practical to contrcl typhoid fever by controlling spread of the causative bacteria and to prevent beri-beri by enriching essential articles of diet. But even in those instances the causes of the diseases are not simple, because some people can carry a typhoid infection Without being sick, and some people will refuse a proper diet because of superstition. Instances of direct cause and effect relationships in medicine are rare. It is mare common to find that a combination of circumstances leads to a reaction. This concept can be called the principle of multiple aetiology. The influences that lead to disease reactions are innumerable, of course, but they can be grouped into a small number of categories. A classification of aetiological factors for instance might be I Infections Nutritional Hereditary Traumatic Chemical Emotional Altogether too often failure to understand an illness is due to the desire to relate it to a single causative faqtor, and particularly to not attaching enough weight to emotionalfactors.·'ci.\:$nY··cases of asthma in childhood will not respond to therapy if attention .is~ta1d. only" ~o infectious and allergiC aspects, the emotional relationGhipa between child and mother are always very important in this condition. A question that is really answered in our definition of personality which probably deserves special mention in this introductory discussion of our seminar is what is the relationship between mind and body. It has been held that the body is quite separate from themind and that the physician's business is with the body, that which pertains to the mind being the province of philosophers and priests. A good deal of what is called the stigma of mental diseases is due to the failure to see tha.t they are just as natural and susceptible to study and rational treatment as are physical diseases. It would be fair to say that it is more shameful to have typhoid fever than to have schizophrenia, because we know a great deal moreabout how to avoid typhoid fever. There is a great deal of evidence that mind and body are two aspects of the same thing. Vie can think of the effects of suggestion and emotion on the body and of the mental effects of damage to the brain. However, this is no place for an enquiry into the subleties ~f----=o", this problem. There does not ~eem to be at present any reason to assume that neurophysiology will over be able to account for the quest of the human mind for truth and beauty. The practical point is that environment, body and mind react on one another and that we must seek answers to questions about health and disease in their interactions. If we can agreo about thuse general propositions, what we mean by personality, and the psycho-socio-biological concept of disease, then we can begin to draw a little closer to our subject. Psychiatric illnesses of various kinds pre-eminently demand a psychobiological approach and a consideration of multiple etiologicalfactors. The psychiatric illness is 11 reaction of an individual to stress but it is commonly the case that the individual has failed to adupt hi~self to ordinary stress rather than that he has been exposed to cxtroardinary stress. There is little reason for expecting that the amount of psychiatric illness can be greatly reduced by the removal of environment stresses. As far as vie can see, the emppases must be placed :rather or: raising resistance thu.n on lowering "tress.

{

.'" .. ~

Exceptions to this generalization will quickly come to mind. Good medical care, good rehabilitation services, good obstetrics, eugenios, prevention of syphilis and nutritional deficiencies, are methods by which some psychiatric illness can be prevented. However, the fact remains that, as far as we can see, our moet effective means of preventing mental illness will be to improve mental health. The W.E.D. Expert Committee on Mental Health has. laid down that "mental hygiene consists of the activities and techniques which promote and maintain mental health". They continue I "Its practice demands that groups and individuals should examine and re-evaluate patterns of interpersonal relationships in the light of their influence on personality development and mental health. To accomplish thiseducation in theory alone is insufficient. It must be accompanied by practical methods of learning through actual personal and group experiences which foster emotional insight and modify behaviour in the direction of healthier personal relations •••• " These words r from the expert committee's report might be taken as the keynote for our ' seminar. Incidence of Psychiatric Disabilities. A knowledge of the incidence of the various types of psychiatric disorders would, if obtainable, be the natural basis of planning for action in the field of Mental Hygiene. So far, practical difficulties have prevented any really accurate enumeration of all types of mental disorder in any large geographical unit. Information from various sources can be, compiled, however, to give a fairly good estimate of the' extent of the problems. Mental Deficiency. The classic study of the incidence of mental deficiency is the report of the Mental Deficiency Commission which made a survey in England 1925-1927. Dn the basis of enumeration of cases in sample areas, they estim~ted that the rate of certifiable mental deficiency for all ages, excIud~ cases which were only educationally backward, was 8 per 1000. Psychoses. Various methods of arr1v1ng at the incidence of the different psychoses have been employed in different countries. Variations of method and differing diagnostic criteria make it impossible to compare them accurately. The expectancy of mental disease in New York State has been studied carefu:j.ly and is reported in the American Journal of Psychiatry - November 1943. According to that study, 85 of every 1000"people born in New York State are expected to spend some time in a mental hospital. The experience of the United States armed services and induction boards provides an extremely broai sampling of men of military age. The figures they have publishod must be interpreted, of course, in the light of the special purposes of the services and the rapid screening methods employed. It is interesting, however, to observe how closely their rate for mental deficiency agrees with that of theEnglish study referred to above.

- 10 _

Causes of Rejection and Ir.cidence of Defects of 18 and 19 year old Registrants Examined at Local Boards and Induction Stations * Number bf Registrants rejected per 1000 examined Total, White* Negro 19.5 7.0 3.7 3.3 11.5 6.8 3.6 3.2 121 .7 10.0 5.5 4.5 32.0 2.4 0.3 12.1 16.3 8.5 4.1 4.4 33.2 3.6 0.8 8.2 19.7 0.1 0.6 15.0 3.1 0.3 1 .9

Defect or Defect Group

Number of Cases found per 1000 examined T. iitN. 139. 8.2 3.9 4.3 33.1 2.4 0.3 13.3 18.1

Educational deficiency •••••••• Mental deficiency •••••••••••• Moron, idiot and embecile Mental deficiency, unspecified 000000"0000000

12.4 6.4 6.0

Mental diseases 27 .6 Grave mental or personality disorders Major abnormalities of mood Psychopathic personality Psychoneurotic disorders Chronic inebriety and drug addiction Mental disease not classifiable elsewhere .7 Neurologic 00.,

27.2

0.8 12.1 5.2 2.1 2.1

0.8

(I"

....

,,0

Epilepsy Chronic encephalitic syndrome Posttraumatic cerebral " Poliomyelitis, residuals of Neurologic defects, other

14.8 3.2. 0.3 2.0 4.2 5.1

17 .5 3.4 0.4 2.1 4.7 6.9

17.8 3.3 0.4 2.1 4.8 2.4

4.4 5.3

2.7 3.6

2.7

7.2

Includes all races other than Negro.

An article in the American Journal of rsychiatry of January 1946 reports that the United States induction boards rejected 12% of men who were called up in the period 1st January 1942 to 30th June 1945 on neuropsychiatric grounds. That was slightly less than 1,750,000 men and represented 37% of rejections. During the same period 457,000 men were discharged from the American Army on neuropsychiatric grounds. These United States figures are cited only because they are the -only ones available, to give general emphasis to the importance of psycho. biological problems. Nothing is implied about the incidence of such conditions in the United States in comparison with that in other countries. The statement is made in the annual report of the Medical Department of the Colony of Singapore for 1951 that "the mentally ill, whether defective psychotic or psychoneurotic, cause greater loss of man, hours, of money and of efficiency, ~han any other single chronic disease entity, not excluding tuberculosis".

-II -

Prevention The history of what. is .called the Mental Hygiene movement goes back clearly to 1908 when Clifford Beers, who had been a patient in a New England Mental Hospital, suffering from manic depressive psychosis, after his recovery took up the task of improving the hospital treatment of mentally ill patients. One outcome was the establishment of the National Committee for Mental Hygiene. Great progress has been made towards the attainment of the original objectives, to set up good standards for mental hospitals, to provide for earlier diagnosis and treatment in psychiatric clinics and to overcome the peculiar stigma of mental disease. In the 1920's the prevention of mental disease became a new, or added, objective. It was felt that treatment of children would prevent the development of schizophrenia; many child guidance clinics, behaviour clinics, mental hygiene clinics were established. Now the objectives have changed a little - mental diseases, and even the one so-called disease of schizophrenia, are too complex for a direct attack. The present trend of thought is towards trying to promote mental health - trying to correct or prevent the development of unwholesome tendencies and conditions that provide the common soil in which various types of mental disease and personality problems develop. Some types of mental disease could be prevented by application of available knowledge. Outstanding examples would. be general paresis, and Huntingdon's chorea, and psychoses associated with pernicious anemia, etc. Geriatic practice conducted with a broad appreciation of the emotional problems of the aged would prevent many of their psychiatric problems. If the management of traumatic cases was always conducted with due regard for the anxiety and suggestibility of patients, a great many cases of post traumatic neurosis could be prevented. This would hold true also for the "iatrogenic diseases", those unfortunate cases in which the attempt to be very thorough in investigation of all possible organic causes for symptoms, without adequate explanation or reassurance, aggravates the patient's anxiety and precipitates a psychoneurosis. However, even after all such det~ils of good medical practice have been attended to, they will constitute only a small part of what is within the bounds of possibility in the prevention of mental ill health. The feasibility of a much more fundamental approach to the problem rests on the hypothesis that the fundamental factor in a great deal of psychosis, and all psychoneurosis, and cases of psychopathic personality and less definite cases of social maladjustment is faulty personality structure. Human personality grows from a basic genetic endowment, and is modified by life experiences. Individuals vary in their native endowment physically, temperamentally, and intellectually. As a direct result, from birth, even during intra-uterine life, each individual faces the impact of his environment with his own unique variations in response. Children differ in their rates of maturation, and physiological tensions and negative emotional responses can be created in babies by attempts to impose routines of feeding and resting that do not suit their individual needs. By the second half of the first year, differences in the methods of adaptation to environment becomes apparent, that is, the first indications of the distinctive personality of each infant can be seen. Slight inherited differences are multiplied by the varieties of life exper1cnce. For instance~~ in a situation where two babies were rather carelessly looked after, so that their feedings were often late and their demands for attenti('r; ;.nconsistently responded to, one, who by temperament was disposed to vigorous' and insistent

to.

- 12 -

expression of his emotional state, might become an angry baby, loudly demanding that his needs be attended to and laying foundations for an aggressive personality. One could imagine him becoming a rugged individualist, ruthlessly __ going after whatever he wanted. The ather, being more passive by nature,woulfl tolerate the neglect and his general development would be delayed because of lack of stimulation and nourishment; he might possibly end up as an unstable discourdged drifter. Principles of Mental aygiene. We have at our disposal a great body of information about development and socialization of children. Workers in the fields of anthropology, eduoation, social welfare, psychology, and medicine, all contribute to it. We can study children in health and disease, in their responses to love and to insecurity, at different stages in their individual development, and under different methods of aculturation. Can we derive from this information some/ universally applicable principles deserving of the term Principles of Mental' Hygiene? In ather health fields substantial progress has been made when we have been able to clarify principles of hygiene and teach the mass of people how to apply them, Perhaps we have reached a point at which we can re-state the purposes of our Seminar. To be consistent with the spirit of the Seminar this statement should came from the participants as a group. But to start the ball rolling I would submit the suggestion that we want to do two things. To derive from our discussions about children's development some generally applicable principles of mental hygiene, and Whilst doing that, to obtain a refreshed and broadened insight into the fields of usefulness of our various profes"ions and an increased capacity to work harmoniously wi th ,~1.U' associates. References. "Causes of Rejection and the Incidence of Defects" by Rountree, McGill & Edwards. J.A.M.A. September, 25, 1943. W~H.O.

technical reports Expert Committee on Mental Health Report of first session No.9 Report of second session No.31

Assessment of Mental Health; Joseph Eaton: Journal of the American Psychiatric 1.ssociation, August 1951. C<>ncepts of "meaning" t'J,:':l. "cause" in psychodynamics, Whi tehorn _ Journal of i>merican Psychiatric Association, November 1947. , The Patient and his Disease. Clark-Kennedy - Lancet; ,Dec, 2 and 9, 1950.

- 13 :r

THEME

1. IHDIVIDUAL.

THE

CHILD

SOME ASPECTS OF PERSOHALITY DEVELOPMENl'

Il~

CHILDHO,D

Elwyn A. Introduction

Morey '.

The tasK which has been assigned to me 11'i this talk is to provide a basic anI definitive oockground against Which our later ,di~cussions-·will develop, ana which can be regarded as a general starting point for con~ sideril1g mental health in. childhood, irrespective of cultural conditions. The more I have contemplated this task, the more difficult it has seemed. Is it possible to talk about such a controversial subject as personality,' and be basic but non-cultural; definitive, but non-provocative? 'Even now, I am not at all sure. In attempting to do this, I shall consider briefly what personality means; the bases from which it arises; and the processes by which personality development takes place. B. The Meanings of Personalityg • To understand an infant, we need to do more than observe lts behaviour. We need to kno~ something of its background, its experiences, its most frequent responses. E~en then, as Sibylle Escalona points out, we can only know the inf~nt to the extent that we, ourselves, are able to recapture its inner experiences - a difficult task indeed for most of us. But it is these inner experiences which constitute the personality; the core of the individual, the inner self which determines reactions with the environment. In infancy, only the beginnings of personality exist; for the baby, as an individua.l, makes minimal contact with the environment. The raw material is there, but the process of fashioning a "self" is long and complex. Individual differences ir, personality traits are noticeable, however, within the first few weeks of lifesome say wi thin the first ten days. With such an early beginning it is no wonder that personality is unique. No two individuals develop exactly the same personalities, not even ~wins, although research studies have shown twins to be iIlore alike, even when reared in different enVironments, than other individuals. The processes by which personalities develop are the same for Us all, but the end results are unique and specific to the individual.

..... ...

In the mature individual, personality is organised and patterned. We oan predict types of behaviour if we know an individual well. Yet personality is never static. The process of living requires the individual to be making constant adjustments and adaptations to new situations. The young child is less organised, more flexible and therefore more unpredictable. He is still engaged in finding types of responses and behaviour which will satisfy him a.nd meet the needs of security, but even so, as Shirley and others have shown, certain traits appear early and persist in later life. If we regard personality as the inner organisation of an individual in relation to his onvironment, its connection with mental health is obvious. At birth, all babies, whatever their intellectual endowment, have the potentiali ty for mental health. If, as 'they grow, their attitudes to the external world become fearful, suspicious, resentful or hostile, personality development is impaired and mental health affected. There is little eVidence, however, to suggest that the main basis of warped personalities or mental ill-health is present at birth.

- 14

The Enses of Personali ty~c.-

Geneticists today are agreed that human traits are not inherited in any simple se.ri~.a.,,:.. ,lt is not sufficient, either, to assume a hereditary basis for traits of personality cortifi1ontoseveral members of a family, since the part played here by learning and imitation cannot be evalua'te'd;-F'rolli. the moment. of birth, the infant is affected by physi<:o;l" con,ta.cts with the environment, partioularly the mother, and the effects of such oontacts cn the child1s inherited potentialities for response can only be estimated. We oannot predict even which of various genetic possibilities will be re~lised through the infant1s life-exp.~rHmces; nor do we know to what extent limits are set onpe:raOJ.l,p. l i ty devei.opmerittnroughhllredi:tary. endowm,ent. Close observations of newborn inflJ.l'!ts l:j.o.ve.shown, however, that there are characteristiodifferencos in'suoh th~~s Il.sactivity level, IiItrength of suoking, amount of crying, sensi tivi ty to sound a.nd touch -- all of which may well persist'a.nd _,affeot the individual's, inner ~tates of feeling and his rea.::tion to others. Constitut.ional features such I1.S, physique, skin pigmentation, fe.cial characteristics, may also affect . person1j.li ty. Indeed, some workers in this field, not ably Sheldon, havesuggested a close correspondenoe between body build and temperament, regr.rdless of life experiences. Infants differ also in physiologioal features,' some of whimh are related to personality. The most striking of these is the relative strength of biological drives, observable in young children and directly related to inner states, in the sense that much behavio~r is dir~cted towards the satisfaction of these needs. With b:1.sic individual differences in endowment of. these drives, it is evident that no matter how constant the environment for ·a group of persons, variations in personality would still occur, that is, personality would still be unique and specific tp the individual. Most of ~ ,our knowledge about these biologioal drives hes been derived from studies of animals, but differences between human inf::mt/iO in the strength of the hunger drive, for' example, a.re evident at birth. Variations in the strength of the t sex drive, too,would appear to be constitutionally determined. One must note, howev,?r, that while these differences are basic, their significance for any individual, personali ty depends on the degree to which.drives, both basic and. acquired, can be satisfied. It is only when they are constantly frustrated and fa.il to find satisfying outlets that they become important variables of personality. .It is evident, therefore, that it is insufficient to consider the foundations of personality without passing on to the processes by whioh the individual builds on these. D. Processes of Personality Development:

From birth onwards, the infnnt is forced to develop in oontact with the external environment. Through those contacts; he seeks firstly, to obtain satisfaction for his inner needs. Through them also" he gradually differentiateshimself fI'omthe world around him and shows, in his behaViour,certain characteristics whioh we regard as signs of the emerging personality •. The whole process is one of interaction between biologically.,.determined tendencies and environment experiences, the two being so closely interwoven that separation is impossible. . The first contacts are sensory, chiefly through the skin . senses. The child1s experiences of the world as comfortable, irritating, cold, prickly, secure, will depend on his bodily contacts.· His early sense of wellbeing is directly related to these M.d to the satisfaction of. his bodily noods. Before he can prooeed further in his IErceptioris, maturation i.s required ohiefly the maturation of the central nervous system which leads to further development of the 'distance receptors of sight and sound •. Al th·o'\.l.g'h, he knows her well through physical con.tacts, a baby' cannot differentiate his mother as a person until his eyes have reached a certain stage of functioning. He cannot even begin to differentiate himself from his environment until he has good working equipment for distance and space perceptions. This usually appears at about the fourth month, when neuromuscular coordination is also beginning to k--

.... 15... I ~"'.

I : .

lead the- inf8.lrt·to mo:re puipO$ElM a.qtivi ~i. Pqrpciseful motor beha;'Q'ionr .is :reb·tad·to personality because it involves fa:;' t,he b~by the choice of goals, the adjustments'requi:red to reach the goals and th~ oonsequent satisfaction or ~trati.on..-<lf .. his 'inner desires. Adaptive bE!h.aviour of this type, while .:.::.:~cl.ependjJ:Ig ~on·maturation, also 'requires ilhe Want to be capable of .. pl:o:Citing froin ~6x;p.erienoas, tha.t is, to have l\earned. It is porAaps here, . in .:the'-begi nn1ngso!:adapti~be.baviour, that .intelU,genoe and personality are ',··moet·-eJ..aa;rly·CQlUl8O'tedl and i.t is certainly truetha,t later -penonality c.harMt... ~. de-pend. .very IIIl1Ch. on the success of thEi babY" s first adaptive. efforts. Learning is perhaps' the ma.jor process' by which the raw material of pers<:lnali ty is fq.ahion,ed.· The infant learns. 'very early what to expect from the external world.--social trust, or basic mistrust, .as Erikson says. The first type of learning we. might call, with Escalona, contagion! the.t is, the process by which a feeling state transmits. itself frqm adult to baby. For instance, a baby cries in the arms of a tense, nervous person, but seems quite content when held by one who is relaxed. Contagion is never fully under voluntary oontrol -- it may be mutual, but more often it is one--sided. It is the earliest type of learning process to affect a child's reaction to his environment and it is a type which persists even in. adulthood when one "feels tho atmosphe:re". Through contagion a baby may grow in confidence, assurance, and responsiveness or her may become nervous, timid and withdrawn. Conditioning is the type of learning through whioh an individual comes to aesociate a certain kind of situation with an appropriate response, so that the reaction becomes automatic and habitual. Through experiences, both pleasant and unpleasant, babies and young children develop certain conditioned reactions, e.g. shyness with stangers, fear of the dark. Communication is above all, a type of social learning. Unlike contagion, it means direct and purposeful c'ontact, but it may be either verbal or nonverbal. In the young baby, communication is mostly one-sided, depending on the mother's skill in interpreting his. behaviour, "reading him like a book", but. with maturation and learning, it becomes mutual, the baby interpreting his'! mother's behaviour and imitating it to communicate to her (e.g. using smiles, frowns, gesture.s, for specific purposes). With the growth of language, (meaning speech - for we must recognise that gesture etc., are important forms of language) oommunication becomes more important in the expression of the child's desires, satisf3ctions and frsutrations and in his perception of his total environment. Thus all these processes load him eventualiy to a gradual awareness of himself as an entity, as distinct from the environment, both internal and external. This inDer self is the core of personality. Later development, extends and en~rges the concept of self through the individual1s private world. E. The Child's Private World;

Like the personality, the private world is unique and specific to each individual. It represents the individual's attempt to integrate the demands of the "multi-dimensional environment" with his own inner wishes and desires. This environment comprises the internal, tho geographical, the Bocial and the cultural--in all of which the child must function. In early childhood, there is a process of progressive stabilisation wi thin the internal environment (due to outside regula.tion) plus orienta.tion to the external environment as satisfying or frustrating. The resultant state of bodily ease or discomfort contributes to the infant's image of himself and to his emotional reactions, and so he acquires feelings of anxiety, guilt, dependency or of courage and confidence; of withdrawal and suspicion of of love and trust. In the social environment, and again when the child learns the customary beliefs and traditions of his culture, a. similar process operates.

11': ...

The priva·te world of tho individual, however, does not always oorrespond olosely with th~ external world, yet the way the person sees himsel~ strongly influenoes his behaviour. Fundamentally, he seeks to aoquit himself well with his fellows. If ~e ~eels inadequate and in~erior, then somehow he must disguise this and proteot himsel~ from the agonies whioh would i,ollow 0. revolation o~ his tru~ self. At the same time, he knows secretly ~hat he has many impulses and desires whioh wo:u.d not moet with sooial approval. Sometimes ho acts in a WC1.y af which even, he, himself, cannot approve. To protect himself from guilt roll ~~iety w~en these things happen, he must have certain personality defe!lceso 'Ihe morG a.rdently an individual gua.rds his private world, the more he ~o~ls th~t his true sel~ differs from the sol~ he shows in publio, the more will ho need such defonoes. Thore are many beh['.vioural aots whioh cannot be understoc.1 in terms of conscious or s~bcor.scious aotivity. Tilose wo assw~e to be due to the operation of unoonsci~u,'; p:::'(lcesses. A large pA.rt of tho unconscic,",g is assooiatod with primitive i'OI'l'lS of ne8d gl'atificat.ion, v;hich "17"11'0 permanently ~rustrateo. in the oourse of trcdning or which had to be inhibited because o~ inoompatibili ty with other needs. '1'h(· unc();Jscious may al so be -though t o~ as a source of energy, a place whe~e tho':lghts are "manui'ac'in•.'od", and a s"';orohouse of feelings and imagos. Under-Lyj::lg drives n:ay express themselves :.n many different ways in beha.viour, v:~'ccb~ O\TGZ't:_y :nay not aPl,ear to be r8V'ealed at all. For example, a drive fo!' rr,cogni ";le1 llP.y show i tse] f in social poise and self-con~idence, or, in irri tAbil:1.ty '.u',J. c.Z2:::'630ion. 'DrivGS WIlicr. cannot be overtly expressed are repres?ed, lJut eve::l wi th !'opress:~on, dangerous tendencies persist as active, dynamic forces j.n the perG~:maE-ty,striv:'~g for ou·nets. The individual is thus forced-to adop-. patterns of behaviour which will satisfy him, but at the same tiroe po:::,tect hi::J ego against anxiety and tiui:":. Meohanisms of adjustment. are t:znQ ~')y ev'eryone; nor:na:~ and abnormal and are important devices in maintain" "; won tal hG:.l the IIT,,,,:'l four.er..vironmenial areas - internal, geographical, so.oial and cuI tural - the child gradually builds up his own personal ideas, his' own special intcrilretatiolls o~ his acts and assumptions, which go to make this "private world", he is rooking for himself a::ld through whioh he functions. The i:nage c:: cO::lcept of himself stands, at tho centre o~ this, and his organisation of livinG d.epenc::.s on thia Wh!l.t he will do or be, how he ,will ~eel tOMLds others! whn:t he will aspire to - all will depend ohiefly on the kind of self-c[,n":lG'!t he u.evelops.

11 '

Con~luAlon~

Ir. coholu8ion, I should like rather dogmatically to list .the points which 303ill 'c'l c':1G7';je from the previous discussio::l, a!ld whioh, I would suggest, are basic au~ d,0f ilii ti vo in pe:osona:::' i ty developmen t ~

Pcrs'Jl1ali t';T is

:;':1

inner

st[;;-~e

a~.:l

not only an observed reaction

II. .

Ps :'8ctio.li t~, is uDiql;O and specifi.c to .the individual depending un niR Q-.m psro"p~io;'ls C',nd x.oTiHl.t:cons I0!.'30llUlity is orgc1;n1sJd and p:!:"8dictable, but also dynamio a:1G. chaJ;lging TejT,~)er~~aent (the em'ltional aspect) and oharacter (the moral R.s:!:'oct) may b8 regc.rdc:l ,,,5 d.imension", of personality

11-;'.

1-1.

Pcrsol1f111ty determines the individual's reaotion to his' Gr.lY:~ -r "nmen t

17 -

:B.

The Bases of Personality: Vl.Personali ty is tho ably interwoven VII; prodno~

.of both lieraeli ty and environment, inextric-

Genetic factors determine: . (a) (b) (c) certain'potentialities which may or m~

/ not be developed

Certain constitutional features (e.g.physique) whioh affect· an individual's relation to others Constitutional differences in strength of biological impulses, general activity level and biological rhythms .<

VIII. IX. Cw

Tho limits which heredity sets on individual personality development are unknown Individual differences in personality arise as much from life-experiences as from heredit~ry endowment

The Processes of Personality_Development: X. Xl. Personality develops through the processes of maturation, adaptation and learning Maturation in this sonse depends chiefly on the central nervous system, sensory development o.nd neuromusoular coordination Adaptive behaviour depends on the ability to act purposefully and in relntion to a goal, to satisfy one's needs, and to profit from past e~eriences Learning and Personality aro related through: (a) (b) (c) Cd) XIV. oontagion conditioning communication association of experiences

XII.

XlII.

All the above processes lead to a gradual awareness of the self, as distinct from the environment, nnd later development extends and enlarges the conoept of self through the individual's "private world".

The Child's Private World: XV. XVl. The individual personality emerges from the child's experience in a "multi-dimensional environment". Personality development leads each child to an integration of the demands of all four enVironments, but at the same time he perceives, organises and interprets the world according to what he has learned and how he feels. The centre of this private world of interpretation is the image he develops of himsolf, and which he maintains by using certain mechanisms of adjustment. Understanding personality therefore, requires a study of the constitutional bases of personality, the processes of development and the ways in which each individual's "private world" is formed.

XVll. , ~,

- 18 .. 2. THE POSSIBLE RELATIONSHIP OF EVEl'l'I'S .AND CONDITIONS OCCURRING IN THE PRE-NATAL PERIOD UPO~;

PERSONALITY DEVELO?MZN'i'.

Professor Lorimer Dc{s For many centuries of the world's history the aetiology 'of congeni tal malformations was shrouded in mystery and supers I;i tion a.1~d these physical, defects' were often interDr~ted as tokens of Heave:!', C:ispleasu'~e or cited as examples of the craf"t and SUbtlety of the devil. The theory that impressions on the pregnant mother's imagination were ,responsible for the malformation of her infant was still widely acceptect' as late all tt3 19th century, but early in the 20th century the Menrlelian laws were resurre:Jted ana, propounded, the "maternal impression" theorie:c VIUre disear:lE:cl and ::'ost congenital malformations were regarded. as f;enetic in o~'igin. During the past decade an increasing knowledge 0:[' tl.10 possibl::> ill-effects of various maternal and external enVirOrl!llental 1<:,0'(0';:'f; on the developing embryo and foetus has shaken our belief in 'the d0~;;~:o';',ic :::en'3T~:;" 3a+;ion that most congenital malformations are genetically dete.mined <:1:.1 ,m '1.0''': e.s~J'.lme ,that the growth and development of a fertilised OVUlll den01"cd firstlJ' on its genetic constitution over which we have no control, except perhaps as woulcl.-be' eugenis.ts, and secondly on va:::-ious maternal a;:-.d exteI'nal enviror~-:iol".;al fac~ors.

':our present appreciation of the p.oBsible significance of ce:~tain maternal and external environmental disturbancc;} as i 2..ctars in the ?et::'ology of congenital mal forma tions stems· directly from Norman Gregg's bril.l.ia;}t incrimination of maternal Rubella duril1~'; pregnancy as a factor re:;/msiblo for certain specific physical defects of the new born infant such as cataracts, deafness and congenital heart d2.seafle. Norm<"n Gregg's i:::-;;l:;.atio discovery. which was achieved in this oi ty during i 9,~() and 194'\ opened up 11 completely n~w and most significant aspect of ;re':'liltal health ,2nd focussed a't'tontion on ·the first 12 weeks of i.nt:::'a-1lLerine l!.f'e _.- t1:.ese h<"zf:.:!:'dcus \"Teeks during which extremely rapid cell division is :::,e,,~;~:--.:;ible for convcrti;l{; r. single cell into: 'a foetus and for cletermini:'lg tl';:) ultir:ate stTl.lctu'e of many import'ant organs. elt..is during t:hese weeks t_la~ a TGI "t~v01y IT.'.:_::1' infec'~i"n such as Rubella or some other. "noxiousinfluoYlce" may easily distu:,:b thd natural process of devolor;ment and so prodl1ce some ann,to,!,j,olll <lefe')'o in the 11cm born infant. If a mother suffers from Rubell" d,uring';lle fb~8''; ';hree cO;l'chs of her pregnancy her infant may be normal in all resDects or ::la,/ suffe::: 2:':':':::::1 cata:!:'<'.cts or deafness or congenital heart disease or eV0n a combinatjol1 of ,,11 three of these defects. The available evi1encc suggest" that there ;.8 ::10:;:'0 than a 3OVfo chance and possibly a 50% or 6a{o chanco t;lat the infant of a mothe::' ,7hc h2.s had RUbella during the first trimestor of r,eI' prq:::nancy will eaf :er fr0'11 0;'0 or !:lore of these classical defects. This risk ff"ll.s very char:ply (,::'tOl' t;~o f"lUr'~h month of pregnancy and reaches negligible -:'ovols a::'teT tue fifth !.lonth. It is obviously i!llportan~ ';hat eV'0r~r effort shoulc. be nad.E- to . impress on the general public the danbers associated \Iith tho C(ut::,"j;icn of . Rubella during the early stages of pregnanc;? 1'.:--id ',;he advisability 0: e:']'l('lsing girls to this disease before adolescence in ';;ho hopo of G.o;liering a TeaSo:1c,l,le immunity which will probably protect the mother froJ'l Rubd-,'1 0.u:!:'inC1Cl' childbearing years. But, having made all young motherf tl.V!a,'9· of ·~h).s haz2.:c·i, '.'J1-:c~t ar'e we to do for the unfortunate mother who develop:3 'l. (~la8s~.crl a'i''-~;:J,cl: of Rubella during the e·arly months .• i ~le:l' pregnar:-y-? ~L~l "T" --.'0 .~,. eo-,"',,:; t and. reassure this disturbed and anxious mothe:::' J:L2ing th(l rcmll.2.r:circ t.1c v .';''-3 of hor pregnancy? The need for early and ad;:;qu::!.te c,r.:',:irc,ticl': ('I;:' ]cOl' il>.':cr:": ::.S obvious. If her infant proves 'co be S'c.:.fferir:.: -~:"L';n ca';e.c'actc. or c10::.f.386 or from SOme other congenital defGct? immedja':;,3 d:L<-"",:)"io'.' cf;;eJ.l:'.c::- .!.:.O([ pla;:-.:J for his treatment and training and emph<.:sib of the fl,'.ti.;r'rc0 ~Oly :r __ 'ml ;,.1 wl-,j.ch h'we been achioved by appropriate therapy in sir.:d 1-::' Cflse:J lJ,-,Y Ice: cf flO:;-/'. he::']? to this distressod mother who shou1Cl. aloo be hu:i.ped to 1 c:;:i f\<:'.~. J "0:: ,·:_C. 0' •.: al·out t:10 normal physical development of her future ehi 1 ::.ro;1.

- 19 - -. reported after"other virus diseases such as-Measles, Mumps and He~:s-'Zo~ter occurril1g durIng the ~arlY months of p:egnancy, •. th~re is not suff~c~ent. evidence to incriminate any of these d~seasE5 wh~ch for the present rema~n suspect rut not proven as pos~ible cau~es o~ congenital defects. Various other "noxious influences" may play their part-'in tne aetiology-'of congeii.iUil malformations. -, There is a significant increase in the iYicidence of congenital defects airi.ongst infants born to m"!:hers of more than 35 years of age and it has been estimated that if the average age of t:he mother in El'lglarrl-'could be reduced by-'five years, tfi~ numbeI,' of infants suffering frem congenital malformations in that country w?uld be halved. Uterine haemorrhagE" of a sigl'lificant degree, occurring dill:':i:ng " the first trimester"of pregl'lancy, is frequently associated with .the b~rth of a malforned infant who is presumably the unlucky survivor of" a threatened miscarriage. There"is a recognised association between hydramnios and COl1ge",ital defects and also a suggestion tfiat lack of fluid in the amniotic sac may possibly"be responsible for certain malformation of the foetus as the result of abnormal pressur~ o~ his limbs or body. .. Very lit:t1e is known about the effect of sublethal doses of" abortifacient drugs on the developil'lg embryo or foetus out it seems reasonable to assume that-'these drugs which are usually taken durii'ig the earliest-'months of intra uterine life may be responsible for a certain number of congenital malformations. It it unlikely that this asswnption"'will ever be satisfactorily proved or denied because of the· difficulty of obtaining accurate information for a"prospective n type of stuQy; . it is obviously most important that: the mother should never be questioned about abortifacients for manY reasons and more particu1.arly because"'such-'questioning carries many emotional hazards, i l1 cludliig that of a sad and longlasting gliilt complex." Radium or x-ray treatment of the pelvis"'during early pregnancy represents a rare but well established cause of congei'iital malformation of ·the infant, microcephaly a 110 mental retardation being by far the most common defect s produ ced." The . many other noxiousil1fluences which may disturb"thephYsical"groWth and development or the health of the-'foetus"or"the new born infant ificlua.e ,maternal Diapetes, Rh~:'iso-immunisation ang. variodstntra-uterine in!' ections . such cis Toxoplasmosis <;tnd"Syphilis ... Alt.tlOu@.gro,sSaongenital malformations . may . be"pr,0ducedin .rat-sana: .ot~er animals·.bydepr~S!lirlg the mother"of certain ". 'vitanuns during' fi.,.r,pregni:incy, . there '. is -'no ey'l.dence tfiat nutritional -, deprivatlon-u!4ring:pregnanoy pl:'0d~ces. any.,gi'oss congen,i.,tal malformation of the human infant.···'; '" . '. ....... ,. .,f.'.>·...·;· . \. -\ -' "

~~.

"noxious il1fluenees" ii1 thfiaetio:t9gy'pf~(irge1:l~t,al, malforma.tions will not giVe ~outheiml?ressi~n t'hatI am: atteroptl"'g .tb·)J,~l:i,ttndnepart played by genetic fact,ors., A 61eft.palate ,~oi'MsOlnepthergrpss":rongenita.J, defect may be."1.."'.~er.·i1;.ed ~r. may ~e. t._.h~:..reS\~l.t. .9f_.;·S.:~'il::~.Xt .. erna.;r.:el'ivirO!2IDent.'a,l d . isturbance o~~ri~g dur~ng johe ea:ly"we~s ?,f<pregnallPY; genetic;'fact or,s :.ni~ be , re spons~ble for acongen~t1lJ.;cal'dlll.·c4efe ct, ..such as patent du ctus artenosus, but we a.lso ktl,9W ttult a,siiil1lar~Q>tdia(f'd\3fe(ct. .may follow maternal Rubella durin~:'th~I3a::r;'tywe. eks 'of; 'p:r!'lgnap,¢Y'.,: InJ9th~~,wO,rds "what 'p.ereqity can do, e.nvirohment can also do". Occli6l~ria:l].Y, acon~enltal"malfCirinationmay be il• the result of both "genetic· .i.I1 cliriati'on and en";hEit1mental. -, ." ... . ' provouatio·n . "

' '.. " - ,~. ," _ .. :_ ,":.-> .") ·s.:. . . . : _ ._ '":' " - :._ ,,-""i. :. ";.. ' r'hope tfi~t:tn.Y:;~pffasi~ 8,t'-thep'qss.it:.l~ part 'played by various "

, " ." .' Although.it~aa~'beenargued th?tgeheticfactors may .... '. occ~s~on<:.l1y 'play ·soptep~ry~:in"t.he a~iologYof:M?n&?l~siii, the bUlk. Of. the a vaj.l.a bleevJ,de,1icesuggesta, ,t;hat maternal al1\"i external environmental duturbaii,oes,.p·robably. occurring 'between the siXth and ninth week of intra-"' . ut~T~ne; Uf.e,.~.reresponsible,for themu:ltiple developmental "arrests" and,', '.' ..·a'."oma1ies·,mid~ con5tit~te this synirome • Unfortunately, we can not define .. ··the 'rn?"~f~Bdnf1U:ences" wh~chmay ... be res~9n'sible tor the production of ., Mongo~~sm; .. ;alth?ugh we assume that adva,nced age of the mother ana:significant .u.teril'le_,haemorrhage occurring during the first trimester of pregnancy may .. . be important ,aetiological"'factors,it is probable thc!.t other "noxious influences" .affecting the embryo during these-·.ear:):.(ei'weekfi ofpregnaney may also be resp,OI'lsible for this syrxireme. In other words, the Mongol may be regarded as ,-'

.::\j~' ~ c'

(i,

:.>

- 20 -.

the urtf ortuna te survivor·' of a physi cal disturbance occurring at about the second month of pregrtancy and possibly any one of number of different facto!s may be re~ponsible for this disturbance.

Irt·'my·'experiertCe, it is usually easier to tell a mother that her new born Infant is not alive than to oreak the news of some gross artd disturbi1'1g congenital defect. How and when are we to tell a mother, that her new born infant is grossly deformed? What part, If any, should we allow the husband to play in breaking this distressing news to his wife? When ard·'umer what'circumstances should a mother be allowed to see such an'irtfant? How can we help the mother or the father to overcome the feeling of guilt or of accusation which may·'be associated with a gross congenital malformation which is obviously inherited from one or other side ,of the family? Fin.:;.llY, whehshoula some explanation be made to the child who bears a disturbing, ·'outward and visible physical defect and what form should .. this explanation .. .. take? A consultation between a medical practItioner and the distressed mother oCa grossly·'deforiiied or mentally deficient·'.infant ·representsan ' extraordinarily significant and·'intimate episode in the, mother' s life which may have far-reaching effects on both·'the mother and the child. 'Ihe appropriate handling of this highly emotional situation calls for a great deal of""taet and sympathy on the part of tlie practitioner who mUst have some ., genuit1e understanding of the mother and her attitude of mind before,he·'can offer her the "explanation'f which Is. the. ~ssent:i<ll object·:",f such a consultation. By "explanation" I mean ~- a reasonable explanation {!);f-'the·' . infant' s defect or deformity -- some simple and carefully. worded .explana,tion of its aetiology, ·'some attempt at 6xplanatiol'1of·'the roaa which li13s" .ahead for the mother' an.d her infant and finally explanatj;,on e.nd discussion of treatment a>id of the general""managerilent of the whole problem, as it affects the mother, thechiId and other memoors of the family. The practItionermustalso·lry·'to understar'jj""something of the concept of,thedisorder iTi the mother.' s rrd.nd·'ard the fears and afu(.ieties associated with this concept and by careful wording of His 6xpl(1nations, try to dispel some. of these spoken or unspokenfear~ and anxieties. James Spence has suggested that in our discussions .with a motner about her ehild's'physical abnormality and. in 9ur attempts to understand the motJ:ler and hebconceptof the. child' s disorder~' we s.hould always . remember Pascal.' s wise, aI\horism'-- "lA coeur a sesraisons quela raison connaitpas". . ' .

(

... ,'J''-,

~I ,,

',}.';

.... :.,'

- 21 -

SOME EVE"'l'S AND

COl~DITIOl'<S Il~

THE POST PERS01~ALITY

NATAL LIFE OF THE CHILD WHICH MIGHT AFFECT

DEVELOPMENT

Ronald Mac Keith ,. All cabies are born and feed and develop, but these pro- ,. cesses are not"identical for each child. Partly because each child brings a"different constitution - derivea from his inheritance and foetal enviroMlent - to me'et these common experIences, and partly because tfie events are not always'·identical. The circumstances vary too; :i,n Burma, youn.g'· mothers ignorant of what to expect are terrified by their first pregnancy and labour. RHESUS DISORDER

Rhesus disorder is the ccmiii.onest congenital disorder; in Englard"it occurs in 1 in 400 babies born. It is not a statistically important cause of death at birth, but a few children survive with ce.rebral palsy. INJURY DU RING BIRl'H i Ai'OXIA.

Birth injury is responsible fcir 15 per cent Of deaths at deliverY. Lasting cerebral palsy follows in a few children who have had brain injury at birth but 9 out orlO recover completely. (Craig 1951) .. Later behaviour problems are, if anything, commoner where labour has been brief.

ANOXIA.

If the oxygen supply to the brain is cut off the blood vessels.' dilate and then bleed. With more prolonged anoxia the nerve cells die in patches here arc! there. The cutting off Of oxygen affects certain parts particularli'the frontal area - producing loss of intelligence} t-he motor area producing spactic"cerebral palsy; the visual area producing' blindness the cereb~ producing ataxia and the basal ganglia In the centre of the eerebral hemispheres giving athetosis. Anoxia has been said' to produce • ,,,'.'7 j failure of visuomotor""perception, briefatte"iitiorispan, difficulty with" '? .?_. arithmetic"and emotional lability. Severe. anoxia is rare"'al'li there is no good evidence that minor degrees are follo~ed by arN brain damage. i

PREMATURITY

,. Prematurity is an inlpOrlant cause of death at birth; it is commoner among poorer people. Improving the nutrItion prmothers reduces" the incidence. Many cases-'follow toxemia of pregnancy;;ii'i this connectiOri recent successful attack on eclempsia by Dickson Hughes and. his team in Sydney deserves high praise. . After the thiro year prematur~s are as healthy as those'·viho" were full term babies. Some are brilliant, e.g. Julius Ceasar and Winston Churchill. MALNUTRITI01~.

It is in the . last few months of foetal life that the" quality of feeding of the '·mother has most effect. Malnutrition is part ,pet he poverty c'tmplex am poverty is associated with increased illness and death rates,~ -'In Hollam Hi the war during a brief periOd of foOd. Slj..ortage ;"the shildre" sat about and aid not play." Chronic malnutrition ir.1'" chilCfren commonlY goes with chronic disease arc! it may be that such children are less alert and have less zest for knowledge etc.

- 22 -'.

Children may react to being patients becil.use they feer'the loss of self determination. A boy in an iron lung for poliomyelitis resented all care and was dOil'1g badly. A Minister saw one of the servicing sessions and suggested his struggles"were a reaction"to bei'1.g a "patient" with everything even his"breathing - done for him. When some of the boy's whims were"granted, he no longer felt a slave, gave willing co-operation and improved (Ignotus 1953) • THE EFFEGrS OF ILLNESSES. Any effects of acute illness on the personality of the child depel'ld on the"reaction to the illness of the adults arol.lnd,the child. It is possible to"inauce invalidiSm in the child by an over solicitous care. ,. W'il1iam"Penn in the 18th century said - "There"cal') be a wantonness in investigatioi'i." We might do"well"to remember' this "Iri'our hospital work with children. "A successIon of needle pricks can. have a lasting effect on a ehi1d's confidence in doctors. Some children like being ill and babyish; some. resent it. Anxiety may be"the result of adults discussing illness across the child's bed. ,. Often con vales cence" is the more d if!'icult·:ptmi?e, "In older children abse;;ce from school may interfere with ectu·catlon;'·-In England, the average amolint of absence··o.! children from school'during,:·to.e ten years of schooling is no less, than one yel.',r. (Bransby 1951):..),.,.. " " .'" ,',"

. FEEDING IN,

Il~FA1~CY.

The infant arrives in the world with only one function fully differentiated, suckil'1g and swallowing. MiddlemQte (1941) observed that some vigorous feeders turn into poor feeders irthei;Y get little milk in their' earliest feed'S. . .. ' , L.: '1'., •

'Isonast feeding important? .The answer depends on·the circumstances •. In England to:..{lay in good homes, there is'nodiff,erence in mortalityl;i.llt.Yieen breast and bottle fed babies. The introduction of formula feeding. into a village in Soilthern Egypt was"followed 'by-:t:he deaths of nearly··all the Eiabies. Breast feeding is now advocat~ as contributing to sound emotional he::lth. This is not yet proved though it seems likely to promote a close .relation between mother and child. The fashion now is to"recommend breast feeding as a potential source of deep physical i:iatisfaction for mothers •. Women with a "frigid" attitude to breast~feeding are less successful at it (Newton a~d Newton 19;0). Do women in primitive cultures get positive"pleasure from it? Gunther (1946) refers to the feeli~g .or-satisfaction and refreshment after breast-reeding and she describes"the sensation of the draught reflex as something between a sneeze an:! ?~ orgasm. Most: infants will easily"adapt to almost any regime, but because a regime suits many children, it does not follow that it C2.n be appliea to all. Four··hour1y i'eeding from birth became a dogma •.. This. was Based on observations made on rour-month old babies"given cow's milk.'" In fact breast milk often has all gone from the stomach in 1 or 2 hours and whIle most four month old children have settled to a re.gg1~r tl.rn,(ltable, newborn babies are"' far more variable··in what suits them best. The dogma ruling the right amount of food"is "2~ ounces per lb. bodyweight per dayl1, but this rule is only shorthand for sayi~g "Healthy"'breast red babies take enough to k.eep. themselves happy and growing; this varies from l~ to 3~, oz. per lb. pe~ dL'.Y, being on an ,werage 2l oz, per lb"per day." Whe~ offered 2~ oz. per lb., those babies who preferred l~ oz. per lb. were all right; the 3~ oz.-ers cried for more. Their crying is

- 23

I:-

still interpreted as "wInd from over-feeding", ·'a miscol1ception sired by a purItanical idea tnnt ihdulgence in food is sinful and delivered by a grannie who has windy dy~pepsia 2nd knows that she should eat less herself. THE PERMISSIVE APPROACH TO :mFAi'ri' AND CHIID W\.i~AGEMENT • •_ 2: _. ... _. The present permissive fasnion iH il1farrt. reeiling is pax:allel~d by 811 increasil1g tehdency to see children c:s indivicl"uals in other things. There are a number of reasons for this.·' This is, of course, 8 return to an approacn common in medicine before a hundred years ago. The great advance~ in"science and especially the work of Pasteur, the greatest of all the great mel1 of the 19th cerrtury~' lead us to consider our patient's bodies as machines a'li to expeCt to fhid one cause for each disorder. We are ree.lising it is n.ct so simple and in a l1ew humility we accept advice from the child as to what are his needs. Clara DavIs (1928,1933) observed children from weaning age about b months to 18 months old. At each meal, the child was" sat at a t8;ble with a dozen foods aroutU him; he pointed; a helping was given him. Over any periOd of two days, the children took a "well balanced" intake of food. At the end, they were healthy and co-operative children. Note that after a year of being thoroughly "spoilt" by indulgence of their food preferences, they"were balanCed··children. The foods were, of course, selected good plain fare. Can one trust children's cravings for sweets and vinegar? .. .. Cattle take the salt they need·'from salt licks, but ··animals do not alwaYs taKe what Is best for them. ATiimals wHo had··been on diets deficient in magnesium and other salts, dId not, when giVen tne opportunity, take food whieh would restore the deficiency (Scott, Verney and MorrIssey, 1950). It was suggested that they liked the feeling of being deficient in magnesium etc • With children, such self selection certail"ly seems"to leave .. them il1terested in food ard"free of the finickyness about food in the second year which mothers so commonly compluin of. Having to eat what is before you goes with having 'to be (llean and tidy arid various other ways in which small children are expected to observe a standard to behaviour ahead of their age. UTER 3EgUEIS OF RIGID TRAINING. Many older children have recurrent symptoms - abdominal pain, headache; vomiting, pyrexia, bilious attacks, acidosis, call it what you .. will. II'! most of these the trigger of the attack is an··emotional disturbance (Mae Keith and O'NeIll, 1951). 1. not un.common ~i'itecedent appears to be strict early trD.ining (Haffner, 19'52). Too often these-'chlldren are ". exhaustively investigated for orgnnic disorder whh:h can increase the anxiety or other emotional disturbance which is usually fairly easily recognised if time is given to taking a history of the attacks. FROM IGNORANCE OF THE NORMAL. .. If mothers am doctors knew more of the range of nonnal .. tiehavlour, children would be better""off. The 1953 euition of a book on nursing says that ~'.if sensibly trained" most children are dry by 6 to 9 montHs. The only series reported 50% still wet at two Y62rs. Mothers rarely"complain that their childre~ are too big, but if they are below the weight line, "they are worried. If their child has"tantrums at age three or"'four they conclude·' they have failed in the upbringing, because they do not know that all children have some tantrums. UNi'l];CESSARY Ai~XIETY

".. mente

PLEASURE AT THE HElM • The epicurean philosophy today is the fashion in child manageProvided permissiveness is not applied··compulsivel.v, it is a practical

-, 24 system for mothers to use but those who. are uncertain of themselves need more rulestQ go by •. The dangers"of overfeed.tng have been greatly exaggerated, but I wonder-'whetner--making satiety our index i:l not an ·over-simplification. It depends .on. thinking of the infant! s appetite as comparable to the petrol gauge on a motor car. It is more complex. Therd is a sucking hunger as well asa .food hunger. With"one of 'my children, I thought I would demonstrate that with rapid feeding, less air is swallowea. I made the hole in the bottle teat larger and he finished tue feed in five minutes, out cried for more. ~'I h'ld discovered that besides wanting so much food, he want~d so much sucking. Babie3 who are not played with by their demand more food just as lonely adolescents ~ver-e~t. moth~rs

;Ii I

are said to

Feeaing children to thei~ demands is said to be aSS0ciated with a generous .2nd co-operative persOnality in adult life whIle in cultures where the infl'J'1t is grudged the breast~' the adult 1'8 stinf:l-and aggressivtl (Hunt 1941) out Orlanaky (1949) fOLl.nct no correlation between the type-'of ee.rlY Cf'.re and the later personality. We should f:::ed a crying baby on grounds of.humanity,

Good developmentanU good health depend on good inheritance, good food, freedom from illness and 'On a [.lothe:'."· Spitz (1947) "compared .babies living with their mother in an institution with others in a high . standard nursery with eight chi:'.dren ·to eacl! r.urSd. Of those. with their mothers all could \~alk at 8-12 months old; of the other group-only two out of 61 could walk qy 18-24 months old. Bakwin (1942) descrioed "lonelil"eSfl In infants". Infant s in hospital had repeated infect lens and f~ned to gain weight; but taken hom.e the infect-ions ceased and weight increaflcd steadily.

THE PSYCHOSOMATIC APPROAW. . There is a need for a .£QlllP:.''''heiis~_ve assessment of our patients' problems, in their physical, ps,Ychological,mi se-chl nspects"'- The idea or a psychosomatic apprOaCtl Is not a--new"or,e--;:'cc paetliatrici"ns. Their understanding iJ¥l.y be based on 11 humane it.d :.n~·"i':,':'''ti p6:'cep'vion, or it may be based on a kno\'lledge of scient-ifi;:: pJ.:rcho:!.')gy. More lasting advances are likel,v to come from the seconu g.~oup. Today, if we flY'£:; to gD 0~1 doing n good .job, it is becoming much more often" imperative to stuC:y l,O\1 emofL~l f:'.ctors have contributed to the causation of symptoms i-'1 the Gh:"ld.cen ,·,::0 come to us, than it was when every summer"'had epIdemics of ;11 :'rhea .. qipflthe:-in attacked 50,000 children a year in Englnnd; Vie had no efficicl,t antibaoterial drugs and poor nutrition was common. l· :")

To notice tht;:sE" emotional factors our techniqQ6s vis:::a-vis our pntients have to becomE' .cdher mOle passive." We hmTi:i to recognise that the visit to hospital is for thai" an anxious iJ':erri:.. --The--importance of recognisi.ng orGan:'~ causes is twofold; they are--more often dangerous to lil <~ ari they <'.i'e often more easily removed than are psychological f':1 ct ors; STRESS REA Cl'IQNS.

Everyone knows abollt the-'secn;tion of adrenalin ~n situations demanding flight or fight. Palpitation and pallor fr.E!.y be re:l.sonable reactions in flO alarming situation or 1.,;;ey ,1!ay be 3ymptoms of: a neurotic a nxiety state.

.....

25" ... SeJ.,ye's concept"of the general adaption syrxirome is similar. Tfie cortex or'the adrenal gland responds to crises by secreting cortisone a1'ld if it is not secreted, the body'does not meet the crisis properJ.,y. Spitz (1953) believes the··developmental failure of motherless"il'lfants is due to a failure of this normlll""response to stress. Asthma and some other recurrent sy11drcmes are"reactions to a variety··of st.resses; they may be associated with deficient secretion of cortisone for cortisone relieves asthma. .' The discoveries of var~ous ger.msin illnesse~ gave birth to an impression that eacn illness has one·cause, the removal of which cured the dIsease. Causation is more complex. --The tubercle bacillus is the "essential cause" of tuberculosis but malnutrition fatigue and mental states may De equally important. In considering congenital disorders, we reaIise now that these are"not always genetically .caused but that environmental influences during foetal Hfe may be"cau;:!ative •. Mongolism is probabJ.,y CIue··to a'·coirimonJ.,y carrieiI gene which only becomes operative under certain enviro1'lliiental corxiitions of foetal life, (Penrose 1932, 1949). Certain congenital""defoImities such as cleft palate can be causecCby a variety of agents injected inte pregnant animals~· t~e incidence of the anOmaly varying with the dose, the gestational stage 1".t which··it is given al'd· the genetic constitution of the motnl'r. The onIy agent that can. be relied upon"t.o produce cleft palate in 100 per' cent of animals treated --is cortIsone (Cl~rk Fraser et al 1953). With a mother of particular genetic constitution, it Is possible that stress' during her pregn.a!'lcy might· affect the developing embryo •

CO"CWSION

The paediatricianTs long term responsibility is great • Pembertol'l ("1951) found that among hospital p['.tients, 59 per cent had diseases in which mental and emotional factors were of primary importance. "The coml:iination of emotional insecurity in childhoOd and psychological shess in aC!ult life seemed to be a common. and potent cause" orillness in adults and he cOY1cluded "while a'·great deal of ill-healt·h can be prevented by'·furtherimprovements in the pfiysical conditiohs of life. It is oecoming clearer that further substantIal advances in preventive medicine will dElpet'\d, ··as much, i f not ··more, o'n improving the emotiorial . and meY1tal environment, especially inclilldhood." W., have the chance. to pecognise insecurity in some children because it reveals itself by . symptoms··wqich take them to the hospital or··to the doctoz:ls conflulting room. OnJ.,y a comprehensive'·approach .will""enable us to improve their mental and emotionnl el'lvirorunent'a:nd diminish the likelihood of illness il'l adult life. . , "For meaicine being a canpendium of the successive and·'contradictory mistakes of medical practitioners, when we summon the wisest of them to our aia, the chan.ces are that we may be reJ.,ying on a scientific truth the error of which will be recognized in a few years' time. So that to believe in medicine would be'·the height of folly, if not to believe in it were not greater folly still, for from this mass of errors there have emerged in the course of time many truths." . Proust (1930)

_ 26 ...

LIST OF B~.kwin

r'iEFERE~rCES

H. (1942)

Amer. J. Dis. Child 63 30 Med. Officer ~6 223, 237

Br::'l>.sbyE. R. (1951)

C1;::rke Fraser F., F;:.instat T. D., and Kz.1ter H. (1953) Neo-l~.::.ta1 Studies g 43. Craig ·W. D~vis

(1951) Arch. Dis. Cr.i1d ~ 325 651 743 410

C. (1928) ~~r. J. Dis. Child 36 (1933) A.uer~. J. Dis. Child ~

. Gunther M. (1942) CO·I'1. Med. AS30e.,J.!:t1 HuHner C. (1952) Unpublished.

Hunt J. MeV. (1941) J. nbnormil & Soci&1 Psychol. 36 ~e

338

Keith R. ~nd OlNai11 D. (1951) L~ncet 2 278. , ..

Middlemore M. (1941) The Nursery Coup1.. LOndon •. Ne,(,ton N. R. !'end Newton M. (1950) P"~ic.trics j OrLnsky (1949) P.;;ycho1o['~. Pembertol'l (19,)1) Le,ncet Pe'!ros .. L. Proust M. (1932) (1949) (1930) Bull.

726 ....

hl?

1 :.' '

.1 324 i '

J. Genetics ~ 407 . . TLv Bic1o~:;y of Mental D..!oct', Lohclol'l _. _. RCi".c•.-"br::' nee of thing~ I'

'.:

P .s.st, T.,," Guerm,);,l5\tes Wc;Y. ',:

Scott, Ver'1ey end Morrissey (1950) 1..-,.>.;1'. J. Nutrition,y. ·')$'1 Spitz R. (1945,1946) Psycho.lrol,ytic StU,dY of the Child 1'53:'& ~ 113. Spitz R. (1953) Rev. Suisse Psychol. ~, 1.

- 27 .;-"':'"";-

4. THE CHILD'S SOCIAL DEVELOPMENT. " by Irene Sebire. There is some danger in singling out for c'onsideration a specif1cporiod in a ohild' s growth, especially if we lost sight of the fact that its development is a continuing prooess. But it is generally agreed that in the formative years of ohildhood lie signifioant responses whioh provide an interpretation of later personali ty growth and patterns of behaviour. Increasing attention is being paid to the conditions and ciroumstances which attend a child's development during the first year, and in examin:i.ng his capacity for adjustment to his social experiences. A ohild p'asses through a:everal' transitional stages in his development,eaoh implying certain expectations in terms Df the norms of his particular culture, and of his corresponding age leval • .Since we' assume that behaviour responses develop asa result of int~raction between an individual and his enVironment, we need to examine what the child brings to his soci.al situation, and what is impose!! on him externally by those ciroumstanoes • . The ohild at birth has a certain physical constitution, a. degree of intelligenoe, and specifio hereita.ry predispositions which represent his endowment, wit,h. their particular potentialities and limitations. He is born into a.oommunity, w,l.th it;e peculiar cultural characteristics, traditional' acceptances and exp.ec~ations, formulated and organised into an established pattern.

...

From responses, expressed at an instinctual level, he is required to ; . develop ina fashion where satisfnction of his needs is subjected to the requirements of' his social group. These anticipate a modification or surrender of several natural drives in conformity with the group in which .he functions. Pressures imposed often conflict with the desires unique in each child, are not always related to his ca.paci ty to a.djust, and are often applied regardless of individual differences. Dr. Morey has referred to tho individual differences in personality tra.i ts with qualities unique and s.pecific for each child, expressed later according to the part pla.yed by learning and imitation in his partioular environment. A child's resultant behaviour, his capacity for accommodation, his success or failure in socillliza.tion,noed to be interpreted in terms of his total whole fqnotioning. There is nothing new in this concept with which we a.re all probably in accord. But it needs restating perhaps as a reminder tha.t each of us with his partioular professional prejudice, and specialized experience, does not always exa.mine a child's tota.l behaviour in the light of its physical, intelleotual, emotional and social oomponents. Much ~ttention in this semina.r will bed-i~ed quite deservedly to the needs of the physically handicapped child, but another 9hild's intellectual and emotional' disabi}i ties are less often recogniSEj.li and respeoted. Psychologists and psychiatrists on the othe:t:1 hand sometimes tend to pay scant attention to physioal ingredients despito an acknowledgment of psychosomatic principles. The child's introduction to social experiences commences with his birth into the family - a social unit, oomprised by a constella.tion of human beings with a oertain fa.milial pattern, inter-relationships already established and a.ttitudes reasonably well defined. Much depends on the ini"ial attitude of the mother, her oapacity for demonstrating affection, her acceptance, rejeotion, indifference towards the infp..nt, and hor preconceived ideas regarding child rearing and ma.nagement. The mother-child rolationship, with its reciprooal qualities, forms a signifioant exporienoe physioo.lly and emotionally; one which determines ·lr-.rgely his progress to further social maturity. She is in a position to provide Gss;ential opportunities for the child's identification with a p1?.rticular figure, thnt important ingredient in all social relationships; and to establish trust and

28 seourity whioh makes him more aocepting of , 1~ters9cial

contacts. "

A fuller appreciation of the importance of the quality and oontinuity of the mother-child relationship, partioul~rly in the first three years of its'1i£e, has . . come from an examination of the effects of deprivation of m<:i.ternal interes·'l;'··a:rtil affection during that period. This· aspect has been featured in John Bowlby's monograph "Matexllal Health and Child Cl'.ren , a compilation of the evidenoe, of some specialists on the needs of the dependent child. The disturbing effeots of separation, both partial and complete, of mother and ohild will be dealt with in more detail by subsequent speakers. Studies of institutionalized children subjected to mass-child care in an impersonal environment, emphasize its retarding effects on a. ~ild's social maturity and the aQquisitioD of speech. Tho rejecting, undemonstrative, or unprediotable mother may be responsible 'in part for cases of the remote, socially impoverished autistic child, who romains internally motivated, and f1O'.ils to become socially orientated. There soems to be growing support for the op~n~on that psychopathy has its origin, less in oonstitutional factors, than in defective mother-child relationships, which negate the acquisition of a social conscionce. Between these extremes, and those who prpgress to uncomplicated social maturity in a benign family setting, are many shades of defective soci~lization shown in disordered habi ta, gross personality variations, and asocial conduc;;.. The source of tho majority of these would soom to originate in disturbing family' rolationships in the first instance, with tho risk of perpetuation in an environment, which dOGS not always compensate for earlier frustration and deprivation. In a normal situation a child's first introduction to interference with his satisfactions comes from certain requirements imposed by the mother, prohibitions and permissions which deny or encourage the exprossion of n2.tural impulses. Conflict and confusion may attend coercion \vith its denial of self demand, with . corresponding re[l.ctions on the p".rt of both mothor and child. Early babi t training, particularly in regard to feeding, sleeping, and elimination, provides an area which may be contrary to self regulation, but need to be rec'onciled to the mutual satisfaction of mother [md infp.nt.' Children V[l.ry considerably in their tolerance of restrictions and indulgences, which need to bo interpreted and applied with 'an appreciation of the individual differonoes in children. One must attempt to discriminate also between what constitutes intolerable frustr2,tion, 1'.nd what serves C'..S an introduction to reality situations in the future life experiences of the child. Too often we overlook the effoct of standardized programmes on a cother who endeavours to put them into effoct, becc-use she intellectually approves, but emotionally does not idontify horself with thoir purpose. A child's re1'.ctions of an:&1oty and aggression in which the mothe.r is often involved are inevitable ingredients in his progressive adjustment to more complic[l.ted experiences. The intensity and frequency of these responses determine whether they are transient or boing incorporated into a child's personality. Generally, however, the child is [l.ble to progress to a stc-to of harmonious accommodation between some degree of self-direction and conformity to social requiremen ts. His social maturity dovelops further as his activities, contacts and interests, extend beyond the family circle, with increasing intensity of his emotional responses. Social interchange becomos enriched as earlior means of communication are amplified by speech. Manipulation familiarises tho child with himself and leads to an exploration of other people and his environment generally. To these int~rwoven oxperiences, tho child is loo.rning to rcd2.pt himself, oxhi0i ting chrlractoristics which rc:re inc'.1rpor1. ted ir,to :ds llcrsc:10l i ~;~r an<' p.-. ttGrns of behaViour. With tho

. j

- 29 .growth of social maturity and confidence, he is being prepared for movement from complete dependence on the mother ~o satis~ing relationships with other family members'. Hi,s first chief area of adjustment is to experiences wi thin.. the home. A child learns the rudiments of social living in the close relationships of family life and is conditioned by these experiences fer an acceptance of the wider oommunity. His social CW1l.reness extends further to include the father with his particular and complementary role. Today's father is being encouraged and is more wilting, to take an active part in caring for the young child, in contrast to his previous nominal fatherhood. Apart from his prac,tical assistanoe, he has an important contribution of a sustaining, supporting quality to make to the mother, in companionship and shac.'ed' obligations. , Patterns of behaviour'develop in response to parental attitude and ex~ ample, as the child isinfluencod by disciplinary measures, indications of ~pprov al or diae.pproval, nnd't!w degree of consistency and accessibility of the parents. External atimul,i, different in variety and intensity, make their impression en the suggestible ,mind of the child. Some reinforce, while others ameliorate" the quality his earlier responses.

Children vary considerably in their reaction to parontal trea.tment and their relationship to siblings. Despite the insistence of parents "tha.t they treat all their children alike" they generally exercise some degree of preferential treatment, especin,lly in the opinion of a pnrticuler child. Disparities in physique and intelligence, differences in aohievement, specific oddities and disabilities, encourage siblings rivalry" stimUlate pa.rental concern and noed to be respected.

Posi tion in the family group is often sdd to be ,significant particulD.rly for the middle child. We find that the first child is often in a worse plight", due to the inexperience and expectations of a mother, fanatical in the rigid' imposition of schedules, ofteneasod with subsequent children. Tho last child in a large family often suffers, in that he is fathered and mothered' also by older siblings; parental discipline has become modified with their increasing age, while the mother now past the likelihood of conception, tends to prolong and enjoy the babyhood of her last inf~~t. The family itself does not remain static, but fluctuates and changes in , structure and funotion, Parents are variables in age, health, economic status, and even in emotional equanimity. But whr.tever the form, the family 'presents further arecs fol' identification to the child as he becomes an integral' member of this social unit. Play activities with their rioh fiold for explol'ation and experimentation, bring improvement of skills, new oontncts in group experiences, and the growth of combined social experience' and individual expression, By thl'ee years of age, self-directed a.ctivities and social orientation are becoming integrated at which stage the average child has, reached c degree o£'prepara.tion for a latel' area of socin.l: adjustment. The Pre-school Agency: I'.l some cultures, most children attend kindorgartens, nursery schools, or their equivalont, prior to the period of primary sohooling. This implies temporary separation from the child's mother and a movement from the intimacy of family life to unaccustomed conditions. It calls for adjustment, also to numerous other children, presenting a Variety of patterns of behaviour and relatively well established habits. He faces a new situation with fear and indecision, or confidenco and courage in keeping ;rith his earlier experiences ~~d immediate expectn.tions. So does every other child, variables in

- 30,~egard

to physique, intelligence, personality social and economic status.

Different f~cili ties for eating, sleeping, toilet, play; the replacement of spontaneity with somQ degree of schedule presenting a different set of prohibitions and pel,-missions, challengo his oapacity for accommodation to a new experionce. Progressive .adjustment to preschool life may result in richer emotional satisfactions.· But in some children one finds i, reinforcement of fears, of aggressive -tendencies, or regression to an earlier level of behaviour. In general, the preschool agency provides a valuable extension of social experiences and home training, and an opportunity to acquire further self-determination in conduct. The challenge of associated circumstances, tests his earlier success or failure in socialization, and introduces him to the dominant features of a wider culture. . It is important to determine how the preschool agenoy can be an adjunct to, and not a substitute for the home; how the influenoe of specialists in child management can flow back into the family circle, and improve the quality of paren tc rC'.ft • There seems to be general agreement th~t the primary responsibility in a child's social development depends on the parents, and influences within the home. This progress to social maturity is affected by the emotional barrenness or richness of family life, its degree of cohesiveness, its sooio-eoonomic completeness, and the consistency of a reasonably predictable environment. The family is surrendering many of its traditional functions, which are being delegated increasingly to outside agencies. Transitional changes are occurring in its structure, as well as, its function, in the prestige and relative status of parents, with cenflict and confusion between old and new social concepts and usages. These call for continuing adaptation in terms of the needs of family members, and the centemporary conditiens in a partioular culture. Plans and pregrammes designed to ensure the mental health of the child, may need to be examined in terms of the likely structure and function of the family of the future. The family is said to be passing through 11 crisis. Some observers suggest th~t eny majer alterations are associated ineVitably with deterioration and disintegration, that in fact, the family in its traditional form, has outlived its usefulness. Others believe th:"t the f['.mily will survive in new forms, acceptable only if there is a return to the domestic pattern and social idealism of the middle of the last century. They rofer to the need to maintain a healthy balance between tho satisfactions derived from intimate family life, and those from an external environment, designed to onrich experiences, while not dictating the manner in which they are exprossed. The chief danger, and the source of present confusion would seem to be associated with two opposing developments, the one represented by the claim of each family member for individual expression, and the other, an increasingly organised, dehumanising socio-economic system within the community.

,5.

"l~

_ ~

...IrI.

....

THEM E

PSYCHOANALYTICAL THEOlU OF EARLY F~RSONALITY

DEVELOPMENT •

Andrew Feto. Clinical observations of feeding disturbances in earliest infancy indicate t hat the young infant is capable of forming object relations, i.e. of experiencing love and hate towards the mother. These observations prove that there are already in the newborn child drives (instincts) that are not in the service of selfpreservation, but seek for an object that gives gratification and pleasure. The one and only object for the newborn infant is the mother, and she re~ains the centre of the child's wor1d in the following twelve months. Freud called the instincts that are the vehicles for the establishment of object relations the infantile sexual instincts and the aggressive instincts. He called the former sexual because they are pleasure seeking, they are components of the mature sexual instinct, and they are distinctly recognisable in the perversions. The first - that appears already during birth - is the socalled oral component-instinct. Its SOUFce is the mouth, its biological object is the mother, found on the occasions of breast feeding. There are, however, intervals when the child'is deprived of the mother as an object, - and this even in cultures where the child spends the first months actually attached to the mother's body. Thus - within any human culture - a continuous frustration results from the separation from the mother, and it affects mainly the oral instinct which prevails in the first months. Deprived of its object the instinct makes the child's own body its' object. The child sucks his lips, puts his finger into his mouth, etc., One of the most characteristic features of the oral instinct, as it is in general of infantile sexuality, is that it is auto~ erotic, i.e. it seeks and finds gratification on the individual's own body whenover the biological object, the mother, is not present. Orality plays an important part in normal and in perverted sexual life of adults. Our language preserves many examples of the earliest infantile component-instinct 9 and of the most archaic object relation ("sweet", "dish"), and so do mythology, folklore, ritu~ls. (Ogres, cannibals, totem feast variations, etc.) The mouth is: also the source 01 oral aggression. Devouring aims at the annihilation of th~ object. The wounds of the nipple, the biting of the teething child witness the early ope rat. ion of this Gggressive drive.

- 32 -

Another source of an infantile sexual component-instinct and of aggression is the hand. (I.Hermann). Clinging, carressi08, gripping the breast are the manifestations of this sexual component-ir~tinct. ~cprivcd of its object, the mother, the autoerotic activity of plaYing with his own hair, ears, etc., display the continuous operation of this infantile instinct. (I. Hermann). There is no need to discuss the part of the hand in aggression. These instinctuai drives support intellectual developnent. They are the instigators of the search into the understanding of the environment and in discrini~~ting between self and nonself. The continuous strean of infantile drives blocked by the inevitable phases of sep::1.rntion frOB the Bother resUlt in a recurrent series of traunatic situations. Instinctual frustration and apparent loss of the !:lother fron tho narrow infantile horizon of the baby crente nnxiety. AutoerotisD helps in overcoming these anxiety states. The lost mother is replaced by tho child's own body, the child- . mother relation cnn be re-created in tho child's relation with his own body. These i.dentificn.tions lead to the enrichnent of the personality, ahd enable the child to reach greater independence. Nevertheless, clinical observations of feeding disturbances prove that "loss of the motherll.and exclusive consolation in autoerotisn may lead to the permanent rejection of the nother. Anbivalence, the feeling of'love and hate towsrds the SaBe object, in the case of th.o infant, the nother, is the characteristic ·of every human relation. The better balanced t he mother is,the nore opportunity there is for the child to build up ..i dentifications with a good mother inago. A mother's unbal'anced attitude facilitates the G.oniru;mce of hateful phantasies. Anlbivalcnce is fed by the pleasant and unpleas::1.nt experiences of the child. The two and three years show a great speeding up of the child's intellectual and physical developncnt. Speech and the verbalisation of phantasies, individual and social play develop with two nD.in instinctual drives: an infantile sexual one, and a new type of aggression. Again an orifice of Great phySiological iuportance is the source of ithis infnntile sexual instinct, the anal conponentins"tinct. The basic physical pleasure is that of passing' faeces through the anal rinG, but what !:latters for the child's enotionc.l developrrent c..re the phantasies that refer to and a~r. mpany this physiologicnl act. The child realises thnt the feeces cones froLl the inside of his body, is a part of his self, the only part thnt conspicuously" and regularly is produced. He associates this fnctwith nallY pleasant and unpleasant sensations which he feels within his body. The pleasant sensations induco the child to indulge in autoerotic renewal of these pleasure·s. The erotic sensations radiate to the buttocks. Chilc1rens' autoerbtic or nutua1. play consists of intruding the finger or toys, rubbing, strokin~, etc., of this erotogenic zone. Playing with faeces, sr.waring are c?nspicuo~s plc..y-activities. Cleanliness-training interferes Qrastlc~lly wlth these grD.tific~tions.

., i

! '

.i - 33 -

Such anal play already reveals the other component-instinct . of, this phase, that of aggression •.. Aggressive anal play and _I>han:tasies are linked with increasing nUSf'!UJ.ar aggression with temper tant:r'U.tls;and wUd attacks against parents and playmates .. 0 ·sexllal

.Ana.ie.rotic-;·as well as aggressive trends playa part in normal life of.adul ts , in active and passive hOI:Lose.xu.ali.ty, in sado-mns-oclli,.si;i..c a;ci;itities, soo,ony I nekropbily. They are presen.t . in _bJ a ok J:J.a.gi.e~. ned.i.a:eval uedi.oine, foll4ora, in. ma.riy jokes,

.:ffilrsjng• . ..... -.. _._/ ',

. "'Th:e-·chiJ.d" -deve.l:ops. two kinds-af o.bje-ct· reJ.a.tions. . Th-evehic-:t:es . .of the posi:tive', loving one are .the anal-erotic pleasures.., the nilder variations of aggression. Parenta:l care gives .ample ._opportunity to develop Bleasant phantasies about being l;ooked after, being possessed 10vingly and possessing through love and force •. Simultaneously the child's aggression, tenpers, intruding tendencies involve hin inevitably in punishnent, denials and frustrations. 'This creates anxieties about not being loved, being threatened and rejected. Tho neglected child then feels hinsolf entitled to hate his parents, to attribute to then through projection - all his aggression. At this stage anbivalence 'cones into force, the child slips into the conflict of atone and the sane tine loving and 'hating . his parents r This creates fear of external authority which is gradually transfor.aed into a sense of guilt as an inner nental institution. The child :~dentifies hmself with the external authori ty I thus builds up a rrighty inner censor which helps· his adaptation to the denands of his culture. The other inportant social adaptations that being to operate at this, stage are disgust and schene. They e.ro reaction fom.ations, by which mechanisns instinctual drives and t heir objects change fron the original desirable trends and it, heir objects into their opposite i. e. revolting, loathsone. Original plee.su:re in faeces and dirt, indulgence in anrtl-erotic and anal-aggressive play activities arc gradually replaced by their opposite: disgust and. shar.lC. By the nechrmism of ~ :L,dentifying hinself with the external authority, the ehild is helped to give up and to despise oriG~nally.appreciatod activities. Oral, anal and the following phallic stage are not clear cut phases, they overlap each other, exist side by Side, change with every child. Cultural and class influences, instigate or oppress, accelerate or delay their nanifestations. Nevertheless every inclivic1url.l goes throuGh then in what we would' describe e.s a basic nnd universal hunan way. At four the child of western civilisation reaches an inportant new phase of his developnent.: The genital zone becones the central erotogenic zone. 'Genital masturbation and acconpanying intellectual curiosity result. Abundant heterosexual and honosexual phantasies develop and the child's enotional object relations reach their clinax. The chilcl discovers that ther~ arc two sexes. The first reaction to it is denial. He naintains the idea of bisexuality. PhantaSies, plays, folklore,witnoss this stage.

•

'_-.

I..

-. 34 .~, , . InstincrtunJ. stinuli' nne"'. growing intellectual capac:i,tyurge the child to inqll~Si tiveness r:.nel to the. fl'cntion of JIlfantile - theories about pregnancy" bir.th ,a~.cl interoo'lrse. Thesetheories de fin! tely bcnr the nnrk of the preVious developnental s.tage.s,_ and have their exact parallels in folklore and in hallucinations and phantasi2s ot psychotics. .', \ ·0·1

There a~re oral, 8nal, urcth~?l, phallic ,,'st¥.lo-jl1l:\SOChiat.·ic :~:.:. theories. Oralexdrlples: the nother beco,l':J.c pregnantthrough'eatirig;. r~ kissing, etc. The baby is vO:Ditecl or spitted out. . '" Anal eJtanples:

an-qs.

the baby is put into the world through the Love naking consistsofsor:..e une.l rubbing, showing"e.tc. Father inprcgnatcs the I:lotherwith his'

Urethral exanple: urine.

The child believes thr:.t also nen can bear babies. Parental ;intercourse is prevailing conceived in ~ado-I:laschis ttc terns., It is nostly the father who is the brutal partnerJ but the opposite phantasy exists also. Since the chilc1 ca~ot conprehend intercourse, even if observed, either grasp it intellectually or emotionally, the act or ·thought of it inevitably creates anxieties. This is so even in extrenelypernissive cul~ures. Anthropological fieldwork and folklore bear witness to th:iSl. The genital zone is stinulatecl through these pha.ntasie.s, as well as through rk~sturbation. This inpels·the child to Seek the grat1!icnt10n of his sexual urge~ He becones,a voyeur or· trieste seduce the other children through exhibitionisn. Genital Dastur.bation is prnctised individually. or nutUally. Both hetero- and hono-sexual experiencesaro sought for, ~nd children of this age are relatively easy victios of adults'secuction •. Anxieties develop in_both non~permissive and permissive cultures. These anxieties are caused by the imler tension 0:( infantile sexuality whi ch can never reach an orga:s.ti c climax," and by the phantasied dangers of the sexual act. Another cause of these anxieties is the child's intellectual and emotional immaturity, he is unable to grasp the real mean:irig of sexual activities. The threats and punishments in.non-permissive cultures add to the intensity of the anxiety. These phenomena lead to complicated emotional object rela.t. ions with the central figures of the infantile world,_..father and mother. The child develops strong phySical desires towards the parent of the ~pposite sex, wishes to possess him or her accord'ing,to his infantile sexual phantasies. ,Simultaneously tender emotions arise, l<!.e longs to be' loved and looked after exclusively by one or other pnrent. Parallel aggression aims at the eliminatiOn of the main rival, i.e. the parent of the same sex. Both drives operate mainly in the child's thoughts and phantasies. The more permissive the culture the more they come into the open: in words nnd acts~

- 35'-

Fear of reta,l.iation and actual refusal as well. as biological and intellectual inade~uacy cause ineVitable frustration. Further co~:pil.ications are caused by the childls-hormonally. determined psyahological bi-sexuality. Unprejudiced observatJ.on and recording of plays and phantasies prove the existence of strong desirestowgrds the parent of t he same sex. Again mythology and folklores serve numerous examples. This factor determines that the child is attached by stormy and also tender emotions to the parent of his own sex, and develops hostile emotions to the parent of t,he opposite sex. The consideratio'Jl!of the child's manifold frustrations br:iings home that there is' ample opportunity to hate both parentE.;, even if they are in reality extremely lanient. Thus a complicated ambivalence develops and the child suffers frOm the throes of manifo:ld ~uandaries. This series of conf'l--,' icts starts at the child's birth, takes different forms at different ages and culminates in what is called the Oedipus conflict whose roots had already started e..t the beginning of life. Sib~ing atte..chments and rivalries run on the same lines as the basic conflict.

Anxi'eties arise lIartly because the child in phantasy ,expacts damage to be done to the genitals s and :;;>a-rtly because he 'expects 1·0 lose the parent's love. Parental attitude to the child is the mirrored reflection of his own stonay emotions. The way out of these conflicts is mainly mnrked by the mechanism of identification. The child internalise~ the social standards of his environment and parental guthority becomes an inner censor. The sense of guilt takes overjhe role of harnessing instinctual demands. Children's play offers the best QPportunity for ~he ohservation of these phenomena, because it is the child's greatest weapon for the solution of his problems. The process of dealing with his confl.icts is carried out mainly through the mechanis.Ira of sublimation in play. Instinctual demands becone in the course of play de-sexualised, and are led into social channels. The healthy child playe incessantly. His drives and the resul ted anxieties are dealt with through continu'ous repetition of the traumatic situation in his play. In play is reflected every possible object relation as it appears in the course of his development. The passing of the stormy Oedipus conflict into the relatively ~uiet phase of the so-called latency period indicates the success of this transition towards socialisation .. Summarising the emotional development of childhood we may say, that the manifestation of infantile se~~al and aggressive drives form the basis for the child:s object relations. These object relations are inevitably ambiguous, they provoke· states of anxiety of which the character chan6 es with cvery age. The facts of the human being' s helples~~-.ess and his extremely delayed na turaticn act ns prirl8.ry factors, 2Jld tho existence of social mores as a secondqry factor, forcing the growing child to adapt himself tc given patterrU3, Thore ['ore I'l2.l1y mechr::nisns i:a tho service of this socic:.lisntion jJroco.sc'. Idontifi catj on and

-" 36 sub~tion are ~aramount inportance. They co-operate with other mechanisms - i.e.i, the reaction formations represented by shane, disgust and morality to lead the child towards his biological and social naturation •

• •

- 37 ~ SUMMARY OF MAIN POINTS IN GROUP DISCUSSIONS. C.H~Gundry.

1. The possible effect of group discussions on the mental health of the participants. By virtue of our own experiences each of us is likely to regard some ideas about child training as being rather sacred. Take the topic of obedience to authority for instance. Some people feel deeply that 'it is of the greatest importance th~t a child should learn to ooey his pa.rents, because they think.th~t such training helps to develop good character, and they hold that the earlier training starts, the better. Any general statement that it might be better for a child to have ~ little of his own way - or that too much should not be expected of him too early, may simply be met by scoffing, or real anger. Such a persOh can experience a good deal of 6pposition to mental hygiene in the bottow of his heart, though on the 'surf~ce he accepts it verbally. His acceptanoe of the proposition that a child should be expected to display only ~ limited degree of self-discipline at a tender age may be modified by so many conditions that while claiming to be tolerant, he succeeds in aoting just as strictiy as he feels. a week's disoussions with a group of friendly and serious Some of the members of the 'group may be products of systems that are the opposite of that which he feels to be right. Some of them may advocate schools of thought that he has secretly despised. But if he begins to respect and understand the other people, it is hard fo~ him to continue to believe that their background has been wrong and his theories the only correct ones. ~.oPle, suoh a pe~son might have his defenses penetrated.

In the dourse

As another~xample there is the person who feels insecure in a free and easy discussion. He is inclined to feel that the weigh~ of an opinion should be in relation to the prestige of the person who utters it. Here he finds younger people disagreeing with older people, senior people willing to learn from junior people. Surely an example of respect for ideas and earnestness of purpose and individuality provides an atmosphere in which he may acquire increassd confidence in his right to think for himself. When items of information are being exchanged and ideas are being clarified ~exposure to the criticisms of other minds, individuals may come to understand themsolves and the general field of mental health c little better. 2. The importance of mental hygiene is ;part of a broad a;p;pro~ch

to medicine.

The prevalent and artificial discussion between what is physical, and whet is mental in health programmes, requires to be broken down. It raised the question of the relative importance of the physical and mental components in illhealth in the various countries represented at the seminar. It is generally accepted that illnesses in which the emotional element is a major f2.ctor in the etiology, comprises a large part of ill-health in western countries. In some of the Asian countries the effects of emotional stress on health arc less evident, but industrialization may change this. The attitudes to~rds this problem have not been constant. The pendulum has swung backwards and forwards betwoen a too organic view, and a too psychological view. Recent discoveries in Australia have demonstrated how the infant in the uterus can be affected by illnesses that affect the mother (e.g.rubella). Hsre is an elCemple of environmental influencea which have a subsequent effect on the child's personality. In disoussing the causes of congenital abnormalities with parents the medical profession has a responsibility to protect the parents from a sense of guilt. There is evidence that much of the emotional stress surrounding

'",.,

,- 0.-~

. ~I

- 38 congeni~al ~alformations arises from feelings of parental gailt, which are as a rule gr6UIidles'S.·· It is well known that some children come through the most distressing; t;y'ptl"s' of upbringing and 11.ppear to thrivo on it. Thero seems to be a faotor ot:06tlstitutiorial toughness about which we know very little.

What is the relationship between physique and temperament?

Th~

9hhdJ s

need for emotional seourity.

It, was admitted tht.t some of the difficulties whioh surround this subject are assooiated with the la.ok of definitions and the establishment·of norms. The tf'l~,a.~ncy to consicer what is ideal as being normal, is undoubtedly a sourco of ruu:ie.'\iy to many parents. The relation of infr..nt security to the length of broatfeeding WilS the subject of some discussion. ,Breast feeding is important, for apart from the strictly physical advantages it confers, it is conducive to a ohild'~ early sense of seourity; "the skin to skin contact" is importmlt. It is sensible that the ohild's early contacts with the mO,thor, the feel of the mother, the smelLof the mOJher, the scent of the mother' s fa.ce, the conto.ct of a mother's arms,. go " a long way towards helping to clarify in the child's dawning mind the image of a person ,who is to be the source of comfort and affection. There has been a great deal of disoul\lsion about conditions whioh make breast feeding difficult, the idea was adv~nced that it is not wiso to insist on breast feeding to the point of making mothe.rs feel unhappy if it is not expedient for them to feed babies at the breast. Sometimes they would respond to tre~tment, and sometimes they would not. There are economic fac¥;lI"s,. ,such as, a mother having to work, and otljer conditions set by the mother',;t;h~t. arl? ;i.mporllant to her, but Which may not see~ important to us; however it is her·opin~9ninthese mat:teI"S which must b.e €iven weight. The iden has been expressed that i t is not proper to.pUt'Unduo'pressure on mothers to breast feed when it ,is possible to, ,':i: conduct artificial feeding so satisfnctorily.

What is expected of a child shou1d be, related to his staieof development.

Many of us have failed to recognise that an infant's personality grows and develops in an orderly series of steps. It seems that parents and others, often· expect children to do thing';! before #ley are ready, A child cannot be taught 1;0 wal.r,c" he walks when he is ready. ",' Fressure placed on the child to walk before he 1srsady, often delays his walking.. Young children cannot be expectga'tO uIillerstand tJie desirability of being clean in 'their toilet habits, yet parents ",recansistently subjeoting children to !kgrent deal of stress on this account.' Some, oftbs membe:J:'s from Asian countries go.vecha.rming pictures of children in thMfHiarlu.' years; being' encouraged to say "please'" when 'about a year old:, anll not be;ingq~1j.b.dected to a rigid system of training. M:tsd~rnem1bii:rsttn,i exc'u~edr" very 1'$'adil.~; ,being accepted as part of the growing up pro'6ess., ',tt seems that example j;al~l';l.ed ullo,n m~ch more thr..n scolding and preme.ture explaining. By contrast the development of children in Western countries is too muoh domination by the idea th"t it is good for the infant's character if he suffers a little in childhood. People often complain that small children are not grateful for what has been done for them.

l:"

,. - 39 '. T II E ;.:J~ THE CHILD AND ITS

RELATI01~SHIP

TO THE

CaMMIJ1~ITY

FAMILY PA'TIERNS AND CHILD. CARE "&¥iilOnd Firth

Prei'.::.ce on Cu.ltural Pntterns and the Chil.s.

H S6enlS advisable"to prefac~ my talk on family patterns Oy a few words on cultural patterns generally, from""the staM point of an anthropologist. The terms Societ£, Cu1tur§, Co«~ni~ often crop up in our discussions arid tnere is sometimes confusion aboo.t their meaning. In"fact, they shade into "'one""another. But society refers primarily to the relations between the numan beings, culture to their achievement;' and community to their localisation in sOllle common field of action. Speaking very siiiiply one may say a·' society is a group of people who use an:t create.a ~ll!~ and lh-e in a .. co~nity. As far as the care and upbringing of the child is concernea, we can··then talk almost indifferently about social patterns, cultural patt'erns or even coomunity patterns. The kind of patterns w~··are interested in here are those regularities of social behavioui' which not only occur, but are e:xpected to occur, and have values or sanc~ions to back them ~p. We all agree how important are thes~ patterns for the development of a Tney provide hiiii with guides to action in a positive encouraging way·'ana on the otner hand, they set limits to his activitY. We"have already seen in this seminar how tfiese patterns differ in different countries. Through the work of Mead and many others, we have been led to appreciate how such differences are liable to affect the behaviour and disposition of the t.hild. child~

•

"An eXample here is the differences in "l'lhat ··may··be called technology of elimination-a child in a primitive CO!IlT.iinity can conduct his·'excretion very simply ard without fuss whereas a Western ch:"ld is involved in and expected to use apparatus which involves trouble for him ard often dIfficulty between him and fiis mother. The lack of obsessive··daily questioning of a primitive child, and general freedOOl f~~om··parental interference in his toilet postpone . con.flict with his parents, for one or two years. " .. ... Cultural patterns are not haphazardly arraDged: they forma systematic stheme. In this there may be some arbitrarine ss - as e.g. in the kinds of dress worn by eitner sex - and thb may create difficulties for the child. But there is a consistency in the patter:1s. Hence the anthropologist uses as:a framework for his studies tIle concept··of a social or cultural system, that is, a set·'of social relations interconYie.::ted in such a way that·distur-. banee of the one·'tends to involvz alt",ration in others. For the young child, the most important aspect 01' thissociol system are the relations of kinship. The anthropologist"'has developed an ele.borate··!ramewoIk for the stui:ly of .. kinship in relation to the child. BLlt. t·ake ohly onG exam~Ie. To understand how a cnild develops, it may be obviously significant to know mat are the , relations between·'the father and i.iother c,f the child, or between the "Child's mother a~ h~.r o~n mothe~> or even with her ~usband' s mot~er. Then in many·' communiti6~, a ch.i ld is 1'.11 ohject of interest to at least: two major groups in the society, the moth0r i s kin group ana the father's kin group. These two groups partly compete for the child as an asset, partly have to treat it as a liability by tr,~ obligation to perform"various services for it. All this is importa'it in o::,der to··understand what a community expects of a child. MCiveme,it of mot.her and child or child alo~ for example, from one house to another or village to another is commonly due to this. (A question here is tte extent to Nhich such movement is liable to affect the child i s health.)

lu",rb i" !Jli.lcL vu.liutiun in tb,,:;c )att"rlis within a society - even the most'·primitive. One of our probl,"ms is to assess the deg::-ee of such variaticn c"'c. t.L" lLj b ·,'.id, t!,,, c': L j,-,::'.:.·l,<-,::t\.jJ by it, 'I h", r-(; is a tendency amongst anthl'opoi£ld$.t_s;.as.well aso~~~ers, to cite the most common,OOtype or eve1"' tfie ideal type"as-'lfit~Ccc)\rered all actual" ~ses. Even in our di5..cus.sions our impressions, singular cases; ora: narrow ; range of personal experienc'e.,D?-v;6 beert quoted· as i f they"were a generai pattern. Much more 'systematic researCh-is"'neededeven in Western • societies to determine what actually"happens to chil..clren through their, social""relationship-e - to establish notmsand variations. Change of pattern is also goIng on all the'time.Sometimes, it is slow and imperceptible a5 in the'tradi.tiOnalprim.ttlve and peasant societ~es. "Some-, times, it is very l'!lpid as"Qften i>1 Wester'", societies at1d in thE> Asian; '<. Pacific societies und~rgoi"'g' inodern urlianization and inaustria'lizat"ion~; 'lli",' Western countries with 3'Jphisticatjd inquiry and fashions in intelleqtuaI as well as aesthetic matters, there iiiay be a rapid oscillation of patterns. (Oscillation in patter"'s 6f breast and bottle feeding are an example qf this, due perhaps ir.. soree cases as much to the convE:l1ience of the moth.. r- as' . that of the child.) These patterns an:r"relationships are backed by social values which gl.ve them significa:r"lce, and forcR, It is the establishmen:. of these values, economic, legal, moral, re::'ig1.ous et7. which often make it so hard t o ' chal1ge~'the pattern. ,. Moreov5r, some of tne most difficult aspeicts of the training of chil.dre1!1 are concerned with attempts of parents and. other members of the society to incillcate: into"themOOa set of values -provided by the society. There is variation a rd change in vdlues in all soci~t.if( s.>. There is also conflict of values. A simpleOOexample of this ist.heper~,;" bulator versus the motor car, a choice often facing'-a yOung marrieC! c6uple~ A more complicated examp18 is the qu.estion of terminating the pregnancy, of a wcman who"seems likely to bear, a defe.:tive chi~d-anOOisslle Where.. ,',,, legal, moral and religious cOl'15ideratlons may al.lehter and not necessari]"y coincide. But perhaps th3 most rei're.ctory"of"'si:,llations of'valuecGnf1,icts" in the field'of child. health are to be seen in countries wht.ch: a,reOOatteJIiPting a rapid technical am economic c',€'vr~lopr.,ent, Be t.hat a3it !OO:y,,-;'mqny:' of,J.lie ' basic problems.of"'chilc.mental f1i;al';,h seem to li3 not so mUch in the':dg'"1~ ficulties of technical a~hievement as in'-those o!.' clarifying am changing our values. "One of the greatest qc.l€st.io'1s t.o answe!' is what is it ,we reallywant children. to b e c c ; , l e 7 . " ...... :: For the child from u-6 the most. important community patter!1#!' are obvious1,y provided by the i'am:i,::'yo Th" elementary' fa;nilj - fath:er,moth~r and ehild - may be called the real--E{~ernal 7ria"'gle in--hlJmanrelatiQrlshj,ps~' . ,Some form of elementary family is univ6!'sal in all human societies.· N"d'Lnatter what the type of society may be;, or even w~:eth€r biological paternity is ,recognised )r not, '·the.re :LS alVla~Ts some .ecogt-iised marriagerule;',i.e. some form of recogn.isoo. udon ofmsn m-,d woman for the production ~r:td/o{ . rare of children. as onG oC.':'::'s. m~or object.s. There is no society wherf) the birth of children by unrrl8:T.led wo.ne!'1 without recogiiised tres to spe"cific men has regular social approval. (Thfl children of Chinese concubines ari! the "illegitimate" childre" 0;: ~ .:.::,,!~:ca a:-e borde:- Une cases, but "fall within the rule.) Sociologically: thei;, ODe m'''jo . : fllnctionOO or'the elementary f~illi1,y is the prov;i,s.ion of security 1:.11d fac':"Ut.Les for hritlging IIp children. ..

But. the attitllde tov:an-'.c; '~h~.·'dhn 'laris's considerably in different types of societ,Y. Eetwee'1 Eisterniind W.-;ctol'n--p8cples, for instance~' tuere is often much v~riat;icrl in technj.(:al !-::nowled:,;e, and jn custom,though an under- -, sta nding of huma,,"rela t,LO; I.'; .5,8 comir',nn tn :.>.11 sodet.ies; a sensitive percep',ion of the emotions ani f:::,a:'..lt iG~ of ir.d':."fictLJals In many societies with a relatively simple technolC';:t;- ",ne: eccncir~' c st:,uctll,e~' this sensitivity is displayed in a striic:,ng way"in the hand:::.ir.!i of c~lildre~, :l'he child is treated as a person, wit,h his own ciie;',1::'t,y O:1!1rl op_r-,::'O"lS to be considered,. thi:iuglj it is " realised that he L~C:'~s the rangr of GJ<"j)erience [cad Sk:;'lJ.3 of an adult: Hence, "permissive"csc" to children i.:1t,hose ooC'ie<;icE ':'sno::' mere i'labbiness; it is an exeinplif ::'c2.Lion of' a 3911,,5.tj ';" 2.G'::' ""de,

.•

-41-

.'.

"0 or

Most oi'"'the llterature on child care is based on discussion of Western Famil,y patterns. But in other parts of the 'Worldth,s .patterns o~tsn differsnt, and sO .... too ...are the problem~. ..,

are

There is abundance or material on differences·in.famIlY patterns in various types of society In Soutli East Asia and the Western Pacific. But; most of it relates to economic and social implications of famil,y differences, aF1d little of it touches the problems of chIld care directl,y. Nor a:oes it even Gover the vtJ.61e field of family patterns systematicall,y, So in this talk I shall be rather selective. I shall be concernec! 'With ,general"'principles rather than with a mass of organised facts:' I shall. Suggest questions as much as answers. And I shall mention what happens in the' practices of part.icular societies to illuStrate points of gener'll importance in jjiy anal,ysis, not because I just want to give infonnationor because I think they. are to os followed as models. Sometimes, I lJ.ay have to go for a good illustration riglit outsiae the Asian-Pacific field altogether. As an !lmhropologist, my main concern Is to bring out how the setting for child training and child care varies in different cultures. Where I can, "1 will try and show how children react to such different social"conditions. But I must leave. ,it to m,y"colleagues and the rest of the seminar to draw most of the practical 'col'lClusions. From this point of view family patterns may be discussed under the following heads: marital patterns patterns of authority and transmission of family. interests patterns of adoptiCln"oi'"'children" , patterns of wider kin interest in ~ildren of the famil,y '

A. .

MARITAL PATTERNS . and their implications for child care: .... . _. ','

•

Monogamous marriage~' similar t'o the Western form,. is tl:le eo,.'nmonest tj:pe:' of actua:i. marriage in the Asian Pacific, region, . But ~n many of these soe1eties legal or cust'omaryruies allow of other forms, which are regarded as ecpall,y proper. Monogamy lamoSt prevalent for, econcmicreasons, or. . following aO'general move to Westernization, not simpl,y because itO'is tpooght to De the onl,y right' course. Polyandry, the practiCe of one woman having . more. than one husoarri;'is rare,·'though it obtains In parts of Malabar al'ld in Tiost. Polygyny, In which one man"has"more than one. wife, is much more commOn," as in the Chinese societies and in i:,he Muslim areas, as well as in parts or the Philippines·'and the Pacific"Ylhich are still pagan. This"has . r.eactiol'ls~onthe position, or the" child in the family.". The p.eculiar i"timacy of the mothe'r-child. relation is not lost ." In no human society~' however eo.mplex··itsmarita~·relations, is"there any complete loss of individ!la~iza tic,." any J.'inal de-personalization of the ties' between motherai'id child •. But·'thereare significant differe ... cesfrOOl the Western type. In the tradi-,' tioiial Chinese upper class famil,yinall ,formal matters~' the child has to .. aCknowledge his father' Bsenior wife aahis' "iriother"~' and his own moth~r, i f the Junior wife, as ·"little m6'th.e.t1f' or "aunt". Unequal treatment ot l'.hildren in a polygynous household can make a child" s lifi;i very unhappy. The ~enior wife"iriay treat her junior wife's children unkindly, and" exercise aO'tyrannous authority over them. The"father may make things worse by favouring them 1iecause they Cl.re the:'offsprIng ofa better loved younger wife, or because one of them is·the"son he wanted, and wfio was not born to him by tfie first wife. Sometimes in CHina, ana almost universally in Malay:~ and ?tr;r M~sliiri. p.arts of·the loo00esian worJ4, ~he"wolst effects of th1s spl1t In maternal discipline and paternal affection are avoided by . having the wives in separate householos. But the ~ontinued possibility of having to obey sOOleoneo'else t,han one's own mother, without the mother's being able tu intervene arrisoften the dIsCipline, or witnout the chil9 ~ s , being abh' to appeal on the intimate plane of personal contacts as it does with its own mother, is likely to have reactions on the young child's sense of security a.nd lead to anxiety fonnations.

- 42, On the otlier hand, such a patterning whereby the function of discipline" is to sexne extent separated from maternal care may nave the result of anchoring the child's sentiments more flnnly to the mother, and avoiding an amoivalent reaction. This aspect is even"more marked in"some of the patterns under B. Tlie possibility of these alternative consequences shows the difficulty" of interpretation of the results of such situations in tenns of first principles. Only actual observation of a systematic kind can show which of these effects does in fact occur - or if both do. B. PATTERNS OF AUTHORITY ETC.

Even in monogamY, ramily patterns often depart significantJ.,y"from what is regarded as the conventional Western. t:ype. r'shall deal with onJ.,y two main points here. In the first place, on the generaI plane, the division of labour between husband and wife in regard to children is"apt to differ from the Western stereotype. So much qf Western . literature in respect of chHd care deals with the mother-child relation;t:hefather is often barely'·mentioned. This is part of the general view that looking after children~'is "women's work ll a view which by the way, has terded·to lapse in practice among many"young ., .. middle-class families nowadays in Englanu and the United. states. In the AsianPacific societies, the father very commonIy shares the care of tlie child"aJJnost equally with the mother. He takes part on the one hand In feeding it,and giving it arink';' and On the other hand, he may"give attent:ion to its-'toilet. (Compare a rrl contrast: 'with Bowlby's -'description of the non-cooperating English father.) I have seen occasions when a f.ather nursing a young chIld in his arms has hastily handed it over to its mother or same other woman when it has begun to micturate or defecate. But"not-'uncommonly he will attend to the matter carefully himself. Baby-mil'J.dil'J.g and nursing are regular male --tasks - perfonned not as chores"but as nonnal ratfier pleasurable activities when the father is not working. Even whe1'l he is working, ,he often t'akes along a young child bareJ.,y able to walk, so that long before it is of an age equivalent to our going to school, the child has"acquired some familiarity with the ordinary"econoiJiic ta,sks or his social universe. T~e role of the family in education, even for .. the young cfiild~' is very important. "( It; leads on in a fairly graaual transition to adolescent and adult participation in the labours of the community, avoiding" some of the abruptness of the home-school-job wrenches characteristic of Western society) • As"a consequence of this relative"intimacy of father and young cfiild in the Asian-Pacific field, it may be taken as a hypothesis that there tends to be Iess resentment by the cfiild against 1ixercise of the father's authority,·' than in Western society. On the"other hand, there are some societies~' as in Majuro and Tikopia, where certain ritual relations must be"observed 'in regard ., to the father. Tr..Is involves"not calling him by his personal name, not tpuching his head or reaC!-iing down things from above fiis head. Hence the young child has inculcated into him at a very early age notions of respect for his father, ideas of social distance which set the father and persons so classified apart frOOl other men" of their general grade. Tbu .not.her, fiowever, in aJJnost every society, remains"the focus of Illost intimate attachment;. She may be described in figurative language, as in a Polynesian funeral song, thus: ''Mother1 tor whom I have wept. While you"lived among men My dwelling was secure. .. ~.

I go rou1'ld about, then visit you. The food-basket is placed before me The water-bottle' is full That I·.nay drink." This dirge stres,ses the"primary attitude towards the mother - as one who makes a childl~ posi~ion ~ecu!.6' The second main point in monogamous family patterns is that"in the Asian Pacific field the"major structural prinCiple is often not patrilineal as in the West., but matrilineal. n.e Nayar of M,.lc.bar, the Khasi and. Garo of' Asse.m, the.

, ... 43 Mena~abau of ~tra, the various societies of MiCronesia, and manY of M61al'leaia all"'follow 't.his general pattern, in descent, property-owning, 'ani succession to office. In such cases the mother is apt to assume "' greater fonnal .importance in regard to matters concerning the chila. A~ t.o the mOther's brother there tend to be attached the respect given the father in patrillnealsocieties. ('Or fie shares it with the father, "'as in Majuro). The mother's brother is not necessarily"'the discip1inar~n of the fa.mD,v. But as the"'head of the child's kin groUp - which tlie f ather -is"' not _obis opinions are gi ven"'weight, and even '8 very young cbild soon learns that here is a person of great importance to him:' Tfiis is often ,.emphasized by the existence of a special kinship term" singling the mother's brother out from other uncles - a term which the child is 'taught ~o use at an early age.

a few societies with a strong matrilineal bias, as in the Trobriands, there is no theory of physiological paternity. The role of the father as a progenitor is explicitly denIed. He is the mother's companion. "'As such he is regarded as a friend to her children, "'nursing them, playing with them, and in later life assisting them in mal'\Y Yiays. It is tEe mother's brother here who is the legal controller of the children:' Malinowski has pointed oiit how tne duties of a child to his .. father in later life .are·' justified not by any- legal rulss but by reference to his nursIng of"it when young - "because his hands were soiled by its excrement and urine ll • And acoording to Malinowski it is·'the mother's brother who"'is the later object of the child's aggressions, as manifested in dreams and myth.

c•-

PA'ITER.'-1S

o~ ADOPTIOi~OF

CHIWREN

•

An important feature of family. structure in, the"Asian-Pacific region ist-he preva"lence of adoption of childre~. The reasOns are"'various;, dE)sire for a son to carryon the line ; ctedre for a child ina childless househoJ;d; wrsh .for a cfiild to 00 the petty tasks of filling water-bottles etc. 'Which an .old person may rInd difficult; wish to help out a relative·· with too mari mouths to feed on a small inCOme. But apart from all this is a very general attitude that to have small children acout the place is a pleasant and good thing, Consequent.Iy, one"may find in a household alr~ady lia;-ge, with young children, a newyou~ Child iidopted. From the 'point of view·'of the'-social organization, too, it is one way of keeping up ties' with kinsfolk. This is especially so where as in rural Japan; a . · ' youl'\gboy adopted by"'a childless married couple is usUally a nephew, lIlOst often a brother's son. This keeps the property within the extended family. Where so too a girl relative is adopted, then a husband may also b~dopted for her. Adoption can'lIlean several things. Iii Malaya, for instance, there are three kinds of practice 'Which are often put 'under this head;' One is the borrowing of a child for a perio::! and taking care of it as Cine of the family; tfiis may be-'called "fostering" tfie'-child, which later ~oes back to its own home. Anotfier is the adoption of a child by legal process;' such that-'it becomes in a 'posit.ion to inherit from its adoptive parents, and remains permanently with them. A-third practice is that of buying"" Ii child, paying money for it as for any other object. Such casesare·'not very . ~ooun6n, but they occur regularly, tEe child"'normally is cought in the first few weeks of life, the selIers"'bei11g a: Chinese family and the buyer a Malay woman"'who for some -reason wants a child. "'The"b,aby, usually a girl, is at once accepted into the Muslim religion, aro is henceforth treated as a Malay. In all these cases , it is almost impossible to detect, any difference in treatment oran adopted child from biological ,offspring except in".thefull substitution of artificial food for breast milk.· . ~en a child is bought there is a complete transl'erence of motherhood, .. and the child Is surrounded by- an entJrely different and-'probably warmer home' enVironment. the former two cases, the situation is rather"'one of alternative homes, and even in some cases, of alternative mothers and fathers.

•

- 44 .... D. PATTERNS OF WIRER KIN l1~~REST ...

In most Westeri'i discussions of child care the in'\:;erest li'·focussed. aliiiost exclusively on the eleme'1tary family. Other kinsfolk are almost' entirely ignored. Thiii ~ 'DEi justifiable owIng to the relative isolat:ion of the Western family-In mOdern urban conditions. BUt even here I would questIon it - the-'grandmother, for instance, is often a very important elemeht in bringing-up the child. But" certainly for the Asian-Pacific societies, the whole set of probleins involved in chIld care would"'be put out of perspective If the wider kin were Ignored (and without"'going too deeply .. into questions of definition, let . neighbours also be included.) ... ... .. , -'In '\:;he first place, as in"'rural Japan, some kin are nearly always preseht in '\:;he-'family .circle, and behave in ordiTiary matters as members of it. When a1"\ observer first goes into a peasant h'ou:sehold, it may Iie'quite difficult for him to"'distinguish who are the actual familY. This meahs tnat the chIld grows up in"public as far as its kin are concerned. Its sleeping, suckling, "'other feeding ana excretion (for the early years)"take place in the presence of others than Its parents, without embarassment to anyone. The defInition of private functIons for the child is less tight and less early in these societies than in the West. Then the range of care is wider. In bodily haiidlil'lg, for"instance, the child gets used from birth to bei"'g picked up and fondled by manY people " of both sexes. There are some jokes in chese societies about men not being able to hold babIes, out they are"few, and a man is usually quite skilled at it. I have ofte'" seen a young man, a bachelor, hold, say, his"baoy boy"or girl cousin, in his arms, fondle it, caress it, talk to it. Infants tend to crawl for refuge to their own mothers"or fathers, to cry for them in trouble; but they are all used to being held Hi the arms~' and against the bare torso or knees, of other people whom they know well and trust. all these i,.,formal contacts the range of security of the child vis-a:':vis the outer adult world is apt to lie wider than in Western"'society. In some cases~ this even eixtends to suckling. Mead has reported-'on coirimunal SUCkling of"infants in Mams. This is rare. But it is not so uncommon for a woman, "'even a grandmot'her, "'to proffer the breast to a crying child ('not her own) i which sne is nUrsing. The common"'practice in peasant coirimunities of the Pacific and Orient for women ana men to sit"indoors or"'even outside bare to the waist~' facilitates also that intimate human bodily contact which affords satisfaction to the child.

t I

As the child gets older, able to unaerstahd speech, to talk and to walk its extra~family kinsfolk take on new significance. Firstly, they are classed in categories by the vernacular language. "'These categories are often very differer>t from those usea in the West. For instance, there may be no ge,.,eric category of "uncle" and "aunt" as we know them. The mother's brothers are usually dngled out oy a special term, distinct from the father's brothers, and have to be treated in a different way:' So also the mother's sisters are separate from the father's sisters-; But on the other hand, the terms for "mother" and "father" usually extend more widely. It is common for all the mother's sisters, and for several other kinds of relatives, to be called "mother"; for the father's brothers etc-: to-'be called "father". This does not mean tnat there is"'no possibility of singling out: the real mother or father; both in language and behaviour there is provision for this. But what it does mean is that for a"great deal of ordinary child's activity; it is custOmary to rely"not on"one woman only as mother, but on any one of a set of women. By the conventions of speech and other usage a"child has a right" to expect fooo and attention from a wide I·enge of women who call him "son". The speCial intimacy with the true motner Is not lost, but there is a diffuseness about"the mother-cnild relation.;i.n many of its aspects~' as compared with the Western"pattern. One might put/1-l!.ther-·forcibly by saying that frOm an early age in these societies there is a 'conception of the mother"'as an " aggregate of serVices, a few of which can be performeCi onlY by one w'Oiiian"' (suckling e.g.), but many or'which a1'e shared out among a number of women, ard that this is expressed in the kinship terminology.

- 45,-

·-

Ap-art. from this, as the child gro"Ws in understanding an:l. freedan of moveme1"lt, it comes to realise that speCial services of a more fonnal. nature are expect8d of it: to"Wards specific kinsfolk, and that it can demarii special services in return. In a society like Fijie.g.,'·the child of a man's"sister, known as vasu, has"far-reaching"rights over tlis uncle I s property. Even "When quite YOllng;-he can"ask for things ana expect: to have tfiem given him, simpl;y because he stands in this"kin relation. " A;::.ong the KaIingas of Luzon, where irif,ant betrothal is common, the two young children rand their"families) are in Bspecial relation, involving exchanges of presents, sharing of meat etc. F ram. il'lfa ncy, "a cnild' 5 developme 1"It in the society, and his ad justiiient in the society, depend on becoiIiing familiar with"relationships of this kind. If they are removed, or denied for any reason, difficiilties may occur. " Implications of all this in cases when children are put into an institution shwld be obvious. '

GENERAL TREATMEi"4r OF CHILDRD'O I have given some of the major elements of a. general framework for urderstanding the family"situation of the child in Asian-Pacific societies. THere are great"variations, and only proper study can proViae us"with the iTiformation we need in any particular society. But something can oe said in general about the way children are treated there, bearing in mind what I have already ~.aid. T~e p~ints

mal be set wt very briefly:

In beneral, in these societies, children are wanted. Cases of faniily limitation am"of abortion by unmarried girls are "ot uncommon, and pregnancy outside wedlock is usuall;y regaIded with displeasure oy the kin. But""the child is usuall;y received into th: famil;y and treated with normal c~re. Children are regarded as sociall"y important." Th1s is illustrated by various pregnancy rules which the expectant mother has to keep~ partly for her ovm ~ealth, but ""partly for the sake of the child • It is illustrated also by pregnancy taboos··in some societies which ,. the father has to keep •. For instance, in"no~east Mi.l.aya, a husband is expected to abstain from eating certain fish lest, it is believed, deleterious ef£eets occur to mother, and child. This is a social affinnation of the-'importance of a child to lather as well as mother. Among Bontoc, LGjJanto am some other Philippine mountain peoples, cfiildren are wanted so much that the ability to produce a child is ol"le of the most important tests of whether··a woman will be a successful wife. Hence the cUstom of trial sex union, when pregnancy of the g~rl give~ t~e sigl"l~l for marriage. Feeding the"inl'ant is In some'respects ii much more permissive process than in the conventional Western schedules.·' When it cries it is given the breast. ~ctation, lik~ pregnancy, is treated as a normal human proce •• , and suckling takes place puolicly, or at least with no great attemPt at privaW' On the other ham, there is commonly the administration of artificial food, from the earliest months or even weeks or days, Cocolllt milk and carbohydrate foods"such as banana, manioc, papaya, yams are--pre-digested by mast.ication by"mother or other woman into a lIlUsh;arid pushed, ortel'l fOrci.bly, into the child! s mouth. (What Mead has referred to in Ba~ as "aggression ~gain~t ~he mouth".) SuekJing. ie apt to be long-com..1nued (the period varying consiClerabl;y, but" often for more than a year -"up to two or three years among the mountain""peoples of tfie Philippines). 'Embree records that mal'\V people in SUyemura can remember suckling their mottiers. Dr. --N, Hirai re~Ords that out of 2475 babies, 50% were weaned only between 10-15 months. The spacing ~t of children"may be governed accordingly. In many societies, it--is thought wrong""for pregnancy to occur wfiile a j/IIomanis still suekli!'1g a child, am in some lihere are taboos on

•

- 46 - • sex relations between husbam and wife during this period. seems a sound physiol?g~cal basis for ..this). (There

5.'

.In some societies weaning is rapid, and nsychological and physical · strains on the mother are recognised. "E,,-t on the Whole it tends to be a protracted process, "though the final break may be sudaen (as Meaa notes for Samoa), and the child sent to slcep ,,11th aunt: or gra"dmother. The process is often assisted by rubbin[,; the nipr:es with an acrid Juice"or other deterrent such as mud. Gene.ra1ly, observations on weaning .:Ire few. But it aoes seem to be not..-.rr " traumatic process to the same degree as in t'he West. (Tempci~ tantrums for several weeks after rapid weaning were notel by Embre'if in Suyemura) • Disciplining of the young child"is apt to be less rigid in form,. 'and more diffuse in exercise than in western families': 110re kin share in it, and less harshly. Discipline and education are apt to be Pregmatic, to be"exercised in reepect of actual situRtions as they" occur rather than in form of respons'3 to general a:::stract ':ules, But it is not eas;r to generalize. Junong the KaHnga, children are never taught to "Ialk, or talk, or to be careful not to hurG themselves. Interference may provoke rage in the child"- used to having its (,):vn way - and surPrise in the elders. Yet even here"there is much .. · instruction in riiles of manners, obedience to' f<inshiLJooligations, status requirements, etc." By adu'lts, disciplining is ofte!'r:ve:'~ho.J, repet'iti ve, an.d 'by Western"standards~'highly abusive.'~ Chil.rtren -often seem by compariso" unheeding on the orte hand, a'1d relatively free to express their a-ggreSsions':against their e.dults,cm the . other. Iii discipline asignificantparl is p'layed by older childreE, wl;lo ,are in ge neral~' both b oy, sand gfrls," capable of as sUiJ.in3 c9"siderable responsibility for thei!' juniors. In many socie~ies, . babies and young childtenup to four Cj:' five 'years are cllC'I'iec: · a'pout continually by sligntly oldar childran~' W~lO han this job to do. In some societies, as Samoa, if the yalnger child c:des C~~ misbehaves, it is the older one who is scolded or smacked.. As Mead points out, this allows the little O!':O to"blackmail the elder by .. threa~ of causing a disturbance i f it ~oes not get its v.~y. Punishment is apt to be physical, brief and sometimes violent. There is hardly ever "withholding of food as a punish![lent- though refusal to eat is fairly common by the child. Puttln t ; c;ut.side the hous~ may be used as punishment - thsre is usually no. other . room in which the child can be secluded.

8.·.

Hi v'lry general tenus, the child in Asian-Fa'ciflc GocJaties is"at an early stage.encouraged to relc:tive ,'n:':o:',andencs ·of its p'.'.::c:tts, by the Kin s.ystem, by the semi-public nature of much dO~Gstic ,. life, and by the aeveIopment of its relations with :,ouseh0l:l ani neighbourhood children.

- 47 2. F~_r.f:X_R.ATTERNS IN WESTERN CULTURE Norma Parker. Professor Firth began his paper on "Family Patterns and Child Care" with a statement that most of the literature in child care is based on Western family patterns. This would suggest-that when I faced the task of writing on the topic assigned to me - Family Patterns in Western Culture - I would have a wealth of material on which I could draw. This would, in fact, be a wrong assumption. A considerable body of knowledge has been built up over the years, but it is still far from complete. This knowledge is from two main sources. One is from efforts to understand and deal with problems in the lives of individuals who have sought help. Intensive study has resulted in a clear picture of family patterns in individual instances, and some causaU connections have been found to exist between various factors in the family situation and personality maladjustments of different kinds. We have drawn inferences about favourable patterns, and when treatment based on these assumptions has proved successful. However, we still know little about variations in favourable patterns in family life and li:ttle about how extensive different patterns are amongst the Western population. This is not difficult to understand. Problems have an urgent quality; people with them call attention to themselves by seeking help. Intensive investig<l.tion is acceptable to such individuals since i -\;. is a necessary part of getting relief. We do not have to date many studies of successful functioning. Is the individual who is not pushed in the samo way to make him seek help capable of contributing so fnlitfully to our knowledge of psychological processe~ ?lant remarks that" it is not yet proved that the ordinary human being will be willing and able to go through all that is necessary to share intimately his life experience." If this is so, then the retrospective study of the childhood years ill the adult who is making a general success of life may never be availablE;l. We may have to rely on the observation and analysis of t~e situations in being. This is not easy where family patterns are concerned;"but a beginning has been made with a cross-sectional long-term research which will enable us to answer questions I would like to be able to answer today, . For our population, we do not as yet know facts, much less anything about causal connections which might exist between these and the development of personality characteristips,. e.g., how general marital happines or unhappiness is, or how common are vp.ri6u,s attitudes about child care. We do Dot laIow what pattorns are norms in our cuI tnre, nor wbat conditions constitute an optimal pattern for the healthy emotional develop..,. ment of the child. The seoond source from which our knowledge of childhood has come has been nursery schools, kindergartens and research projects in child development in Universities. Here the effect· of family patterns on personality development has been assessed indirectly through 6~·serva tion of children I s behaviour. In this body of knowledge the evidence on some subjects in this sominar seems strong; on others we need to wait further exploration. In other r1.reas, we can only speCUlate. Muoh of this pa.per has to consist of such speculation. Family patterns in the West as elsewhere are determined in three ways:1.

by the personalities wi thin the family group and their interaction. by the specific social situation-in which the family finds itself, rural or urban locale, socio-economic status, exposure to experience of social stress, unemployment, chronic illness and the like. by the oulture in which they exist, and the form the family takes, ideas about roles within it, traditions and ideas about child care, cultural changes which are taking place and so on.

- 48 In the lifo of the child from birth to six, it is the personalitios within tho fnmily group which are of direct and primary importance. All that we have learned to date definitely indicates that personality development takes place in relation to the specific interpersonal forces of family life. Environmental influences, provided they are not so unfavourable as to threaten survival or impair growth, reach the young child not directly but through the significant adult3 in his life. Culture is transmitted in this way and social stresses take on meaning for the child when, and as parents, by their reactions give them meaning. We are interested in variations in family patterns of living which come 'fxom personalities and circumstances affecting the day by day emotional climate in tho home, and the handling of the child's behaviour during the various developmental stages. Marriage and parenthood in Western culture are experiences to which ideally individuals come in their maturity, hr\ving had their emotional needs adequately and appropriately met at earlier stages of development. They enter into the marriage relationship to meet needs for sexuality, dependence and companionship, and if the relationship is successful dorive deep satisfactions from it. Parenthood is a next step to which thoy pass on as a further stage in self expression and achievement, fulfilling their creative drives. The common interest of the day to day oare of the ohildren adds extra satisfactions to existence and provides a cohesive emotional bond for the marriage. We have already discussed the importance of the quality of maternal care in the early years of the child, and that the father assumes considerable importance as the child Brows up. Effective fatherhood has a dual aspect; a good relationship with his wife, from whom she draws a sense of security, support and help; p~d a direct part in the home, fitting harmoniously with his wife. This is the ideal picture; obviously these conditions are sometimes absent in families. Individuals are often not ready for the responsibilities of marriage and particularly of parenthood when they assume them. Some parents are, themselves, the victims of severe deprivation and maladjustment. In their childhood they have been unloved and unwanted; they have not had their basic human needs adequately met and as adults are preoccupied to seoure self-gratification; they have not reached a stage in their own emotional develop'ment when they are capable of unselfish love. Their children are seen merely in relation to themselves. These parents follow their own impulses without any concern for the child, they never spontaneously think of the meaning a projected m~e will have for the child. When the child is sick, they do not start as parents ordinarily do from a keen appreciation of the meaning the experience of illness or hospitalisation will have for the ohild and from a desire to minimise as far as possible any disturbanoe he may be going through. Children of IE-rents such as these usually fail to dev~lop the sense of emotional seourity, we have already seen to be one of the first essentials for healthy development. The rejection which children suffer from such parents may take many different forms. They are often unable to relate positively to any human being; their suspicious and mistrust colours all their thinking and feeling. Or, if they have received some affection and care from their parents, but not enough, they may oontinue to have deep seated and strong needs to be dependent Sometimes the marriage partners are not able to meet each other's needs satisfactorily. Children sometimes are put in the position by a parent where they are being used unconsciously on the part of the parent to make up for deficiencies in the marriage relationsh.Lp or to oompensate for their disappoint.ments in it. The environment in which the family has its existenoe is of considerable importance, since family patterns are affected both favo~ably and unfavourably by what is going on in the society surrounding them. Some parents have difficulty in giving enQugh to their children, not because they did not develop a capacity for giving love in their own childhood, ~

...

- 49 but because their present oiroumstanoes are demanding, frustrating and disturbing so they have little creative energy to put into relationships with their ohildren. In one way social stresses have been steadily diminished in most of the countries we think of as oomprising the Western culture over the past fifty years. Acute hardship leading to starvation, and exposure to the rigours of the.waather has disappeared.' Wage scales have increased and material standards of liVing have improved, and social security measures have met some of the effects of various vicissitudes. These provisions are often inadequate l and life for. the family oompletely dependent on public assistance for any lengthy per10dis hard. Soc1al stresses of a different kind are nssociated with urban living in hUge·:1ndustr1al cities where large seotions of the popu:!.ations in our Western cultures live. As oities have grown larger with industrial development, more .people have their dwellings further from their place of employment. Travel to and from work has added to the length of time spent by the father away from home and often has added to his fatigue. Since the last War in Australia, too, there has been the addedd stress of an aoutehousing shortage which is not. yet :fully relieved. This has Wldouhtedly provoked anxiety ih some family si·tuations. One of the results of the increasing concentration in hugh centres of population has been a weakening of the ties whioh link families in 0. community and in the shared communal life. Associated with this is the grenter mobility which modern transport and modern economic condit;i.ons have made poss;i.bie. Families have moved more often and farther from their original homes than they used to do. In Western oul tures, numbers of children born into families have been. beooming smaller so that the typical family has. three children or less. Itis also true in that there has been 0. change in what we might· call the family cirole,.or kinship group. Once the meaningful family for the individual was an extensive one, including many relatives. There is little help ava;i.lable for parents today. Some parents find,it impossible to have any .joint aotivities outside the home during thei~ chiidren's early years. Relatives, once helpful in this regard are no longer. Going along with these changes, have been changes in the quality of social living. Satisf!).Ctions coming from association with persons and aotivities outside the home but closely related to it. ~rc perhaps not so readily available. Curle and Trist refer to the "atomisation" of Western 'industrial society in this way, "whatever their origin, the atot:listic tendenoies of modern life have' . greatly reduood the size of the fWlctional frupily. The family of today cannot be regarded as a widely ramified system of organised and positive functional relationships,which fo~ a bridge between the individual (and his family) and society as a whole. Outside an individual's immediate family, parental or mar;i.tal, most relationships of a,n effeotive and reciprocal nature into which: he enters have 'no socially organised pattern, and nosanctions, other than those of loyalty, or other ties. In a sense, therefore, the individual can be entirely alone despite these rel~tionships - a situation which is made all the more possible through tho economy by which he lives. This lack of dep~ndable support seems to be one of the major foci of anxiety in Western society. It is, moreover, an anxiety condUcive to a withdrawal from possibly painful contacts with society and thereby to a neglect of those mechanisms of interaction still possessed by it". Again they comment - "what we have callod desocialisation is a general social phenomenon •• of nuch overwhelming significance that it would appear to be a foc<'l.l point of study for 0.11 soci<'l.l scientists." Expectation about requirments for children have changed, p~rents in these days in our culture expect and arc expected to g;i.ve their ch;i.ldrcn more opportunities and a high standard of care. This includes attention to recreational hoalth and educational needs. It is icportant for them to be good parents and being a good p~ront in those days of oxtensive knowledge of infant nutrition and child management is more difficult than it USGd to be.

"'I

- 50 -

There are different expectations too, for women as to the kinds of ways which they will seek satisfactions. Thcro is less scope for i=ediate gratification through all the home making cmd housE)keeping activities so much to the fore in the past. There is less nocessity for the possession of tho traditional feminine skills within the home; the demand is for the personal qualiti'e'swhtch cont:l'ibute to succesaful family living, and these are not so easy for women." At tho' sume time thE) modE)rn world prosents many opportunities for activity for women in the comounity at large beyond tho home. Many mothers come to parenthoo,d wi ih an experience behind theD of purposeful and satisfying activity in some employment situation, They niss many of the satisfaa'tions in their ,roles at home. Might this in some casos havo sono bearing on their deficiencies as parents? If so, what are the implications for us? Changes, in f ,'mily functioning and patterns of living today call for now facili ties to help with the problems which new conditions have created in countrilis like Australia. Kindergartens, baby-sitting services, housekeoping services " serve an undoubted need. Interesting questions for discussion are: Should the oo=unity adapt itself to the changed state of the fM.ily ~nd hO'Wcan",i t come to the help of parents sa th:1t they C3n do well tho important job they have in hand? . . ' . What is the aignificance of all these social factors in relCl.tion to the parent*s part in the child's developm9nt? How closely related arc the social stresses which h('.ve boen described to difficul tics showing up in child development? Which p1.rents are affected ~y them and whichtarc not? We await scientific work which will answer thcsequestions for us.' Two thillGs call for attention. The first is'the provision oi'sel'Vioes of vc.rious kinds to help pnrents in our Western cu:!. turl? There is a good cleal of clinical evidence to show thnt the qur.lity of parental care in sooe cases varies with the s::J.tisfactions parents are deriving from living and support given them. Social hgencies and fhild Guidance Olinics do see great inprovements ±n family atmo,sphere as mothers feel supported in an understanding rel"-tionship with the social worker or clinic tear.!. SOl!letimes this support is associated with helping thomothc'r work through involvecl feelings, with all<l,ying anxiety," increasing confidence and acldine to knowlec'cge. Sonetir.ws this is not so; interest on a less intensive basis nnrl shnred concern bring goo(l results, e.g. with mother's groups in v[l,rious settings. It would appear that a nUr:Jber of parents in our community need support of this kind. ' The seconcl area of concern lies in the community. Much has been said of stresses =d strains as they soem to be affecting the family of today; but in a paper on "Family Patterns in Western Culture" it woulct be wrong to enc'. on a note of gloom. Stresses do ~xist anc, create problems for parents in chilc1 care! but ~hese are probler.!s which are the products of growth and change. We are aware, of' them a.ncl concerned o.bout then; they should not continue indefini tely, for they are probloms about which sonething can be done. "'" If, as appears likely, thero is some relationship between inadequll.c:t, of opportuni ties and satisfaotions in social relationships in the cOml::luni ty ancl quali ty of ])<1.rental care, then action to :prevent personality naladjustment will not be adaquate unless it concerns itself, not only with the individual responses of discontent and resentment, restlessness and the like, but ,nth community conditions which are creating them.

•

4>,

,.. I

-",'

- 51

"'1;HE CHILD AND THE COMMUNITY IN

SOUTH EAST ASIA". J.F.Bulsara. 1. The subject of the t~lk comprises r~ther n v~st field difficult for one man to cover in any very satisfactory manner. Further, the speakeri~ not a specialist in any subject and speaks only as a goneral observer, who had the opportunity of going round the region in the course of his official duties. He claims no study of the region from the standpoint of the subject of. the Seminar, and what he has to:~a;y will have to be taken only as one particulnr viewpoint, to be amplified, reviewed, '-corrected or cOlllIllen ted upon, as the case maybe, by tho country-wise participants and the specialists, who have studied the. theme in general and the problems of ench of the coun1ries in particul!ll.'".-

The subject of the talk is divided into four topics, viz: (a) (b) (c) (d) General background Specific points of interest Values and Techniques . ,--~

• -

. (a)

Gene,fal Background:

3.. Most of the countries of·the SouthEast and Far East Asia region, except Japan and Thailand, have achieved their independence only recently. Most of ' them except Burma, the Philippines and Thaila~d have very pressing food problems to solve. The per ,capita in take of food ranges from 1570 to 2020 calo;t"1es, as against, 3000 in Western countrios, although, the need of the former may n~t' be as large owing to climatic conditions. Thero is a limited ltiversificaiion of agriculture and the milk production is extremely low except in Japan, it ~eing about f<J)lr to six ozs. per person in India, and much less in the remaining oount'ries of tho region. Food production has lagged far behind the growth of population, in the last decade the incroase of food being <ft, n.s c.gainst an increase "of l~ ,in population. 4. OVerall litcracy ranges from 18% to 90% in the countries of ~he region, except Japan, which could bo~st 98.5% literacy among the,~chool-going population beiore the lnst World War. The pergentage of literacy among females, however, is less than half; and sometimos one_third or one-qu('.rter of the o.verage literaoy in the country, mothers thus being at an advantage or disadvantage according as one looks at the type of prim~ education received by them. '5. Public health and medical services are scanty, although, they are gradually increasing. . At present the ratio of trained allopathic doctors ranges from 1 to 15,000 and up to 50,000 of population, !o'.nd th9t of nurses from 1 to l5~000 ~m(l up to 1000,000. population, Japan being blessed vii th :one},q.Qcjtor to about 1200 population,-a ratio perhaps hieher than that of some of the Western countries. The training feoili tie~ are equ21ly sc=ty except in Japan, which ~~aims to have developed facilities for training 2000 to 3000 doctors per year as r~!inst a few. hutldred, in India. 6. If the above be tho condition vl'ith regard to: the fundamen-t;al necessities of nutrition, literact and medical care, it'cnn be imagined what attention would be given to the more complex subject of I:lcntl'.l health, the recognition of the importance of which for tho positive total' ,hoal ~ and sanity of the m tion is of recent growth even ,:l,n advanced and inc.ustrialis'ed countries of Europe and ,',.!:~':~:.:_: '\.:;.':':,t :t ,,"-" ,; ~

... " ":.

!', '

• ,

~"-.'

... , ~.,

America. With this paucity of study, research and promotion in the field of pediatrics and mental health of children in Asian countries goes on equally, profound paucity of the study of pSl?h?logy, psychiatrt and psycho-analysis and facilities for the .. tral.m.ng of needed personnel in the psychiatric and related fields tf mental health. . With the introduction of increasing public health and medical servil:!es, death and infant mortality rates are falling fast in all countries - in some they have been halved, in others reduced by more than one-third in the last decade. The birth rates however, remain the same except in Japan and the survival rate :'s shooting up. The ratio of children under 15 rises as high as 40% ef the population in most technically retarded countries as against 27% in semi-industri~lised Italy, and 21% in highly industrialised England and Wales. It is computed by demographers that if the present birth-rates and death-rates continue, the pOpula~n of Asia will be 7000,000,000 in the next one hundred years and that tf India and Pakistan 2,500,000,000 with n density of 800 persons per. square mile. ~. The immediate and urgent problems of ASiancountr:ies in the next few years are going tobe increased ter-acre per capita prOductivity and pO~lntion control, coup ed with increased education and better he th, with all the economic, scientific and .ultural advancement and community organisation and d~velopment that such raising of the ov~rall standards of living implies.

~b)'·ipeeifie points of interest: .

A few points of interest pertinent to the topic under discussion may be alluded to here:

;;-

i. Though the subject of mental health of children may not have ref'leived the scientific attention thc>.t it deserves.in Asian .ountries, it cannot be denied that its importance is as fundamental to Asian as to any other group of countries of the world, for the s~Pl&tao~ 10ng recognised in ~ll cultures including of of Asia, that lias the tWig is bent, the tree is inclined find the ~hi1d is father of the manll'not ignoring the other or dul.y prevalent proverb - "like father like son". This is a popular WRy of ~aying th&t the first few years of thechild 1 s life are most significant from the standpoint of laying the foundations oftp.e adult's character and p8rsonality with the ~ualities, attitudes and habits of mind and body that they impLy or include. ii. E~cept for Japan, Asia being nearly 85% rural and agricultural, the tempo of life is comparatively slow and the extent of psychosis, neurosis and ins2cnity, appears to be ouch less compared to the proportion of similar C2cses in highly industrialised and urbnnised western communities. (It may be a mntter for argument whether we would be justified in inferring from this thnt the proportion of mental heaJ_th in Asian populatiort whntever we understand oy it - is higher than in western countries - pe.rticularly that part of our poise which enn."hles us to understand sudden shocks or stresses or strains. ) 111.

There are certain traditional traits and customs of child rearing which seen to be widely prevalent in Asian societies. To name a few: (a) The average ~hild grows up in a joint or larger fnDilYi

;

, ,. (b)

It remnins for n muoh long0r period with the mother, is brenst-fod .:'.s a rule by her, n.nd the breast-feeding lnsts 2.S long ns two to three ye!:l.lr'S, and certainly ten to twelve nonths in an overwhelmingly large .. percentnge of feniliesj very' '. ~ ( c) Fron/o8.r1:y infancy it hp.s n :much closer associtttion.; being and movemont anong the younger and older nembers of the fanily kinship group 1 nnd the ir:modiate' neighbours, and is on tho whole nuch fondled ~d loved by the o.dul ts ('.round it; . • ( d) In the villages ::\s anong a Inrge nunbar of. url;mn. i'ru:rllies there is on the whole, loss conscious , atteupt on the·p<:'.rt of the nother or other elders in the fa:nily to interfere with the child's growth and developnout; thore is nuch less ~onscious design to bring up tho ('hild 2.ccording to any preconceiveq norns or notions, though it if? told M9- taught.gener0.1 ·rules of behaviour valued 1;Jy the group OJ;' comnunity, such as respoct for cIders, gratitude for. gifts, filial piety, obeisnnce to the fanily or cOIIDunity gods, . , good nanners as understood by -the eiders, aridiiri 1:!:iated early into the ('enily chores of life according to the child's ~G and co.po.city. ( e) 'Anong the rural and less sophis:ticated fahilies, there i~ by an~ large greater ·tolerance of the child's spontaneous activi·tios anclbelk'\viour, partly owing to tradition, pnrtly owing to ignorance, partly becc.use of gen8ral imlifference nnd preoccupati-on of the. mother in the heavy chores-of the home and fam or . factory; . On the who~e, the child in rural andagrinultural societies anc~ the lower or poorer strata of urban cOIIDunities, helps in the daily cho.:rcs of life and enters into the adult ways much earlier than in Western cormunities, though this is a diudnishing phase as civilization becones nore con~~x - ~this being a good Q i':f.3 IC, t to the wid.ely prevalent. laok of educational facilities in rural Asia; The ratio of urbanisation and the consequent proportion of stress and strain beinK,nuch less, the force of tradition nne. public .opihion being stronger, the psychic life a't--a'lower level me.king for nuch less inconpatibility' of tenperanent, and the wonan working as hard as the nan, the rate of divorce is cOI:lpare.tively low, and the incidence of the tramla of separation and broken hones nv.ch lower with regard to children. They can grow up more nornal and better integrated than in fanilies with enotional tensions and instability; The denands of the cOr.ll~unity fron tho child and fauily are less severe and the struggle' for individual existonce and advancenent does not take on the forn of a keen conpat1~icn as in industrialised corrnunities, becnuse of the low subsistence level at which life is lived and easy satisfaction found for el~JentarydaaireEk The ddvine discontent of Western society is conparatively less narked, paltly perhaps because of clinatic conditions and largely because of the fatalism and

(f)

(g)

(h)

and resignation with which one's station in·life is viewed these being obviously ~ouble-edged weapons. (c) Values:

10. If the above picture of life in the hone and fauily and the status of the chi1c and the corcounity in South. East Asia can be taken as approxinately accurate for purposes of discussion, the question arises as to how far would the Asians thenselvcs be eontent to go on with this life, and. how far would a change be desirable or acceptable? We cnnnot consider this problen of ~ultural change a~~ values without unacrstanding the dynanics of 1I0cial life. Viewed e.s a society infl.ux thct Asia and other less advanced regions present, we find that even within a single country and connunity in touch or contact with another or others, changes are constantly taking place in the econonic, social, cultural and politi.al fields. Cultural patterns nust be relatively stnble for any society to subsist and function, tut they are neither pernanent nor unchangeable. Further within the sane society, there are seotions and incdvicluals who do not' Clcnfo:rnt whOlesale to the traclitional culture~ patterns. Tine, cline and circu,nstance necessitate changes in attitudes and custons, in beliefs and ritual, in nores anG. nanners - which nay have been built up to satisfy ~onten porary needs and noet local situations. In a general way, the incUvidunl level of tJ1inking undergoes change with variety of experiences, and with increasingknowlGdge enotional attitudes give nore frequent place t~ rntional ones, and nagical behaviour to natter-of-f2.ct activity. Applied scie:"lce begins to cover an increasingly larger field. One has a feeling that this is going on all the tine in every hunan society at a slOW or rapid pace ae~ording to a ganut of ('onditions, economc, social, psychological and cultural. It is hap?eniug now in Asia and at a rapid pace because of a coincidence of i:tlternal and external nircllustances, whi~h one finds rather difficult to go into in the G0~"_1'sO ofa brief talk. The pace of change is going to bo nore rapid than sone,tired or~luggiSh. ni~ds nay like. because of the. new. factor injected\into socJ.a! chnngcJ.n the twentJ.eth century, VJ.Z •. the replncenent of... . drift by ;1esign.. Groups anc~ societies have 'tastec1 tho e fruits ~ planning - not only individuals but groups and societies are con~~ to feel with a greater degree of ~onfic1ence that nan is the n~ker of his destiny or the architect of his own fortune. Perhaps a part of this s·elf-2.ssurance nay be nis?lacc;d - sone of the fruits of planning have been as bijter as sone h:cve been wholesone. The student of so('ial change th'-1refore, proceeds with caution anc. hunility th2.t all 'true knowledge and science and intellectual integrity denands. He together with his collaborators in varied fields of knowlec1(Se, science ancl technology can nuster up a good cleal of usefullknowledge rend technique of social change, but as a true 800ial engineer he adni ts. his lini tations ariel noves with caution and circw::lspec.tioi~ on the steac1y ladder of gradualness and. not on the electric escalator, or the flying wheel.

'i'l

11. A further factor for change in the Asian as in other regions cannot be ignored. It is the high state of readiness and rece~tiv i ty for change that has. cone over Asian peopH,s' becrl.use of their ir.mediate historical past and their close associntion with the fast Boving Western culture of the G1Gctr~c age. This social phenomenon of rapic1 change is also as olel as tiid''''G~her one of inerti~, sluggishness and resistance •. There are seC'hons of the self-sane society that adhere to the one or the other. Social scientists have to consi~er these vnried forces in their survey, planning and execution if they nre to nvoiC. c'o,ngerous results and repercussions. This woulc1 bring us to the consL~erntion of the ctifficul t subject of 11techni'lucs of social change. ! • I

- 55(d) ~eolm:iique s

12. Before we can talk of the teohniques of promoting mental health in -.hildhood. in Asian countries. we will have to assume that the' ,peoples, their leaders, or substantial sections of specific communities do ap?reciate the need of mental health for their children, and that they are willing and prepared to invest in personnel, institutions and equipment that they may 'be required for the purpose. Without entering upon a lengthy discussion, we can say that there' is in every Asian country considerable interest in child care and development as their'substantial contributions' to UNICEF funds and keenness to draw upon various WHO/UNICEF projects for infant and child welfare indicates. The interest in mental health of several of the countries '1:l!l be seen also f;rom the presenCe. of the specialists in varied fields at this se::dnar, and the instituti'OllS like Maternal and Child Welfare centres, Child Guidance Clinics, instruction in parentcraft, kindergartens, nurseries and like, pre":,,school centres for ohildren, Mental Hygiene. Psychiatric and Psycho-~nalytic Associations, etc., ,_ established. in them~ What the proportion of expenditure on the promotion of mental health will be in each country will depend upon the interest of governments and voluntary organisations. There is no doubt that for every new idea or movement, an important and useful technique is of pioneering.by individuals or small groups of interested people and experts in the field. We feel that the pioneering stage of the promotion of mental health MS already been aooomplished by IIOW in most South East 'or Far East Asian countries whether represented at the seminar or not. 13. The difficulty that may be confponted now would be the wider disseminat-

ion. of the knoWledge, accumulated by countries which have made great advances, amongst various categories of key personnel concerned with the medical care and education of parents and children and the treatment of cases of mental illhealth. Here we may consider the vascillation that has been expressed by some of the participants in the adoption of forms of social behaviour which ~s foreign to their own cultural patterns and the adoption. of which, they fear~ may lead to unhealthy or unforseen results. introduoed disixl.tegrating features ~ t.heir social patterns and disrupt sooial and cultural values. Th:is fear may be well founded if we are trying to adopt rr.ores from one tQ another which bears no relation to the new milieu, if the introdion Qf the alien. behaviour pattern will disturb the social or familial and equilibrium, or the adoption of'the new system will so transform t normal structure of society that its members will Vehemently revolt against iV' F~ example, the j.ntroduction of meat diet in a vegetll,rian society, or Qf Uquor in an abstaining cormmmity. We can. therefore, consider this aspect of' tec~que 91' alien importation only on the merits of each more, behaviour pa~~ern. Q+ value. While diffusion of culture is a wellknown phenornonen known to all ~f us, it would be unscientific to generalise on the advisability or othe~se of the transplantation of any particular alien trait, pattern or sys~em Of one culture into another.

•

9ulture

14,

15. But here the cUltural t.aits or to be Of uni~ersal int~uc~iQn would

question, it seems to one, is not so much of adopting behaviour patterns as of scientific knOWledge, wb:j.ch seems application, with due adaptation where its application or change very much the acoepted mores of a people.

To take bne exnnple by way of illustration, if soneone unkno~~-· of~rilk a day to every child in the region for its hG~~thy growth, not one country in the region with perhaps the exception of ~apan, will be able to follow it. Neither is that quantity of nilk produced or likely to be p~bduced in the near future in the region, nor do the peoples of the M(;>ngolian stock like drinking it. Besides many social and eponollie dis,turbances will follc;>w in the wake of such a' step, witlt nore haZ'ards introduced in 'the socie-economio and cultUral life of the p60pte the.n the renote benefits that nay accrue ~' It, ' should i rib't however be forgotten thftt Japan was in a sinilar si tuatiOiioruyaQou t thirty years 'ago , ,and today. Japan produces " sufficientnilk for"her needs, and ~apanese"children have gained i.nnenselY in:physicol growth, strength and rosistance to disease, whi.ch !:lilk proteins alone a~e st?-ted to give. " ly advocates the giving of 16 ozs.

-15a..

If, howeve:r, the studied research of scientists shows that -theOhlld's persoIlc'1.li ty can be tenporarily or pernanently injured by incqnsidcnrte behaviou.r of parents or elders irrespective of ~ul tliralpatterns,_ its application would be universally desirable in so far as all races on o[1.rth lova children imd would like them to grow up as heal thy, 'socially integrated persons. If). 1-1; will be useful also to look at another aspect' oftechniquein relation to disseni~tingthe knowledge of nental health and the application of its basic principlesanongst th(;)parents and the general.run of citizens. How we 'are to do this with the help of various:catcgories of trained personnel, through appropriate institutions like schools, clinics, connunitJ centres and rural ... communi ty organisation and developuent projects suited to the :r.'OgiQ.nal countries, using all, the available nedia of audeo-visual andotheJ7km.m aids will be considered as a separate thene. of the semip.ar,and I need not therefore dilate on this aspect of the technique here. . --"J ., ,

-:;~

• ..1

'::.'" 'f'

." ..

·-"1" ".~ 'f"' i

... ,;. ,

!. ,

"""

".'

4•

CHAlf}ES IN AUTHORITY. AND CONFORMITY OF CHILDREN (JNAUSTRALIA) by , Gladys E. Pe:.dred

Introduction --The difficulty of presenting a picture of the relationship between -parents and children in our conununity is the absence of serious·-research on·' the Australian·TamilY. There is iri"onnatIon relatIng to·'residence, religion, occupational and economic status·; ancl·-ethnic origin but ho stuClIes have been made·'on psychological attitudes nor on environmental I1conditionningl1 due to living In urban or IUral areas. n,e .naterial in this paper, therefore, is based on a purely empirical approach. ' The 'iuestion·'of authority and cofif'onnity poses a fundamental problem that faces a COJnmunity that believes in a democratic way of life -to reconcile the needs of each child to develop his own persona1ity~' at the same time to equip him to be'-able to take his place in society and to get satisfaction from contributing to its welfare. ' _. ~.

·;e know that a child, by reason of hIs humanity, is drawn towards other human beil'1gs, to begin with in the person of his mother (or mothersubstitute). We believe that the quality of the relationship w~ll be a·' vItal faCtor affecting his relationship with other people. We have begun to understand something of the stages through which all children pass on their road to·'maturIty and are beginning to appreciate the wide range of ihdividual differences in the maturing proces·s. This kl'1owledge suggests two gen_eral principles of mental nealth with un~versal application which Dr. Gundry was asking for in his openil'1g lecture:(a) the basic need of for emotional security; _. each individual _. _. that social demands for conformity need to be adjusted to indi vi~ual 11 make-up 11 and stages of developmen~. -

•

(b)

We have seen that each society accepts custodial and _educational care of its children. That the family, whether it be the large "kinShipl or the smaller "domesticl1 type, acts as a miniature _soclety~-- preparing the child ror the larger community and that t:,3 satisfactions ancl·-dissatisfactions, the successes ana failures he has experienced within the home circle go with him, influencing ~is later behaviour, for good or ~ll. Characteristics of.the Australian f:.milf for the first guart~r ce~u:ry.

·-Z:immerman's classification, "domestic" - i.e. parents and children of tel') grandparents; father, the head of the family; authoritarian attitude to children - affectionate or he-rsh - acknowledgment· by children of parents' authority (some rebellion·-but general obedience, reinforced by rewards and punishment); some differentiation in treatmel'Jt .between the sexes, boys allowed greater freedOm in outside contacts, gi.rls expected to take same part in home-making and to enjcy quieter games. After W-orld War I, a £-reat many factors led to a growing awareness of the importance of the individual. r'ew ideas began to circulate based on the rE:search of the team of workers in the field of child·'devel~pment ., abroad. Emphasis was given_ to·-the importa'1ce of childhoOd and its relationship to subsequent adult personality; child rearing began to be thought of . as a science, with experts to tell parents what to do. -" -. Much of the infonnation which reached parents was of an authoritarian nature, based on standariiised tests; i;;mphasis was ofte'1 on_ particular aspects of growth or behaviour and parents tet'lded to seize on the aspect that had most meal'1_i"g to them.

Somewhat later, certain ieeas becaue acceptecl and began influenoing the practices of a number of parents; the importance of well-balanced meals and of regularity, (by the clock), in all phase., of physical care - (Infant Welfare Centres were becoming Gstabl::'shed rapidly and played an important part in this field); the belief that repression of children was responsible for personality maladjustment in later life and therefore the old authoritarian attitude must be replaced by greater freedom for children; (the fact that this principle ran contrary -to the new emphasis on "habit training" was not recognised); that conpanionship of a child wi,th his peers was important to his social development and should be provided for; that companionship and friendship between children and perents waz enriching to both. These ideas are, I think, now generally accepted by parents ~t all socia-economic levels. These cha.nging attitudes have not affected everyor,c, to the same degree. The older generation were brought up in the oarlier tradition, which is sometimes the cause of conflict ,nth grru1uparen~sJ also there has been no sharp break with earlier practices, new ::'deas may be incorporated, or grafted on, but old ideas still influence p·ract:JJces. The recognition by the com::l:J.ni ty generally of the importance of children is refleoted by the provision of a large variety 'of books especially written and illustrated for the pro-school ch:i.l d, by the wide range of good play material available, much of which is based on that designed by kindergarten teachers; the space 'c-"',·'·\ :1.1 daily papors and magazines to articles on child care; the broadca.st sessions planned fcr pa.rents and the "Kindergarten of the Air" programme for children in their own homes; the provision of selected films on Saturdays, etc. Authority Today. In a report"not yet publis~ed, on the Au~tralian family done by the Psychology Depo.rtment of the University of Meluourne, for U.n.E,S.C.O, one finds the family structure dividod into three gr·oulls.(As thisfull report is not yet available, the findings could not be incorporate>'. in this paper). j

Autonomous - Husband acts and decideD a.bout an activity by himself Wi::e II 11 " n" 11 11 herself Autocratic Syncratic

Wife act.s, husb~.,d decides. Husband acts, \v2..I'0 decic10s. Co-operatlv@

'l'hey both act together.

Where authority is shared by both par8n~s, it has given rise .to the problem, which is acute in s.ome families, of cli.l'ferin:; concepts of discipline beld by each parent. Since the d,~sappe[l.ra.nce of c.0'nestic help, many young fathers now take an active part in t.he care of the c:ll:l.V.rGn ch.lring the hours the fathers are tl.t home, but a grerct doal c:f aFi,;writy is '.ested in the mother. In the area of physical care thers is still a genera.l pattern of conformity expected at an early age, though a more pernissive attitu<ie is developing. The standard of physicC\1 cm.'o 3.t :111 socio-Gcono'llic levels is, high but the number of children showing problc'll", of e,,-";1r: 6 C\::1 toileting suggests that there is too much a sense of urgency :',n o~r SOCi2,1~,8iw,: prOG308. The possible effect of early condi tioning in late:::" ailu:o. t ?ersC'''',':,l~ 7.;," is disc'cl.ssed by Hall iday in his "Psychosocial ~Iedici~'lG'·. £0 pointo 't:t ',:1~ 'n..lue of tho early strict hygiene care ,;f infants in reducing tho p~'ovio',C:~IJ2!alJ,ingly high inf[l.nt mortality rate, Vihich h[l.d been sX1)P0tci, buJu y . . ~ oi'::ect of modifying the :foundation of personality struoture lJ,",(l" no'.; l\·](L, foreseen. He discusses the areas of depri«l.tion ancI c,;"1.::i~,;:;,, "l. t 888tnc' r8~sonab18 to surmise that the changes in the conditioning 0::' i:'fo.;l'i;s d::'cl not bogin to ::ecome widespread

..-

...

59' until after 1920 at least. On that assumption, the incidence rate or' psychosomatic affections could not be fully affected by the alteration. in the milieu of i!'1fan.cy until after 1950 at least-; It may;" therefore, be concluded that in so far as changes i" the risi!'1g incidence rates of the psychosomatic affections, their full effects in, this respect have still to become ma"ifested." ~orit.v is exercised the mother am older members" of the famiJ.,y in the area or-personal propertY". "T""is is more noticeable in the middle class hcime than that or-the lower i!'1come. (Our society places great emphasis on perso!'1,al property, 11'1 the family as well as in the cOllllllUnity.) -. -. ~. ~.

The young child, with hiS i\'\9istent "need to investigate everything withll'1 reach, has to face marw prohibitions in our small suburban homes with ,their multiplicity of objects am tidy well-kept gardens, . 'planned primarily fOl'Mults. If a mother has understanding of the iiriport.ance of this early J,.earningi then she reduces the prohibitions"to a minimum and applies them . reasonably and consistently. The chilo then has the security or-knowing what he may and may not do and learns"to conform-to the family pattern without strain, rather with conf idence in his' growing ability. For the things he may do, with the attendant success of maStering new-'skills, outweighs the frustrations, especialJ.,y When-'dohe-'in-'the company of a mother who respects and appreciates his growing independence. If there is constant frustration. some children learn to associate coiiformity with passivity, lrgoodness 11 with inacti:vity, except for a few sanctio1'\ed outlets. 'fHe's no trouble!" If this child comes, later"to kin<iergartel:1, it often takes time for his natural urge for activity to "break through", -'when it does, the instability of behaviour that follows-' suggests something of the control the child has previously been exercising. Sometimes, by 4 years, ~"here is a cO!'1si~tent withdr~wal for a long period.

", other Children reber-'- "He won."t do a thing I tell hiiri u • This child; 0\'1 e"1tering kimergarten, fs OTten at fIrst very resIstant to al'ly kind of authority~' but he is usualJ.,y"'full of zest in-'participating in all the activities al'ld often. develops il"lto-'a leader among children. What happens -, later to"these chilaren if their only experience of authority is a coercion ,'Which denies them"'an outlet for their normal activities? Here authority leads"';: not to conformity - but "to rebellion. Are these children later, "' t.he il'lnovators, the ~eformers and artist~ in our so~iety, or the delinquents? Authority operates in the field of personal relationships. i _ . . .

TAis seems an artificial diviSion as personal relationships are i"'herent in the-'area of phYSical care and personal property already referred to, rut has been isolated as showing an area in which children have to .' learn to adapt primarily, to people ::-'not only in teI.'llls of basic relation:: ships but also to the traditIonal manner"s and courtesies to-'which different par~nts give varying importance, dependIng, to an extent, on the socioeconomic class to which the family belongs. Parental attitudes. During the""early years,"the "climate" set by the parents has a profaiind influence on the-'childfen. When there is 8.ffection in the home, a genuine respect for the individuality of children and a sense of values by which parents consciousJ.,y direct their own lives, one finds them sharing these goal:{'with their children. "'If there is tolerance for i,malaturlty but stability'in the dayby-'day guidance, the parents own example and supportive authority gIves children a sense of order and direction."' Have we here a third ge"1eral principle of mental health? that an atmos here in,which ther is a hierarch of value is\conducive to mental health b rovidi a ke or mechanism b which conflicts ma be resolved.

•

;

.....

.,,'

:F'· .: ::".' .~~.

"". ' :

. hier~rchyof

-" ' .

" 'Iilien tl:lis v<llues the .home, .one,' " oft'en finaS"thatthe,stardaras expecteqof ,childrefJ.; and for which they wa~ pUTushed if they~aii., i&.' conSi.d~ra~ly,~ighertha,n those .pr~ctiseq., by, the ,~. oarents" s'6 that there ,are two d~st~nct sta.rdards of eth~cs o~e:.ahng; Chi1dre~ in thesefaiziilies must be faci~ a sar-ies' of confl.ict~ andd~~~, illusions about the yalu.es that should .~~ve ,~oherence <1M. meam~ ~.o bf~ • . . " .. _. .'., , ~,' ~.

i$'··~btd·em.~~~t:t~t~·c~n

M~f~-'bhildr~n today, than formerly , 'suffo;: frblli.the·,llicons.~sten ..: ; ....;.; ... cies of parenes :who ha.vediscai'ded'the old"authoritaria~ atti~u.de, ;:.fl#."!;.::~. varioiis reas.ons,',bu.t'wpo: have'noclearprinyip~es on wh~ch to bas~ t'h:e~r' t, m . ',:I", ..,'." guidance.·lfu11y'cif these"parents hava a ,hieroil.rchy of values and theory to obta'in'ooedience"through cooperation. -'But they seem unable to -.. .... bring hemseiv~$tci the point"of 'thinking out sound methods to gain it,' They let the 'children takecontrol,the:n wh7n ccmformity is !equir.ed, . '. ., barg<linj' suggest,,?ersuade and, nag ana ultimately fa~l ~ck on"the ola,authoritarian attitud\,fwhenthe limit of endurance has been reached. To an' ext~nt coni'onnityhaii b$E;n reachea l rut thechiI<i"is left in confusion. These parents have no realisation that ,children need adu'lts to set liiiiits"to behaviour aM that rules framed in relation to recurring situatiOns amto"tM child's stage of development relieves him.-' of unnecessary strain, ,A few" , years ago, the em.pnasis was teaching parents to say "yes". Now ~tWbuJ4 ' appear that sotne' neeq ~elp inwhel'l to sa~ "No'~' James HymE!S d~sOJ.sses this ",' ... , ;in an article "When to,Say,No to' Your Ch~ld" ~.Q P.:-..rel'1t's M.:lbil~~ne#, Jafti a I7,)'19,?--" ..

wa::

,:~

J I

'-' . • -.

"....

c-,.

_~_

• ' ••

szureki'>1 nPublicHealth is Peoph" ~kes"a distinctio!,'l between . , ' , ".'''',::.L "authoritarian" ancC I'authoritative" - "Authoritarian" "- the coerciVe powe.r.>C-',:,L:l~" ,cc.::,:exercised by the domi"ant person primarIly for his own, rathe:r than thesub-: ,<', ordit'late's immediate gain;"- "AJ.thoratati ve" - where the authority':deriv6s'" lCJ:: • :;' t~Dm superior competence ,an.d sKill, the purpose b6ing t'o p'romote and,..' fo'stet' ' ..,~, t.he acquisition by the subordinate of the competence am skill of: the,au:~horfti~ ,," " ~, Ttle relationsnip is cl1aracteristic by flexibility of attitl.ldes'·coupled wl~fi')' f;irm co!'!sis/:,ency:~ ,·,jTh~ir, COllllllon effort is ,to';grow more like, in respect to" ' , tne power which the c,ompetence brings and eventually to achi~ve equalityatld genuil'l6 freedom of e~cho,t;her". ' ,-' ,': "

j'tad

How faroah this"be achieved in the ,pre-school yearB? .U tJa~nt't'c, this objective as a lq~tenngoal,'hOwcould it ii1fluen~practic~s.:ln' ' ' ,," the early years? ' ..

ThGre is also a certain number of parents whose expectations of behaviour Is far too high ,for the child's, stage of development. '. These;>arents are over::anxious and benae, are afraid t'o trust their own intuition and af~ection, a~' constantly press children beyond their ,ability. General Qommunity Attitudes. 1. ., Our authoritarian attitude is seen by the way we cleal with emotional problems. The general temency is to say"to the child ",you must be ••••••••••• kinder to youIt~litte sister", or, "less angry", etc. We press for outward -canp~~nce .~itheut h~lping the child to face the hostility or fear or anger that ~s mohvat~t'lg h~s behaviour. Sometimes, we deny the reality of the emotions and worder at the "kiss to say you're sorry" that turns into' a bite! Or!. we,dismiss the",~oti?n ?n mo!.al grounds, that it is ""rone"; ,therefore, the cillld must overcome ~t, how, we are not sure, so we leave it to him to fInd out. Is our non-recognitiqn of this problem because we"tend still to be' in£lueHc~d by ~he 7olllllloru.y accepted beliefs of an"earlier generation to whoal' the concept of amb~v91ence would have been shockIng ~ and that too few of us have been trained to face the 'destructive 'emotiol'1s in our own lives with at,,:,. ,.,' least some degree of honesty? ., A"characteristic also of our-'society is tm,t we tel'1d to rely too much on wOrds, ge"'erally ~ with young chil~ren-'as a methoq7t1i.ilding appropriate fonns of behav~our. Obv~ously words are esset'ltial as a ,~eil!3 of cQIUlIUnication rut" there is far too nttle appreciation that what children feel about a s1t~atlon largely, detennines their"behaviour. In recent years hascame the broad

- 61 .-

recognition"u.r the conununity of sCientific concepts of physIcal health and its importance i"1 the care of yOung children. Wrw.t is urgently needed now is the broad recognition of scientific Co.,cepts of personality development. This might be considered as a fourth,.general principle o! mental health. "

''".

The cr~ticism that is often levelled by the general public against pare..,ts who try to relate their demands for behaviour to the child's stage of develop!i:ient suggests:- (a) that the concept of the l1good ll child as one YI.Iw is well-ma"..,ered a;u docile, sUll persists; (0) that far more needs to ~ k:1'I.own by the cOirununity"concerning maturation and characteristic bi;ihavioiit' of children at different age-levels; (c) that a great deal of C01'1!usj.orl , exists as to what are the ultimate goals to which the training of cb,Udren is directed. Miother attitude, which I thHik is relevant to this problem of authority ard conformity, that is"growing in our society is that more prevision should be made for opportunities for pre-school age children to meet in"groups for play am a"wider social experience than can be provided in marty of our hOmes. Parents, themselves~' are the prime movers in establishing pre-school centres, recogl'l.ising that many of the"problems of behaviour that arise from a child I S loneliness or restrictive environment can"be reduced by the child I s attendance at a tentre for a--few hours each day~' and that through the close association that exists between teachers and parents, both ~ develop deeper insights i~ meeting the needs of children. The importance of children's play. It is evident that in any home in our society that a young Child faces a series of situatiol'\S in which his natural behaviour"is constantly bei,",gO'mCidified and directed into culturally approved patterns mariy of which are unintelligible to him. ' We cannot make life free"from te,",sions, they are il'levitab1e and provide a stimulus for growth but we need to be alert to see that "pressures are not too great. stresses can ocCur or-which the aault may be u,",aware, but by watching a child at play, we--can often get some insight as to whether--this is happening. We can also learn a great deal about the essential ..,ature of childrer1 - the types of aCtivity and experiences"that give them deep satisfaction, the--way they idel'ltify themselves with and interpret their environmel'lt, their concepts of time and space, their sudden cha"ges from reality to phantasy, the way tfiey"relate to other children, how they react to ;;ew situations, to frustration,"and failure as well"as achievemel'lt;' their concepts of moral values, ther- kil'1ds of things that engage their attention and the use they make of them. Watching them, we realise how differsnt their world is; it is related to ours, but has a reality of its OWl'l.. It would seem as if the principle of fiomeostasis can well be applied to play for this is a childrs way of mairltaining his internal environment - his "inner world" - stable.... ul1der varying external conditions. _. -' .. _. o , o ,

• What we learn from watching and listeni"g to children has relevance to"this question. of authority and conformity, for the understanCiing we gain oan g~e us In our expectations and help us to adjust our demands to a child's p.ersoflalitY"nd,stage ?f development. " 'In ConclusIon.. Conflicts provide dynamics of growth~' but i f they are not integrated into the child I S total personality, they can lead to undue stress. A child needs the conc§pt aro presence'of authority. He is not able to carry the responsibility for his actions alone, but needs support and guidance, and only through the presence of authority, is he able to develop guiding ideals.

,THE CHILD IN RELATION TO THE COMk1mITY. Summary of Theme by Professor R. Firth. It is difficult to distinguish this theme clearly from that of the Child as an Individual, particularly for the earliest years. Moreover, since I am no expert in' the study of children, I may be oversimplifying some of the argu~ents put forward. Since discussions on this theme are concerned so much with the nature of community relationships, it was natural to expect that the regional differences of experience ot the members of the Seminar should emerge more obviously than in the earlier talks. Significant differences in family structure and community values have been shown to effect the development and welfare of the child.· A relative deficiency in total resources available in the East for developing social services to aid the mental health of children has been ~n important element in the discussions. And a sense of urgency at the rapid and gross changes taking place in the Orient has tended to dominate' many of the contributions by our foreign visitors. On the other hand, the immense amount of common ground has been very noticeable. The importance of the theme which may be .expressed as lIiss Pendred put it -- to reconcile the needs of each child to develop his own personality, and at the same time, to equip him to be . able. to take his place in society and to get satisfactions from contributing to its welfare -";"has been recognized as 'basic by a:n participants. To the question of whether there can be any fundamental principles of general application' in this field, the answer' is ce~tainly yes. There is general agreement also, that these principles, £If! for example, when it is a matter of distinguishing stages or levels in the development of a child, should be elastic in their conception, not rigid group norms. Both East and West are prooccupied by their practical problems •. In the East, a larger proportion of these deal with the changing conditions in rural communities. 'But in the east as in the west, the prob10ms of urbanization and industrializationuX'e felt to be acute for the welfare of the young child. Both East and West emphasize the changes that have taken place even in a generation. In Australia, for example, marked changes of attitudes to children can be seen when the Edwardian period is compared with the present day. Yet, there iS'somo questioning as to how far patterns still remain.. For example, is the father still not kept in authority by the mother Who uses him as the ultimate court of appeal in the family, partly because she, herself, does not wish to assume responsibility for what is traditionally regarded as a male role. From the East the question, a worrying one is asked; is the tre.nd to modernization, and in pnrticular to westernization, inevitable with all the tensions which seem to accompany it? Can some traditional values be retained? Here the harshness of the modern c ontrA-sts may soften in a 'generation or so, as the example of Chinese family life seems to indicate. The time factor of generation change in itself may be important. Some western opinion has tended to feel that the desire for retention of traditional values was rather like wanting to have one's cake and eat it. On the other hand, I think I detected an impression that westerners, while rpcognizing their advantage in public institutions, feel that there may bo something to be gained from the experience of their eastern colleagues in the family treatment of children. A rather wistful note seems to h~e come up in discussion of the relative permissiveness of the eastern handling of cllildren. Some basis for this, perhaps, is given when one hea.rs from the Philippines that rarely are preschool childron brought to the Clinic with problems. But it is important to recognise tha.t values cannot bb transferred in a simple way from one cultur0 to alother. They operate in elaborate systems and selection and r"ejection wi thin the system is most difficult. Moreover, oach community has its own responsibility for the decisions as to what will ultimatoly be accepted or rejocted.

/2 ....

... ~

A few methodological points may first be made about some of the methods' of discussion of tho theme. (a) Methodological Points. (i) need for more research. 1.s tho discussions proceeded there came a growing awareness of tho impressionistic ni1.turo of much of the data presented. Even though based on the very wide experience of most of the members, most of it was not systematically collected. Middle class intellectualistic practices were often cited as if they were general. Magnitudes were often not given to the problem. At many points then, there came recognition of the need for surveys to study just how children actually behave. As Iviiss Parker said, "We do not know how common f=ily patterns are". A suggestion with possibilities made here was that clinical records of parental histories etc. could be made more systematic and assessed'in order to give some dimension to the conditions described. These records should be taken for "normal" as well as "abnormal" children. Different approaches often led to similar themes. For example, one group came to consideration of the need for Community Social Centres from a discussion of education of men and women for parenthood. Another group came to the same topic by considering what could be done to provide some interests outside the house for mothers -- to check what was described as the monotony and loneliness of full time domestiCity, to give her social contacts without diverting her full time activity from the home. (It may be noted that some distrust here w,-::,s expressed by some men that prOVision of craft functions might enlarge into a moneymaking device for women and so to some extent defeat the purpose) • Much of the argument proceeded by opposition and to some extent resolution of alternative elements in what approached dialectical methods. For example, it was suggested that changes in child rearing practices over a generation have created anxiety in parents through their uncertainty between the old and the new. On the other hand, it was suggested that this anxiety may have been there already in the parent's person~lity, that the parent who is uncertain because he is anxious may well himself have been insecure, in any case, in his relationships. Again it is argued that in applying controls to the young child, consistency is important. But on the other hand, it is suggested thct such consistency may perhaps be most fruitful only in the earlier years; that in the later years, too much consistenoy may not be stimulating enough. Or again, the question is raised, should one tell a problem child that he is a problem child. The first reply is, no, certainly not. Tho second is that ~t ages rather about six years, many children arc a.t least semi-conscious that their treatment is different and that they are in a sense a special problem. On tho ottier hand, it is argued that while the child knows this subconsciously, he rofuses to accept it. "md finally there is the point that perhaps the parent or other adult owes it to his own sense of honesty G.nd to the training of the child in honesty to explG.in the situation. The resolution of most of these issues is pragmatiC c.nd usually in terms of compromise. Such compromise often in discussion m;,y SeOG1 at first heilring to have the flavour

(ii)

. (iii)

•

what is colloquially termed a "bromide" -- one of those obvious truths mean nothing in the abstract and that send send one to sleep. The statement that "parents should assist t:le child to develop in accordance with his capacity" might come ncar this. It has meaning, only if there are recognized ways avnilable to the parent for measuring his cap3.ci ty or h,wing it me.Lsurcd. Yet, as one ponders on them these words take on sense. I think it is important to realise too, that, in pragmatic clinical situations, these compromise statements, these smooth generalizations, may if accompanied with other advice, be excellent means of helping parents. (b) Content. In the discussions of the theme, a number of important concepts vrere revealed. The Seminarseema content to have accepted thG virtual identification of" society, culture and community given by the Anthropologist for ita purposes." "From the Anthropologist's point of view, there was little examination of what is meant by "family" when the term is used and. of the different type of structure which can be considered under this head. But the focus of attention being the young child, family structure as such is less relevimt than type of kin or household relation to the child. The content of these relations could perhnps h~ve been investigated further if time allowed. " But the concept ofp_ermissiveness was scrutinized and seen to have a number of different contents each of whicih implies .:l. somewhat different meaning or degree of operation - as in breast feeding, toil"et training etc. The impression of permissive behaviour held by people external to the culture was not always substantiated by members of the society concerned who participated in that culture.· 110reover, permissiveness is a term which should be applied to freedom from restraint in specific fields of behaviour Dnd not used as (1'1.o.b81 for the quality of a. cuI ture. There are no "permissive" c'll tures. All societies impose rest;nints in some fields, and"those in which most leniency is ShOV.~l in the very early yea.rs of childhood may be very harsh -:;0 the later yeLlrs. " One group spent some time or the examination of love. It Vias recogilh;ed that this concept is differently defined, (though I obtained. no definition). But the practical point at issue was to stress the importance of not simply using the term ;flove;f as description or injunction in r~ -to a mother's ;Jj:,jelltion for ;,er child or a nurse's handling of it. Some~hing more empirical is needed to describe the bodily actions which should m:1nifest love. .'g.J.in love is not the onl~' thing t:lat 11 child needs. Sense of apprecia.tion, sense of achievement, sense of n par~icular quality and intensi ty in the mot!c"eJ?' s rplp.tion <;0 the child are all stressed as important to it. The community bears 011 the mental health of a young child in many WCLYS. PostmCLn, milkman, little boy next door, 1:.Jigabour's dog, mc.y all help to form his values, affect his social contacts, contribute to his fruBtrations ,=d anxieties. III Bummarisin" this whole theme, I have selected t~rGe main fields ot relations.

...

Specific Community Organisations. Discussion o't:j:nf'ant ~f.a.re~entres,_ Pre-.Sohool Centres, Spastic Centres etc., has, come at many pO,ints lin a discussion and M~ss Pendred in particule.r, made reference to some of thelli. ~tailed consideration of that belf'ngs, probably, rather to the later pl~session. But oertain problems of interest may be considered. / ' One is the poss~ble effect of conflicts in values ~r in answers t. questions between sohool ald homs,how far do these affect the security of the-child? This type of problem, : flal t keenly as important by some of our fl'lreign visi t,.rs, is probably greater where e,ducation of a Western type is newly intr.duced and the parents are still traditional in their rutlook. The example ~f ~e United States is of interest here.' Parerrts tliere, who have emigra~ed.;from Europe, have, learned much frOm their children at school. But in this case, the pe.rents wanted to beoome American and have had gre,ater reoeptivi ty to the acoount of their children's experience and new evaluations.,' In soine O:dental oountries, on the other hand, the parents' .'do not necessarily want to beoome anything else but what they are. The field of possible conflict here is open, and examples may be f,und in differences of training in personal hygiene. The inference in this is the need for a pe.rental education programme. Such a programme has begun in Taiwan. It needs co-ordination between teacher and,parents - bringing the pe.rents, :bf need be, into the school. (This links up with a point made about Australian Pre-school 6entres that possibly is more important than immediate contacts for the child is their aim of facilitating parental contacts and parental education. A second pr.oblemwhich points a thought towards the Planning Session, is that of cost. It may be crudely put a.s, "What is the worth of a child in the Community"? Put another'wa.y, what proportion of the total resources of the community is devoted ,to saviilg and aiding children? Such economic magnitudes are somtltimes not considered in emotional appeals for children's services. But a. question is asked - if only by financial administration, are there pri,.:d ties in children? It is sometimes asked: Is:it sound social thMry that where r:nly very limited funds and personnel are available, it is better to spend them on healthy children? On this, one may oomment how far is the modern western awareness of the problems of children a reflex of the relative scarcity of children? Preferences are certainly expressed - maybe in expendt ~-ure of ml'lney en children of soho.l years over that on the Pre-sohool child. i'ht if the period 0-6 is so vital, then should the very young child not get first financj.al pri~rity? Or is it that the State does not beliE!ve the psychologists? The comment has been made that the State is impressed by survival and so supports Infant Welfare Centres. Butthe Sta.te as yet does not appreoiate fully the importance of what may be called emotional survival. A further thought here is that proper therapy at an early age, there may be greater savings ip institutional provision for the otherwise unfit, qui to apar-~ from the economic gail! of productivity of people restored to $oi-ivity. The Home. The major field of direct community influence on the child from 0-6 is the home. This means in most eases the-/fl'\lllily. So much in fact is the family a filter mechanism for the ~mpact of the community on the child that the ti tIe of this part of the seminar the!OO might well have been the "Family and the Communi ty". It is at least as imyoriant -to improve the emotional condition of the family, as of the child as such.' This v'lew, puts the young child in a. constellation or cystem of social reI atio"\13hips , prima.rily those of kinship. And from this point of view, looked at cross-culturally, "family" offers veryva.rying conditions for the development and security of the ohild in different

•

parts of the world. Here the presence of our Asian visitors has been of great advantage to tl:Ie Seminar, in bringing home by a wealth of personal experience, some of the main types of family structure and organization. ',be al'ranged ,under three heads; (I) the cons titu tion and working of the

,'Of:i'the ,ma.rl7 problems discussed by the seminar, most in this field can , elell!srita;iy·.family ~ the "eternal triangle" as I rather provocatively called 11; of mother,fl'.th<:lr and child; (2) the character of motherhood and the possibil1 ty and scope of more diffuse and/or sUbstitute mothering, (3) potentialities, controls and conformity, in the fcmily circle '. ...

....

: "../

Asrega.rdli the elementary family, there has been support, of a rather 'I/lodifi;-edkind, for my view that not only in many Asian-Pacific ,cultures, but also .in Western. cuI ture., the role of the father has received less a.ttention '. I th<U). ,-i:~',lII'i1ri 'te. .,The importw.nce of the father is recognized as giving emotional and' e<;i,orioOlic.- securi ty to tho mother. It is held also that the child has a need, up 1;oal:!out 3 years, for known persons in his social enVironment, and the f~tner prcivid,~~ one ,of the most useful of those. And from about 3 to 6 years tho 9.~.ild' s growing awn.roness of the mother and fil.ther as ,\ couple, ,1 uni t, with complementary authority and roles in the home, is very importo.nt. Here .1;he 'fa.ther is viewed, r<:.ther .Jessimistically, r.s L1. complement to the mother ra1ih.erthan in the more positive role he fills in many Orianta.l societies. ~uthe is important also as ,l.n object with whom identification oan be made. ;>::i " .' "

, On this basis it has been argued that separp.tion from the f~ther in iiestern societies - n.tan earlier ,:;.ge than, say, 2 years,c<'l.l1 result in only superficial damage to the child - thoueh, if he returns, there m£l.Y be additi'onal damage through rejection of him, if approJ.ches are incautious. Later separation, if prolonged, between about 2 and 5 years, may cause more severe damage to the person:::.li ty. For the mothe,c.', it if! held, the reverse may be the.case. It is the ~nrlier period th~t with her is so important, and later seperation may be less damaging. This l of course may assume very . different levels of intensity as between athtudes tOothe two parents, 'the severe damage by later loss of the father may still be~though of quantitatively as p.erhaps less than that caused by later loss of the mother. ,. The Seminar on" the whole seemed contc.nt to accept the notion of the, "eternal triangle" as a sociological ril-ther than a melodramatic concept. The qhestion was rightlY"raised P..S to whether communal settlement relations in 'Israel ~d elsewhere have not effectively broken up this family unit. But i t was shown that eVen here the time spent with children by pa.rents, even with the establishment of communal creches, mainte.ined the autonomy of the elementary family relations. Still, definite threats to the stability of the element::ry family can be noted. In the East, many modern influences have this trend. To mention only films _ the sOllhistic~ted film, with sex empha.sis, is held to promote a life of bachelorhood free from marital restraints, and an iJ.rtifici'al' sta.ndard of living whe~e motor cars and mistresses replace provision for child care. Again, with tho disa}JpG>arance of the trc.di tiond concept of marital jea.lousy convenience is given to extra.-marit~l liaisons. These are serious problems. Breaches in the structural unit must occur with widowhood and divorce. The la1;ter was discussed under the head of "broken homes" or "broken families". This term was interpreted by some to cover &11 c~ses of regular dish~rmony between pllrents, but by others, more usefully,l foel, to mee.n only cuses where there is physical separ~tion of spouses, witheither log31 sanction or definite social recognition of the fact. Where em olementary family hilS suffered from !l.

~ ,

bro,'.ch in the h·,rmony of its int0rn.1.1 60ci,11 rol~tions, but still· functions as iJ. uni t for resic.entin.l '':lld probn.bly economic purpos6S then the concept of a "break-down" in the f·~mily seoms to be acc0pt·able. ' In l'c.g.J.rc'~ to divorce, ,1 newsp<\por ". fow days ago listed quarrels over the upbringing of childron ;:unong the frGo.uent Causes of divorce. This seems pl'1usiblo. But it WJ.S ,:gr(;ed th"t such qU.:l.rre!s m.1.Y well be simply a. symptom of underlyiu!; friction, th.ore before, :.\nd taking the position of tho child .'1S .1. convenient ob.joct for exprossion. On the other hand, .while divorce itself may be the result of doop-seated tensions, the n.ctu~l rate of divorce m"y be 2, function of c more goner'll s oc1.1.1 environment. It waspointed out tha.t in J1l.p:-m somo inquiriGs showed that the rc>.te of divorce was much higher ~ong couples who had chosen one another in free selection, than among those for whom SpOUSGS h,l.d been selected by their elders. Prima. fncio this might be r1;lg.).rded 1.S evidence in f,wour of the stabili ty of the I\rranged marriage. But this is true in only a limited sense. The couples who had been able to exercise free personal choice in marriage were a.lso those for whom divorce w;:s reln.tively free. For those whose spouses were selected, divorce was highly restricted also by the dict&tes of their elders, irrespective of the amount of mari t::1l unhappine.ss i\nd any resul t on the person?li ty of their children. From this comes an import[,nt inference - that the study of marital relations,s they "ffect the mental he."l th of the young child should not concentrcte only on "broken homes;! i1nd simil"r phenomena, but should include attention to wh;.'.i 3.pPGnr to be ordinary frunilies.

•

( 2)

Character of Motherhood •

The problems of the character of motherhood have received considerable led In part by my own citr,tion of m<,terial from non-.isstern societies showing how the sorvices of mothering tend to bo distributed through a set of women members of the kinship group. EVen sucking can be got from n woman other them the biologic \1 mother,. though suckling in the sense of a protracted lacta.tion arrc,ngement between infant a.nd woman, is restricted to own mother. The general view of the Semin.:::.r seems to havo been r"thcr cool towards the notion th.'l.t tho services of motherhood - and. f described motherhood, in early stages of child's lifo, ~s ossenti.:::.lly an gggregate of services - could be eff6ctively divided and shared to give full effect to our idea of all thn.t is implied. Mother-substitutes, if they ~re prepared to give the child ample and properly intimc~te i1ttentions, CM ':'Ict as :J. "next best", but never fully replace. It was stressod th.',t where there must be l, mother-substitute, consistency in hor relationship is most important, change tends to insecurity in the child. ,~ttention,

Yet the groblem, I think, still remains of the advantages that may be gained from introducing the young child from birth to the intimate care of a wider range of women <'-nd men than he hi,S in an ordinary ~/estern society. associated to some extent with this difference in the view of motherhood is the opinion th,'.t modern fi1D\ily in the West -- at least in Austrnlia _ .. is "r..tomistic". By this is !lIcant usually th:<.t it is residentially isolated, with kinsfolk often far ::1way, apd relations with them neither frequent nor intense. In particular, these relations do not usually affect the mental health of the child. The mother's mother may either provide a pattern of child tr~ining for tho mother herself or compete with her for possession of the child, but the impression is that those rel~tions are not common enough to be generally ·----significant. "' sub-developro6nt of this view is thl1.t the "atomism" goes fuf'ther'-: that the members of 1m elemento,ry f;,mily have e(~ch their own occupJ.tiono.l, recreation,11 cmd other interosts "'hieh so fril{;roent f.1mily life thi:.t the conti1cts~ stimuliltion .md socurity of the child nro limited <~ccord.ingly.

.. '.'

lie now come to tho very import=1t problems of .controls. These have m.l.ny complex ,".spocts. But tho Semin<u h<'.s nQwhere seemod to hold the tradi tional vi~w tht'.t discipline in i tsolf i~ ,1. good thing. One view hl'.s been that for the child up to ~ months treatment ~ust be m~inly·pormissiv6. From 6-12 months there cem bo .~ gradual introduot;ton of mO;J:'e controls as the ohild is able to take them. This thome of temperi~g controls to tho stage of ma.turation of tho child is reg<o.rdeclts being 'of cardinal significance. On the other hand, no view of the validity of oQmplete permissiveness obtains. Within this general pattern of thinking, thore ,'l.ro vi.rious emplnses. One is that there .lore frustrations whioh must come into the life of the child. 1!. very simple example quoted is the ~one of the ohild "crying for the moon". There is even tho view that frustrations are not only necessary but are actually dosir"ble for tho dovelopment of tho child. Yet frustrations should not be introduoed arbitrarily "for the good of the child". Along these lines, it is felt that after a point in development of the child's behaviour in a given field, decision may have to be tuken by ~he pa.rent - that the child needs guidanoe in the development, say, of his tastes. Another empha.sis somewhat alternative to this is th".t the child Gxerts his own controls, and mainly by identification. He imitates the behaviour of his parents and it is primarily in securing this imitation that the parents can achieve th~t end. In thinking ~long these lines it seems that imposod controls are likely to be unsucoessful. ~other fQ~m of expression of this whole p~oblem is briefly a.s follows. Tho porson~lity of u young child in a large degree is ~ funotion of the personality of its ~arents. It depends then on the existence of harmonious relations between them. If rcL,tions ~rc h"rmonious, then identification by tho oh ·.ld is en.sily secured ,-md there is need for only a minimum of other controls. If relations are not h.lrmonious, then more negative controls are required a.nd these may be stultifying. (I sf..ymay _be.cause like most of the propositions put forwnrd in the Seminar, this is expressed only in terms of pr()b"bili ty and not of com;plete a.ppiica tion necessnrily to all cnses.) On the other h;:md. i f haZ'l:llonious r~l:1.t1ons' exist then a Wider degree of discipline is possible, the p,1.rents will be .,ble to s'E-cure the co-operation of the child beyond the r:l.nge of identifioation.MoreOvco:', control should contribute to security not insecurity. lience a very important element in the applico.tion of controls is consistoncy, on'lbfing the child tofoel some suroness in his relations over time.

(0)

Coillnluni ty patterns ,md Values.

I pass now to 0 briof discussion of some of the community patterns and values as indirect influences on tho child's mental health by their influence on tho paron ts. Hero ,,-s a genere.l quali ty, one can po rcei ve the growing ilW11.reness by the community dt 1.'1.rge of tho significcl.nce of the problems of the young child ~nd the noed of some cohorent methods for tackling them. Planning for childhood by modifying the Dt1.rental environment is now t1. sonscious J.nd i1.rticul·~to process by the State - the repla.cement of d.rift by c1Gsign, as Dr. Bulsar::! h,"l.S put it. Of the mnny issues hore, I mention only a fow, a.nd briefly. In the discussions, tho impression has emorged for me that much in 11estern community lifo ?.nd il.lso in the changing E"stern community life is thought to be hostile to or a.t le?.st difficult for the development of ha.rmonious parent-child reLc. tions. Tho enormous complication of the modern technologicn.l and economic organizr>.tion is 2. thr" . . . t to the en.so nnd comfort of parents and so rea.cts upon the child. One m.c.y mention hore only tho stress of long tr'l.vel from homo to work p.nd b,l.ck in modern trr,nsp'Jrt conditions in oi tics, or tho gre0.t problom of tr,l.ffic noise in urb'll'. life. ¢?orh,\ps "1.S 1l.Il offshoot from this is the thou(~ht afton stressod in tho t:;omin:'.,r· tha.t while enrly psychi.1tric,-.1 d·:,t,'l. tm1de<l. to s'tL'GSS the complo:!:i t.y of modern o;dstencG, tho

.. failures in m(l.teri;:>.l and fnmily ?C.;,lS';Il1ent, :1.nd F,0 to create nnziety, most mod:ern psychi2,trists strive fo:::' more positive affirmations which shnll build up p0l'!fidence in parents and ohildreh.) A linked theme here is the problem of the multiplicity of :objects in the gene.ral environment of the young child in modern conditions. :Whereas the broa.d tendency in all our discussion is to suggest the need for simplification of emotion11.1 relations and of oontrols, the modern community tends to complioate rather thnn simplify the material environment of the young child. Does this matter? Opi'-:tion here seems to be that so long:J.s the many objects do not shift :1.round too much in his neighbourhood nnd are relatively stable, their mere number does not tend to cause confusion in him and contribute to his mental maladj~st~ent. ~oreover it is also pointed out that even very yo~ng children quickly attain in modern conditions a familiarity with quickly moving and possibly cOnfUSj'1g objects, such as motor buses and aeroplanes. On the other hand, 11 somewnat different view is that in play therapy it may be simpler for the ohild 1::' the objects in his immediate environment ,~re few -- it is easier for him to make his identifications then, than if he is confronted ~~th a large number of objects. The occup •• tionpJ. struoture of ::.. modern cOlll!llunity is very significant in this whole rCl.llge of problem. Work relations are felt to be of very great importance for the mother of the you.~g child. The Western pattern is expressed in terms of a girl having a job, leaving to get married and having ohildren. What, then, is to be her rel2.tion to a.ny future work outside the home? Here v~rious p~opositions have been advanced. One .is that the young moth~r misses the comp,-mionship of the girls she knew in the factory or office. Her earlier experienoe in industry often lends her to be dissatisfied with motherhood. Various expressions of the monotony and difficulty of looking after young children were given. It was realieed that some of these were exaggerater1., but +'hat nevertheless, they did express a real pro1)lem. b. COll'llllent on this (by Dr. Gu!.c.ry) was that there seemed some incons~atency in the fresentation of the situ~tion. Why should girls who, when at work, so often complained of the drudgery of the factory fly to the equal drudgery of the tome? This seems to indicate that part of the problem lies not in the situation btlt in the inevitable contrast between the ideals and fant,l.sics of the inC') -",idual herself an.d their realisation. But as a practical consideration, the Seminar seemed to feel that the mother of a child under five should nOigo out to work. Therefore, the setting up of day nurseries should not be encour,~ed. It is better for the community so to provide for the mother thn.t she does hot have to go out to work, even if she belongs e.g. as [l. widow, to one of the more vulnerable economic categories. (~his, of course, does not affect the creation of _ Infant Welfare Gentes or Pre-School Centres, w~ich have different functions). It was fel t then that the:>:>e is need for no'll f:1C11i ties such as Community Social Centres to cop'; wi tb +,hi s problem and provide outside social contacts for the mother. Part of this probl0m ,:~s I see it lies in the difference between a rura.l nnd an urban environmEmt,::.t lsc.st in those communities where small agricul ture is still the pret'i.omin,'1nt form. j, peCl.Si:n t woman tclces her child wi th her to the fialds and Pl:--CS i t unc:.:~r ['. trae, corning b3.ck to it constantly to give it a.ttention. The womr,n V\'crki!',g in ,: fcc(;tory cnnnot put the child under a machine nor. give it frequent ,:-.~+,cnt1.on7"'.nd tho outco:ne is the da.y nursery or creche with their well known yroblems. !

I come, now to the lc~st point with \Ihich I cen den.l, educ:::.tion. The very young child needs only" sme.ll r.mount of Elducntion in ...!!:e conventional sense of the word) or ~t leGst this is comprised under most of the various topics we have discussed. But ~ven before the age of 6, ~rt.:.in questions do :l,ris'3. OnE> is thO' possible conflict between whtl.t the child learns at home and who.t hE ma.y le:::.rn frem ·J.bout the :1.ge of 5 onwo.rds at school. iUlother is the import,mt pre'-blem of ths teaching of moral values and in particull1r the most approprinte age at which this teaching should begin.

But ()iluc."tion fer parents mc.y be 0. problem of equal moment. Some form of assistence to pc.nmts in eV:l.lu:l.ting the needs of their children n.nd tryine; to meet them W:J.S n.ssumed to be of v:J.lue. The stage at which some form of tr.:1.ining should be given for motherhood is regarded as a ver7 importa.nt question. Here there are some diverse views. One is that :::. lot is lost by trying to teach girls too early -- say under the age of 14. But it is argued a girl of s:::.y 11, playing with dolls, could be interested in some of the problems of motherhood. Against this, it is held that motivn.tions are all impQrt:mt in thie problem, n.nd that motiv;.'.tion for motherhood i1t this stage is not reali it does not become effective until later. A fairly firm view is th"l.t educ::tion in mothercr!;.ft should be a defi~ite part of prenatal care. Another more eclectic view is that there should be different types of educ~tion for parenthood ~t different stagea, but that some type of tr:lining should opem.to "t all stages. I ma.y conclude this review wi th two questions raised in the Seminar. 'I'he first is, is motherhood after all the prime aim of womenhood and should all this urgency be directed towards tra.ining to this end? But this question, unanswerable or meaningless in a general context, is already met in the particula.r conteAt of this Seminar. For our purposes, motherhood is aprerequisitc for our dinaussionsj we assume the positive answer.

does 8.11 the prop:lganda directed at mothers with its institutional accompaniment of pren.J.tal clinics, infant welfare aentres and the like, tend to cre:J.te rather'than to allay anxioty r.bout the :ferils ~md difficulties of child bearing and child rearing? Can it in some measure prc~ote the mental ill-health of the child? There is some feeling thnt while the bro:J.d positive value of all this work is patent there is' some evidence th~t this question has significance and deserves attention.

A more difficul t question is this s

•

. ,

- 11THEME III ..~.

THE EFFECTS OF SEPARATIo.~ 9.!~ YOU!~G CHILDREl~ Alan Jel1.nings.

The subject "Separatio:in h~s been placed i~ t~e t:heme,nB~a:viour Problems of Children", so will be discussed from the po~nt of new of the adverse effects it--may have on. personaliti-development. It has been said that the significance of humal1. living is il1. the acility to relate satisfactorily to other humal1.s. '"The first al1d iiiost'-fundamental relationsnip is to the mother. Anything contributing to an abnonnality or a deficien.cy in this'-relationship should·be studied carefully and the results evaIuated. Recently, there have been a"number of surveys conducted in Western cultures, on the effects of separation of tne very"young f.rom their motfiers,' by Gessel ... and Spitz In America, by Bowlby in England and 1;r. Roudinesco in France, while Goldfarb am others have related certaII'1. conditions to separation in tIieir retrospectIve studies. It is mail1ly on t:hese surveys that the following descriptions of the effects of separation are . _. _. -. based. _. c.

'"There bas been wia.e il;greement amongst independent workers and their conclUsions indicate that Infants· and young Children a.eprived of adequate materMl care may suffer in their physical and emotional development. It is difficult for an adult to imagine the feeling in a young child··when he'-has lost the care of his mother, but the film "Grief" gives some indIcation of this. Tne reactioYlS to separation vary in degr'ee. They'·do 110t occur in every case andt;he'-following account is of the grave reactions. The syiriptoms vary'· depending'·on the age at which separation occurs, its duration, the mitigating -factors and the state of the child's emoti0118l development at the time. The role of other factors is less clear. _. Little is known of tfie reasons that sOllIe children can tolerate separation better than others in apparently similar situ8 tions • . , Infants .in tlieir first half year of life~' When separated from their mother and"left with on.ly routine feeding and cleaning become listless," immobile am emaciated; they sleep poorly, lose their sucking habits; and there is an increased susceptibility to illness. 'This may aevelop insidiously. It is not seen in the fir5t few weeks Df'~ife when provision of pnysical care appears adequat;e, but .it occurs in varying degrees after tliis. In the most severe reactions, there is a drastic fall i'1 the development"quotient, l'bich may 5e difficUlt to overcome, even when the child's situation improves: The i"fams respond well'·to a mother substitute, such as a reasonable amount of nursing and a~tent~on du~ng this p'er~od. When separation"·occurs in. the second half of the fIrst." year, after the mother has been recognised'·as a particular individual,. infants react at first. wiUi weeping and apprehension. ,- This may be followed cy a severe depression,. with arrest of developmem, loss of"acqulrea functions, a reduction of responsiveness ard. a rejection of tne environment. Provided this is not too ad vanced, there is rapid recovery on return to the mother. A mother substitute'-h~lps co mi,,3Jnise the reaction, so does allowing plenty of ,activity al'1d giving plenty of a~tention. Some infants of this'·age do riot react in this way to separation, the tie to the mother has been poor and they have lacked the capacity to relate well, -- -_. Separation in the secord and third year may be tolerated i f it is for a short period. However, the r~sponse is usually just as severe as in the first year and is accentuated because mother substitutes are also rejectea. The child under three'·is very'·intolerant of frustration, egocentric and unless there has been some interference with his relationship with the"mother, '-his depeooel'1ce on'·her is at its iriaximum. This refers to children in Western -. ~

- 12 communities-- ani the situatio" may ,_ differe"t with failiily patterl'ls in which--the 0"0 to tnree yeo.r olds ere roared more by a number of oldor siblings the" by an individual mother or mother sUbstitute. -- -, Even the most skllled say t~iat they -are unable to--prevent regression in--this age--group. On separation the child may- show an i1'1.itial phase with corifusion and anxiety. He weeps, refuses food, calls for mother arid may stand violently shaking the cot. After a few hours or a few days, this may change to despair and the child becomes withdrawn, apathetic a'll de-·' pressed. -, Physical activity is--reduced and--the child makes few deiIi.ands on the attendants. This may erroneously be interpreteCl as diminution of the child's distress and he is--thought to be settling In. Later he may appear to recover and show more interest in his surroundings. He will look for comfortifrcm people other tha,,'-his mother. He may'-be·'able to adopt a subst itute -and build up a relationship, or he may, finding no substitute, ., relate only in a·'very superficial way-.- He will show little feeling when the parents visit, in"'fact, he will show ""0 real feeling for anyone. He is in a .state of "frozen emotion". :'If he returns nome after a few weeKs, there will"'be, in the "iinfreezing", a confusion. of hate and love al1d the demanding behaviour of an insecure child. If the relationship--in the pre-separation period was good, much ··of this will still be prese"t and with understanding and tolerant helP:, tIle child will settle down, again at home. There may, however, be ui'iderlying al'lxiety \'Ihich is, reactivated at later separations. If the unfreezing is met by host~llty, the child may be --driven to further protective mechanisms. -, _. _.. _.-. If the separation continues ana: the state of "frozen emotion" pe~ sists, it may become irreversible, leading to a character defect, when the child is unable to respond to or reciprocate affection, though he may crave it.

. "~n the histories of delinquent and disturbed characters, who show - j no-'apparent a1;iility to love or feel guilt, separation from the mother for a l.ong period in- tlie first years of their lives appears a pril!le cause for the faulty development. Such defects are notoriously hiird to treat due to the i"ability to relate. Children Who have suffered long periods of isolation develop isolated, aiiocial persot"'lUties •. This maY follow lack of opportunity' to form an attachment to a mot.her figure, early institutionalisation or frequel"t changes of foster pare!"t. When there have been periods of deprivation followed by periods of satisfaction 1':'. ambivalent, antisocial character may develop, the sep-aration facilitatil'1g di~turbances at.,later separations. Separation may still be--serio:.ls i",.-'the three and four year old groups, Dut the wnerability belgins to decline. These children can have the situation explB:ined ~o ~hem, ani the! are mor~_ to~erant of frustration. Explanation and careful hardling can minimise the effects. At this age the better the child's relationship with the parents the better he can cope with separation; the ~nsecure child has his conflicts activat~. -'Five year olds and over may be homesick, show poor concentration .' aMd vagueness'-after separation, but they are better able to suspeMd relations· with the parents, -. to take them up agai!'_ on returro. -.. These -investigations h::.ve int'-i.6ited the major reactions to major degrees of separation, more is to be learnt or-the minor responses to minor degrees of separation. Relatively little-j s known why some children can tolerate separation be~ter than others, in apparently similar sItuations. That scme do react to a lesser extent than others should not minimise the efforts to overcome ~aternal deprivatio~ whe~ possible. -What happens to cause the chal1ges In the--children described in the surveys and show,., in the two films "Grief" and IIMonique ll ? Only ·an hypothesis ean be put forward, a'X! dynamic psychology gives us useful mechanisms for consideration, which are helpful for an approach to cli,.,ical work.

- 73, •.

Tne infant at birth, thougtl a>1 ii'idiviCiual, has no persol'\ality organisation and his relatiol'\ship to the 6·wironmel"lt is a physiological one. Re feels in telutS of tensions causl~ wakefulness and relaxation which all~ws sleep. The environment is mainly the mother or mother sUbStitute"who iSo,not sensed as a separate oDject, but part of the infant's gratification pattern. The psychic system Is not differentiated from the sanatic. Towards the end of the first six months, the ego beginS to differentiate out of the psychosomatic id, with the development of ~onscious perception and memories. During the very early period relationshIps areo'il'ti.tiated and stimulated by the mother. With the development of consciousness behaviour becomes pleasure seeking and unpleasure,avoiding. DLirlng the first six months the'infant iso'establishing"arelationship with one clearl,y"identifiea person arid he learns toO'differentiate himself from her. Deprivation of maternal care in the period can cause the physiOlogical responses, (shownO'in "Grief u), to the passive craving for satisfaction am release of tensions. The mother is not clearly identified and adequate and°' consistent care from' a substitute appears to overcome the effects of separation. from the mother. _. -. 0'

In the secord halrof the first year, the ego develops in response t.o the demat1ds ;for adaptation frOOI the e;;vironmel"lt. The sense of being separate from the mother develops with increased activity and ability to initiate"'relationships. There appears to be a radical change atO'thIs stage as the infant°'can now feel aggression. Loss of the mother, after a!'l°:init1al state of anxiety is followea by feelings 061' aggressio",. It he can act' out -, these feelings aggression, or if he can initiate some substitute relat.Ionship, he can De helped. If he is left his aggreasive"feelings grow to consume him. Being unable to release them; they are turned on his own""weak ego. Tfiis causes the depressiVe reaction similar to the"mechanism in adults, with il'lhibition, regression arxi"'denial of the environment. The susceptibility to i:l,.1iiess and' the wasting conditIon fias been cOmpared to suic1cIe intfie adult. When established and t?ere is no interientiol'1,; the depression does not"" "" appear to be, self limiting •. , Regression al'ld inIiibit.ion can reduce the infant. to idiot level." This is shown il'\ the film."·uMonique ll • Moniqueo'and two other O chIldren are ' shown .at what appearso,t.o be an imbecile level,. One child' 0,

denied the enviro\'lJ!lent to the extent she was thought to be blind. Subsequent treatment showed, these children not to be imbeciles a tYl to be capable of mum greater development • . ..',' . just as the egoO'developsih adaptation to the physical environment. so adapt.ation to the hUJl)B.n eiiviroiiment "leads to the development.' of the ' 0' super-ego,"the self-regulating conscience. The curbing of instinctual demands and t.he renouncing of the pleasure princIple for t.heo'reality principle is for the sake of the relationship to the parent figures and depends on a healthy relationship. , In the secooo am third years, as t.he ego is mOre developed and the super-ego is developing, theO'child is Jt his peak of depende"ceo'on the mother as an individual •. Separation at this time causes il'ti.tialcraving tor the mother and a~ietYI with Qostility direct.ed outwards. The child mB¥ then be overwhelm.ed by tilehostillty with reactions of despairjthe despair may beOOtlle intolerable and apparent emotional"'bluntlng develops with the inability'to relate minor disturbances or a Change of routIne mayo'cause the underlying anxiety to break through theo,veneer of emotional blunting. If the chilo returns home, the hostility is acted out. and there is demanding behaviour until the relatio1'!ship is re-establisned. If the state protective IIfrozen emotion" becomes established with inabilit.y toO'relat.e and identify, the affectionless character oevelops, the super-ego being improperly formed, conceptual thinking is interfered with and the usual ideals are not introjected. 0' 0'

O. At iEiter ages, witfi the establishment of the reality principle, o cO'"lceptual tfiinking and a sense of time, a child can cope better wIth periods , o! separation, ~fJ however~ there Is complete absence of' one parent figU~ in

the home, there ma,fbe an interfHence with the process of identificc,tion, it maY 1e&d to' an in~reased- atta.r:hmert to the remalni~~'With -ambivalent. __ _ -..f.e.e.lirgs which may interfere ;1ith non:"] devel0~ .~ . --. . ., - ~ntere~-to CO::lfli~b .-:r.:eaot..io!"ls_·-at these various ages to '. unsatisfactory p!lrent--chi1d r~latic"1ships stemming from other causes, ·'e.g. - the autistic child, the p'rod'~ct of ~xt,rejlli:;lly co~d or emoti~na1ly absent parents. ,-

From the eviden.ce of recent sLlr"eys on separation, it seems safe toassume--thar.: prolonged separation may cause--suffering in all below three years old, in- ,llany between._thre~ an.! five, c.nd i~ a few o~er five. Tfie frequency and causes of the sepe.!'ation of a child from his mother at an -early age vP.:"y- in diff&ren'.;. cultu!'es. In Western industrialised communities, w)-;era family mob~::.ity is !~igh, the family tends to be a relatively small isolated unit comparsd wHh rural fa;nilies where many relatives are at hand to help ifthe·-mother is i!",capacitated. This places greater respo"sibility on the parents in .i6stern cultures. Separation may bE; caused·-by the cidId b€.ing removed from home-'by a s9c:iA1 agency or for medical reasoYls. It may be caused·-by death or illness of the mother, or the family breaking up with separation of the parents, by desertion of the child or by·-socia1 .lpfieavals such as war. Relatives may not be there to help or may to help. .. be unable _. or unwilling .. The question is how can its effects mitigated? sep~rdtion

'.~.

be avoided, or if unavoidable,

When a substitute f~i~ly is required as with an illegitimate child whose mother -is unable--to car;;; for him, early adoption. within the first few weeks , is- recoirunended, with as lit tIe institutional care as possible. The i nf;'3.'1t Is' probably·-best matched to the aio':J'ving famIly on the grounds of ht;reaity, infant testing being'-inaccurc:te for. prediction. T_o say a child is u';_fit for adoption is to·-deny ld.!:', a hO!!le, Carefld selection of adoptive parents is required, with knodedge .of why tbe.7 'Nish to adopt a child. Every effort·'should be mado·-t,o keep tfie young child home. The mother without a husband and with young children should be helped. If a mother has to leave home through 111l'1e3s, c. relative or hOusekeeper who"takes over·-the management of the home, is better tha'1 dispatching the children to an lnstituti-on.·- Agel'1Cies s-hould be ready tD help chiIdren at home rather than in their institutions. A bad hOi:J.e is hetter than no home, and before a child is "saved" from a bado-home, the alternatives should be carefully evaluated, whether they mea" inst_itutio,.,alizc_tion or frequent changes of foster·'home or t1Ot. Hhe'1 a child goes to a foster·-home, sOille contact with his own parents is recoIDmended, rather thel'1 a clea'" cut, expecting t;he cfiild to suddenly·-start afresh. TheI'e shculci be case work with both parents and foster parents. i ..hen the faJiii1y is -failing· due to parental relationships an::l attitudes, marriage and fn,;;J.J,y gui<1o."1ce may be of some avail·~ Bowlby poi1"lts out how deprived" children of broken and unhappy homes frequently reproduce a similar condition in their turn causing a _. viciollS circle. _. ~.

The hospitalization "r vert :ioL1.ng children should not be undertaken lightly. There is a move now in_ sorr:e,Vo3te 1'"'1 countries towards providing accommooation for mothers of young children ad;;utted _to hospital. With -older children the moth",r should [vi;) encouraged to Set' the child to his bed am then frequeii.tly visit him and perhllps do 50llle oft1.c'-nursing, instead of the hurried and: confused farewell at the aJmi.3sion depo.rt:nent _;.nd subsequent rare visit. Before a child is r"movtid frofll hon:3 for medical or social·-reasonS, the various factors must be carefLilly -'l3sessed and- if the separation is considered essent:i.al as much as possible should be done to mitigate the effects.

- 75 2. THE EFFECTS OF SEPARATION Andrew Peto. .. The large scale military operation of the Second·World Yfar gave a 'sad opportunity to observe their devastating effects on the mind ot the growing ·child. ·'The slightest trauma ,relatively was·;that represented by the fathex:' absel'1ce. Love as well as hate were concentrated on the mother. Ambivalence developed·'to a higher oegree. The sense of guilt could not·'develop ewnJ.v because one of the main figures - the source of helpful identi£ications was missing. A wholly unexpected consequence was that ever,Y child developed phantasies about the mother's responsibility for the father's absence. They blamed her for theit loss. Ladk of familY securIty increased the anxiety situations and aroused an exeess of aggression in many children. Extreme haroships - if they were not permanent - had only an indirect iilipaet·'upoli the small child. 'l'he following factors exerted a beneficial effect in counteracting the disruption of the·hame • . 1. A well-balanced mother gave the cliild a feeling of'"" security. Tne mother's thoughtfully protective love was a strong. barrier between the child ana'the outer world. Not·'oHJ.y reality but also the child-mother relation was an important determinant in danger situations. '2 •• ~ U the danger situation lasted over a lortger period the child's opportunity for playing was of great importance. The horrors had to b$ pla.red t.hrough. ·'This was a·'desperate effort to overcome anxieties through the r~petiti~n c~pulsion of play. Constancy·'of milieu was of paramount importance. Permanently uprooted children were"'unable to play, destroyed everything, foUght aimlessly, recovery began only after seve:.al months o~ optimal conditions. These traumatic situations were often aggravated by starvation"~ The starving ch!ld blamed the mother as the representative of the whole neglectful world. Phantasies about the dangerous mother and father imago prevailed. Food is the symbol of parental love, ir it is scarce, tbere is less opportunity to build up helpful identifications. Anxieties and subsequent dullness or aggression follow. Those children who were exposed to these t.raumat.a showed in overwhelming majority behaviour aisorders after the lapse of two or t.hree years. These disorders were often of a grave character. SUMMARISING: The mother's emotional stability is of decisive importance ~ times·'of""social upheavals. Her psychological protection vanishes in Cases of continuous starvation. The basIc hUman processes of sublimation and play activity are impedea. Emotional and intellectual development come t.o a ' - ' st.andstill. The consequences are behaviour disorders in childhood. \-

O!~

CHILlllOOD

- 76 -

.9BlJ.~P_RE:" Il~ HOSPITAL - BEF_Q.I§.a... DURING ~ AFrERtlARDS. ~ld

Mac Keitl}.

This is a picture of a on(;; year old cl".ilcC'Who weighs 9~ lbs. SIie nas a hare-lip"wl:ich' was re,paired at . 'about three months" old. She has been. in ,. hospital unC~r my care alinost continuously for 8 months. The oru..v period. in which she ga.il1ed weight weH for a 1ve<>k W:J.S when her mother waS iidmitted to be with her for 24' hours a··day. 'Ihun she"loft t,ecause her husband said he would lE.:-'.ve h"r if she d5.dl1.!t"cor.le home 'met ·"w'J.ld leave her if' she brought home tbi s cli:'.'l wnC'1ll fie disowns bc cause of t, he hare lip. Three paediatricians have failqq t:'i find any org8.nlc disorder, I thb.i{ s~e is suffering from ' hospitalism a~r.i lac~ of .rnatern;>.l C:lre. So seve::":;; a degree as this is rare, but one 'shc!J1d remember "Ghe. possibility •. . .. Ml1.y I rEmind .'lOll cf Spitz t observd:.:i.nna? Of th() 61 children without motliers, onl,v t;,[O could wah, vihi:.-a cf 69 with tfieir mothers all could walk when ato 32 ;;conths o;l.d. Thc--mothe:,:,less childrer, lost grourrl wh~n followed by their Dc~elopmenta;L Qu~ie~.

Bakwin's observat-Ions on 11Lonoliness in Infar±:sll"'are illustrated by" this chart. rhe. +Q(leliness appears to l'OOlACO the infants resistance to infection, ard his' capacity to fJ:7.L~ use cf food. . LeepJ,\l-nrkoy.·.cGme to my "Ward at Guy's to record the expressions of cnildZ:fJ~,1n ~oE~i-'H·l. Tnc: f:'..:::st , Child h~. !'7corded proved to h~ve a mother under·'tr~at.ment for psychoneQrosls, so we d~scarcled the photographs of her. . i' ,. These are photographs of tl:c nt::x!:, child. 'He was 3 years 0lP. and· was not . " . pnysiqall[iIl,:,l:u~ the first a,W"he (;idY'ot i~ant to eat. He was' Visited" .. in the 'e1.,er\i"'g~:S.ir hismot:1tlr and next day he had c:.n appetite~ . The third 'day he . was checrttil •. · . . If you talk to mothers'soon '2fter thoh .;Little chiId.ren:Jhil.vereturned from hospit:al~' yo\~will often..; o.lthough not a1.ways, learn that the child has becane clinging, won't: be left .• a10ne,wakoscrying"'inthenight, or hiis regressed to mare inf:l"ItiJ.elevel of beh.wici'-1.r, r.ot speaking, westing the bed, and so on'; T.his is true of sarno chilj~;en -who have seemed" contented enough wfiile in hO.3pitaL·· '!: he [!'.ct,ners often "ay--the child' s"increased rntolerence of fru:,;"ratiun is Ut';;,2'lUSC he :'.::'5 l)o:Jen "spoilt!1 in hospital~ bo.t . no hospitd h~·s unou.ghnur2e::; to spbnJ.. timE! indulgi."1.g tile .child.

'..

'Ihp pos.3J.b.:.e side effects (;1 boing :;'\1 hospital include: for

fora.~ ~

b('1'bies-. ~ •• ,

0<,.."."

~." ~

.. ""

"ir~ectIDns ]'')'102.i'1e58

mara8IDUS

for older cc.il(-t."::en .••..••• ,,. e .infections-lu,:~s of cO:2fidc;!1ce les'; 'ofsch :;)ling-hs~ing fears of needles, of doctors in hospi tc:. i"' dude: V\"D6,) t·;1e sb;)' is C\

f::.:c:J:':.~.'1g§.EL§<;..sl:,

the possible side effects of being . ::j} f"·,;.L

'..

for be.bies •• ; ••••• ,., •• , •••••• stanting of gro:vth, --intelle·ctual physica]. am emotional ,;

.. .

for oldE.>r ch:5.Uren •••• , ••••••• 10s3 LOSS

o~ ccnfitience ofschccli"g

. It iC'.aJ be sc.id tiL c, (·ho '.:nridon(;-.:l for this is not conclusive.

1 agree.

- TI.Medicine may."be an art, "or"maybe a schience, "but"all doctors would·'agree that it is a" occupatron in which"we"have constantl,y to plan·'action on provisional conclusions reached on insufficient evidence. In this matter of children in the ~ospital I felt some six yea,rs ago that; 1. The evidence suggested that further research would be well worth doing, and, 2. Meanwhile·'r should take action as 11' it were true that the separation of hoapita~satio~ cou!d be h~rmful.

Just as we take precautions against infections lilich children might not eatch and Aiight recover from i f they did catch them, so we, sfiould take precautions to minimise the possible harm of hospitalisation.

----

At t:he hospital I work in, we spend time in trying to establish a general urxierstanding that children"!n hospital migfit be ~; might be rebeIl1rts, either as"a nealthy or neurotic reaction or might be guie ~gain ether froiii being normally so"or as a psychological reaction. . he noiey ones were not to be thought tlnaughtytl; am the qiiiet·'ones·'were not to be thought "good". It"is the quiet ones to which"attention of nurses and doQtora has to be dravm - the .... grief they feel -. is not appreciated.

f, .

.. .-

liter ten months prelliiiinary discussion we started dail,y visiting. The ten mom.ns were well spem. because this meant that at the end of this period, the nurses wanted to have"daily visiting. "Newspapers often discuss the pros ani cons of dail,y visiting.·· Doctors am nurses are kindly people; why don't they all have dail.Y visiting. There is a historical explanation tor this. Sixty years ago inStitutions"were death traps·'for babies;. of healthy children admitted wfien less than on e year old, ·'nearl,y one hundred.·' .. pe~ cent died before reaching the age of one year. Even forty years ago, one in -4:.hNe died." Even seven years. ago in the. good fiospitale in· "England seven per cent of""illnesses were acquired after admission arxCfortyone deaths oc~red of childreri with hare-l!p am pyloric stenosis. Looking atter other·.·people' 8. c.hildret;~s -a heavy re.sponsioilit.y. "Wecioctorst!.ied~o maKe thiJ'lgs .sa1'epi;, excluding sources of these infectl.ons, so we forbadevIsiting.- :Maybe we were x· right then; are we still right tohavevisitingonl,?" .. ; . .., _... _ . . .once . . 'a we~. _. ,.. ,',,;,' . -.' "."

., . Inf'act·'haniling ,ofba6ies rooucest;he ,l'!iUnber ~f intectionl;l caugpf: itil hospUalam dai1,y visiting gives no increase. - W"e find daily visiting . is"useful because infants and·'chil{fren are happier and are more··easil.Y .. ' ... managed'; the charge nurse"spends less time throughout the day answering .. telephol'\e calls from parent~. Most hospit:als have or'le or more rooms where m.otherean be admitted with childre". In many cases the mother. isadinitted because·'she··is sucKling the baby. It is a great pity to admit a-mother to"a roan ani· onl,y bring her to th. ward five times a day to feed· her baby. In New Zealalld tfie Pickerills have built a hospital on the Chalet' system so that mOthers can come in·'with and care for their babies when they have c~eft lip ani palate operations. At Guy's HospItal the local education authority has supplied school·' teachers; the students are encouraged to play ~ith and pi,~ up ~he children. . What exact13 does a child miss? Children of six months ani upwards mss"the comt'ortil"lg mother they were beginning to form. relations with. Infants;' I thil'lk, miss the stimulus of physical contact witti their mothers. The·'French say that love is t,be contact of two skins. In England, we tiad been so led astray by the anti infection "don't toiich the l:iaby teachingll that a poster could De issued IlCuddle your baby when yOu· want toll. The lonely infant-'lies in his cot tor 24 hours a day with no cuddling - the ward. at~f can go off duty and get it. . Anna Freud has 'said that the chHd in hospital has tfiree needs; to be told he is still loved, to be told he is not there as a punishment, to be

- 78 told he is getting better:' These three"things should be put into words to child patients however young tney are and should be expressed-'both-before ,-' the child goes into hospital and after he is-'in there., Can anything be done before a-'child is admitted to hospital?-- When a little child is admittedO'for operations such as tonsillectomY or herniorrhaphy, we have time.-' We can explain"'mat will happen, we din explain about the anaesthetic and so on. Children can enact the event in play. Miss Parker told us of a cnild' s remarlc wbien was most illuminating to me - "YOU told us what would happen, but yOu did not te~l us h?w we would feel". I~ future, I shall try' to meet this _,need. The nurse in cnarge of a children's surgIcal warii told me a. few months ago that the children of four doctors had recently been-'admitted an:!. that the mothers had said as they left "I'll be-'back in a fewminutes"~' or, "Mummy will be sleeping in the room below". -. Arising from this, I wrote an article about preparing children for operation which will appear in the Lancet in about a month's time. ' W"eshould, constantly try to avoid taking children under five into hospital and when they areo'B:dmitted get them home again as soon as possible-'- full recoveryO'can often be completed at home. Manyoperations~e.g.' t'onsillecto~, can often be put off for a year. Herniorrhaphy can be done as an'outpatient procedure, or a Child may be able to go home for the local doctor to remoyEi the, stitches later on. ' I don't believe that all children who go Into hospital ara lastingly , damaged inO'their personalities, but for children under four years old, it ;is ; 81'1, experience which"'leaves some effect. Often there has been no obvious' : harm, but i f a second hospitalisation occurs, or i f th~ mother goes away _t~ci, have a baby within a few:'months, then the child breaks down, revealing that' the firsto,hospitalisation had diminished his reserves:;oC self-cc!ml'idence.- ' Even i f it were discovered that: Spitz, Bowlby and the otherswerewro"g8bou about the' relation of hQspitalisation'anddelinquency, andother·forms of" " psychologicalu.pset, is clear that chililren in hospital are often sad and. that is a good reason for doing . , , .... ... what we .',can.

":1t

C~n I see another's woe Ana not be in sorrow too? C,~n I S~(j another! s"'grief And not seek for kind relief?

.,",

Blake - Songs of Innocence.

_lJ DISCUSSION. the group l!lee:t1nq" 1., In rpost at' ,theAifJian countries it seems there are genera1],ymoth,el' substi1;~ utes within the family ready and willing to step into the breach whenever the mother is not able to fulfil this role. The large family, as a ruls means that thesemother-substi tutu have this funotion through the life of the ohild. In' these oiroumstanoes maternal deprivation should be less in thess oultures, than in our own.

2. Has the oiose individual tie between mother and child in some branches of the Western oul tures any relationship to the prevalenoe of mental illnesses in these oultures? This might find some support in Bowlby's statement that it is the infants with a very olose intimate loving relation who suffer most from separation.

3. It seems tha.t other factors besides a closs and intimate tie with the mother are essential fol' mental health. Similarly, there is still a lot to be known why some children oan apparently tolerate separation without the disastrous effects of being reduoed to the "idiot level", or the state of an"aftectionless delinquent, psychopathic and hysterio". 4. The evidence about the effeots of separation on some children is suffioient1;V deUni te to make it a.dvisable to avoid separation of mother and child i f this is at all possible. It is, however, doubtful i f widespread publioit;V at the level of the la.;v publio should be given to the possible effeots of separation, for this must inevitabl;v lead to unneoessar;v anxiety and distress in man;v homes, particularly as some of the ourrent literature (e.g., Bowlb;V's writings) express fe'ar as to th~ possibility of reversing the ohanges set in motion by" separation over even comparatively short ,periods. More so is this warning desirabl-ewhen we know little or nothiJ!g of the li:mg-~e.1'III effeots of separation, , '

,Thesedoub1;S are due not only to the possibilitythCl1i the interpretation of the ' evidenoe ma.;v be faulty, but that dootors,pediatricians, psyohiatrists, or justtilain doctors, teachers, nurses and all the rest of us have already too much on our consoiences for the undue parental di.tress and anxiety due to errors itt the past. '

,.fIt

Emphasis on su.ch factors as feeding by the clock four-hourly, or three hourly with exact ,amounts of ca.lories etc., the necessit1 for breast feeding even-by unwj,lling mothers, the need for early .and rigid toilet training, the need for routine and disoipline from early infanoy to build up strength of- character, the need for oleanliness, the avoidance of "repression", i.e. saying "no", and!lla.l'lY other items ,of advice and warning have all done harm in spoiling the jgyof. mot)lerhood, and haVe surely hindered thll development of a "close and flatisfying. relationship between mother and ohiid". the dire effects of m:\ternal deprivation is to be t.he next item of educatiohgreatoare must be exercised. After all, man;y pediatrioians have shown that many children fret in hospital and mothershnve often been introduoed to overcome the ba.d effects on the child of sepa.ration. The plight of the orphan has been causing tears and money to flow for many generations, and the effects of ill treatment, isolation, and poor nutrition have also been known for generations.; The poor motherless ba.be hns,alwny~ been known to need a mother's love, but this should not prevent a mother from having a pea.oeful holiday frOm the cares of a young family which has been loft in the charge of a relntive or friend while she prepares perhaps for another addition to the"flock'J Nei ther should it make us forget the benefits often obtained by n temporary, or even, prolonged break from a wholly unsatisfactory ~tmospherG in tho home with anxiety, neglect, hostility and even cruelty playing a part.

- 80 .. 1. Sotn;EL TYPICAL.-l'IS..T~~~QEJS

IN CHILDREN

AND THEIR

ME!.~~

A.R .Philli.E:!..!. Pseudo Feebl~m..~nAe_c!.r!.e~

Many disorders of children result in retardation of development or even oause regression, and the resulting appearanoe of intellectual subnormal! ty may oause a child to be labelled as "mentally defective" because he may appear to be defectivo on the application of the ps~ohological or even the social criteria of deficienoy. The diagnosis of mental defioiency is often easy but sometimes quite diffioult; unfortunately, it is not a matter of life and death like some menidal or surgioal diagnoses - merely a matter of life, but it is the whole future life of the ohild whioh may be at stake. Reading D~fficultiesg These ~re only cause retardation at school, but set up a series of difficulties for the child which result in social and emotional disturbances, and the discouraged child falls back further still. The development of School Psychological Services and the establishment of remedial reading classes for the less complicated cases, mean that fewer of these children need be allowed to become so disordered that they hiwe to be brought to a psychia.trio clinic. Speech Ret.£l.rdation: One of the common causes, of course, is deafness, which 1s so diffioult to detect in the young infant. There also appear to be oases of auditory agnosia of obscure origin. Some of these may be ~e to the sort of focal destruction of nerve oells described by Professor Dods as ocourring sometimes when the baby ha.s suffered from asphyxia, or from other birth injury, or deVelopmental defects of the bra.in. A form of mutism which is apparently psychogenio is one of the characteristics of autistic infants, and will be discussed later. You have already seen films showing. the failure to speak of infants deprived of their parents, (Monica, Laurence, Jack p.nd Christine, in "Maternal Deprivation"), and the speech retardntion of children brought up in institutions is wellknown. Even in the presenoe of the mother,disturbanoe of the child's relations with her during the critical period of commencing acquisition of speech seems to be a oause of psychological mutism. In some cases, the child will not speak at all to the parents and subsequently any adult, but 'will speak quite freely to other children. Physical Handicaps; These may be a&sociated with true mental defect as in many children with cerebral palsy, ciften exaggerating the appearance of defeot; or, in other oases, may stimulate mental defect. On the sensory side, deafness has already been mentioned. (myopathie~) "ron.)' cause a child to be~egarded as mentally-defective. .

Not obly disorders of the nervous system, but purely musoular diseases :.

Delayed Maturation: Individual differences in th~J:"a.te of mnturation. have to be allowed for, and I have seen rare and most excEiPtional C<;',SKS where no other cause for apparent feeblem~ndedness could be found,y-et :the child lI)ade a. remarkable reoovery. Severe illness.:!.s a retarding factor in itself, but is likely to be oomplioa.ted by isolation and separation from parente, and other psychologioally traumatio experiences associated with being 111 and in hospital. The Tavietook Clinic . film "A Two-Year Old Goes to Hospital", by means of a visual study of a. very minor oase, gives us a hint of what may happen, even in the most favourable oircumstanoes. Educ.ational defects also cone in here, not .nl~ in the sense of loss of sohooling, but in the wider meaning of lack of social experience. Personality Disorders: By this rather ambiguous term, I mean the socalled behaviour disorders, psychoneurotio manifestations, and psychoses ocourring in children. which are the subject of the seoond part of this talk. In oertain •

- 81 circumstances any of these may give rise to the susP1010n that the child is mentally~efeotive, and this applies espeoially to the sohizophrenic (autistio) !-

ohildren •. . ' My exouse tor spending a I i ttie time on the. subjeot of the differentiation of th~se disorders frop mental defect is, tha.t ohild psychiatrY until the end of the first deca.de of this ttentur,y Was practically confined to the study of mentally detective children and only began to develop further after tests to distinguish the true defectives from others· were invented. We psychiatrists still lean heavily on the psyohometrists in the matter of diagnosis and will oontinue to do

so. CAUSES 1. ~~EUDO-FEEBLEMINDEDNESS.

Speoial intellectual disabilities or idiosyncrasies which may be confused with poor general abilities, e.g. ohildren with reading difficul ties. . Speeoh retardation, whero non-verbaT abilities are found to be well developed. Psychogenio mutism. Physioa.l Handicaps: (a) SensorYI Defects of sight or hearing. (b) Katorl Cerebral palsy, ohorea, athetosis etc., Myopathy, . Brain injUrY from trauma or disease which may interfere wi th some kinds of inteUectual activity but not with others, e.g. auditorY agnosia from temporal lesions. Delayed maturation from severe early illness that delayed mentai development or from other oauses. Educational defect e.g. effects of institutional environments, unsatisf~ctory homes, lack of schooling, etc., Personality dlsorder e.g. , Psychoses: Schizophrenia, including early infll.lltile a.utism. Psychoneuroses Conduct disorders Seve·re habit disorders Effects of deprivation

5. 6.

1!!.E MEANING OF CHILDREN I S BERAVIOUR

DISORDERS.

Behaviour disorders wny be secondary to some pathological condition, or primary, i.e., reaotive to the environment. This discussion deals with the primary behaviour disorders, which can be divided into: 1. the habit disorders 2. primary conduct disorders and 3. behaviour disorders of psychoneurotic origin. Habi 11 Disor.~,

These are exoessive or persistent manifestations of certain aspeots of infant beha.viour. They represent the earliest deViations A.nd may exist alone or associated withconduot disorders or psychoneurotic traits. The disordered behaviour relates to the child himself rather than to others, but habit disorders may have an aggressive oomponent' and may be used as vehicles for hostility against others. They arc; however, primarily defensive measures, with the function of discha.rging tensions and rclieving anxiety,·to whiOh the infant is po.rtioull'.rly vulnerable because of the absenoe of a well-developed ego. Since on the functions of the mother is to act in place of thecgo, adequate mothering is the best preventive against habit disorders, but as no' hhild, however carefully protected, escapes the experience of some frustration ~~d anxiety, some persistent habits will be observed in most children. Of course, the estimation of what is or is not a habit disorder varies widely in different cultures. Tho detailed causes for a ha.bit disorder a.re to be looked for in the individual case,but some generalizations can be made.

- 8:; ..;. Finger-sucking may be taken as an example. Sucking is a pleasure in· its own right apart from its :fl.mction of nutrition, and a baby needs a minimum of sucking every day as well as an adequate ration of his mother's milk. If for any reason he does not obtain sufficient sucking satisfaction at the breast he will make it up to himself in his'-own way. But finger-sucking is also a means of reduo_ ing the anxiety of separation from the mother, and aiding in the hallucinatory restoration of the absent breast ahd all its conforting implications. Infants are commonly seen to aid the Ulusion by auxiliary a.ctivities,such as, stroking the cheek with a blanket or other piece of material held in the free hand. This beloved blanket may'be carried around for years by some children as an aid to seourity. One would expect that so successful a means of overcoming the anxiety of separation as thumb-sucking would be useful for reducing other tensions, and it is not surprising to see older children regressing to the pOint of using this device in times of stress or when relaxing into sleep. The other habit disorders are equally subject to interpretation and some of these, including finger pulling, nose-picking, head-rolling, head-banging and rocking. Constitutional predisposing factors may playa part in the development of disorders, but no baby can escape the experience of having to deal with oonsiderable amounts of anxiety and aggression, derivations of its own instincts, • whioh threaten it from within, nor can it be wholly protected from external dangers which threaten it from without. Absolute protection from these potentially traumatic happenings would not be possible even if it were desirable, but adequate mothering supports the child a~~ offers him the neoessary degree of protect~ ion, modifying the impact of the outer world, leading his instincts to permissible forms of gratification, avoiding excessive frustration and at the same time teaQhing him to bear frustration. ~~bit

When motherirtgis inadequate or exoessi,e there are various possibilities, 'of disturbance. Tho ovel'-stimulated child beoomes anxious, the deprived child begomes retarded, <md the over-protected ohild prolongs his infancy. Habit disorders may be part of the picturo in all these Cases. 2 Primary Conduct Disorder. The behaviour disturbances in 'primary conduct disorder are massive and mul tiplo, the child tending to be disturbed in all areas of his behaviour, indicating a deep-seated and extensive personality disorder. The aggressiveness, aoquisitiveuoss and sexual activity shown by these" children indicate their need for immediate instinctual gratification without regard for the consequences. The child acts out his impulses. He does not respond to punishment except by inoreased hostility and is un"oble to internalize aggress:Lon'. He shows an apparent absence of guilt feo1ings or anything reoognizable as an effeQtive conscience. His relations with people are superficial (because he has not been loved he has not learned to love) and he shows. an inability to .. give or reQeive affection whioh makes him relatively inaccessible and difficult to treat. There is a correspondingly high degree of self love or narcissism so that he . • vervalues hilpself and under-rates others, a.nd this again makes it difficult for the therapiSt to gain prestige in the ohild's view. Some children have" often been deprived of family life from an early age and in particular have suffered a prolonged br,Gak: or disturbance in the mother-chlld ", . relationship during the first three years of life. The deprivation of the mother is not neoessarily o'~plete, but may be intermittent or consistent ofa'oomplete or pa~tial denial of affection by n rejecting 07 caprioious .other. Intermittent or partial deprivation seems particularly likely to produce an aggressive anti-social character. Children in their sGcond and third year cannot tolerate prolonged separation from their mothers and "tend to lose their emotional ties revert in their instincts and regress in their beha.viour" (Burlingham and Freud). They often reject mother substitutes, behave aggressively and show many conduct and habit disorders as shown vividly in the films "Grief" I'..nd "Maternal Deprivation". When the mother is restored the child may refuse to recognise her, or again show

'II

- 83 dl.o~d.red

behaviour. !he 1088 of ability to develop love relationships Ls sometimes masked by faoile shallow attachments to any adul1i. Types of Maternal deprivation likely' to produce primary conduct disorder. ' 1.

Complete deprivation, with no substitute, before the infant is a.ble to establish relations with his mother as a. whole and clearly defined person, oertainly not later than the first five or at most six months. Complete depriVation after a mother-relation has been established $Cd' while the child still needs the mother as a constantly available compan~ ion. During this period he is unable to maintain a secure relationship wi ththe absent mother for more than a few hours. This is the state of affairs for the first three years of life. Partial deprivation in various forms, including deprivation in the physical 'presence of the mother when she is unable or unwilling to give her infant the , necessary- loving care. The degree and pattern of the deprivation help to determine the partioular fOrm of the personality deviation which it bringe about. According to Bowlby, "The evidenoe suggests that three somewhat different experiences oan eaoh produce the affectionless and psychopathio oharaoter. ' laok of any opportunity for forming an attachment to a mother-figure during the first three years. deprivation for a limited period - at least three months and probably more than six - dUring the first three or four years. ohanges from one mother-figure to another during the same period. Quoting ~owlby

(a) (b) {o}

againl

.. ~e

"It would appear that the more complete the deprivation in the early years the more isolated and asocial the child, whereas the more the deprivation is interspersed with satisfaction the more ambivalent and anti-social he becomes". The ego is weak and poorly developed .because it hae been deprived of oonditions neoessary for growth conditions properly supplied by the mother. The weak ego oannot bear tension and seeks a. quick outlet for instinotual exoitations. The super-ego is also oonsidered to be weak beoause the child has not been able to identity with parent figures who ~re absent or hostile, and so, using Dr, Peto's words, has not been able to internalise "the social stando.rds of his environment". In his ca.se parental authority has not beoome "an inner oensor", he remains free to direct aggression against his unloved pa.rents and all subsequent authbrity, instead of that aggression being plaoed in the service Cf the inner censor to be dirooted against his own self in feelings of guilt and ~o~se.

A uBstion for discussion: Is there such a thing as psyohopathic personality, "moral. deficiency","moral imbecility"), regarded as a constitutional defect and not re1a.ted to any emotional disturbances or deprivation in infanoy?

. 3. BehaYiour ,

DiBorder~s Psychoneurot~c

Traits. '

!!'

In another group of cases the picture is some,what different. The disorders .t beha.viour may be severe but are not so widespread as in primary oonductdisorder, e.g. the disturbance may be confined to the school or the home and aggressiveness may be directed only at certain people. Sometimes,,:the complnint refers to one symptom only, stealing, for example, or setting fires; at other times there may be considera.ble aggressiveness and destruotiveness,resembling primary conduot disor,der, but the causation is different and the disordered behaviour is not a. mere '!l.Oting out of impulses,but hl\S a pa.rticular meaning and value for the child and a substructure of psychoneurotic symptom-formation. In these cases the ohild is attempting a solution of an 1ntra-psyC'hic oonflict, eud,tb.e symptom-formr>.tion is an attempt to cope with anxiety, the result of instinct frustration. Suoh children are l~den with anxiety and guilt which may not be directly evident but may be ml1nifestvd through affective disguises

-84.such as depression, or through unconscious self-punishment such as accidentproneness or offences oommitted with the unconscious purpospof oourting d~leo~ ion and punishment. In plage of the high narcissistio self-evaluation of the child with ~~i~ ar,y conduct disorder there 1s a lowering of self-esteem and a feeling of )~~esQ, The neurotic ohild directs a good deal of aggression inte~nally, again_thim.elf, so that he not only unconsciously punishes himself,but he is able to a4C~pt punishment. In spite of his ambivalence he wants to love and be loved, so thnt he oan enter into relationships and develop transferenoe, making him a favourable prospeot for treatment. Retrospeotive studies in these c~ses show a period of disturbed relations oharacteristically extending into the latter part of the pre-sohool period 0-6 yea.rs) and relating not so much to tho experience of actual or psychological separation from the mother in early infancy as to emotional difficulties in relation to both parents, i.e. the fe..milin.r oedipus si tua.tion which lies at the oore of all neuroses. Van Ophuijsen describes "reaotion to the parents a.s a. coupa.~ I as characterising these cases compa.red with "reaction to the parent as an individual" which refers to the child-mother relationship in the first three years, so productive of conduct disorder if badly disturbed. This oonoept serves to emphaeise an important difference between the aetiologies ot. the two conditions. but we must be careful not to over-simpiify our thinking about two complex and overlapping disorders. Psychoneurotic Disorders in Children. Psychoneurotio symptom formation as seen in adults or older children pre-supposes a certain degree of complexity of the psychic apparatus which --the inf,ant or very young child does not possess, but psychoneuroses are based , on anxiety, and anxiety does appear in the very young infant as a result of instinct frustration as well as of dangers threatening from without. We have seen how infants reduce the level of anxiety by means of manipulations and types of behaviour which may persist as habit disorders, but these simple devices are not usually called psychoneurotio. Frustrated instincts can also express themselves in children even more readily than in adults through disturbances of the functions of organs, oausing such syrilptoms as vomiting, abdominal pain, diarrhoea, headache, asthma, etc., The· Deputy Chancellor, Dr. McDonald, inhis speeoh at the ina~ration of the seminar, gave us a pretty example of anxiety in a child setting up abdominal pain and stimulating appendic~tis. In spite of their psychogenic origin these psycho-somatio disorders still do not rank as psycho-neuroses and have a simpler and more primitive structure which we cannot stop todi~cuss this mcrning. ..., When we come to the common nocturnal fears of infants of. three oriour years who declare that wild animilJ.s or dangerous horses etc., threaten~.e~ at night, we are definitely dealing '.7i th psychoneurotic symptoms in .'tllfl form of phobias. They are due to the unconscious hostility of the child to the parent and to his ascribing a similar hostility and aggression to the parent through the mechanism of projection. Psycho-analysis has demonstrated that the paront is represented by the fantasy of lions and tigers prowling in the darkened bedroom. In the ritualistic play and obsessional: counting games of ohildren, and suoh well-known peculiarities as reluctance to step on the oracks between paving-stones, etc., we can recognize oompulsive symptoms of a minor degree which seldom require any special attention. Fear of touching and contamination sometimes become serious matters during the so-called latency period and can often be shown· quite readily to be associa.ted with guilt about sexual fantasies and masturbation, and compUlsive tics may arise immediately after a child has abandoned masturbation after. being discovered and threatened, or even after he has overcome the habit following a long and lonely struggle without even having been discovered at all. Of course, the tic is not only an outlet for tension and a substitute for the masturbator,y act, but it may also have a component of aggression,

- 85 (making faces at people). The parents of children with facial tics ar~ commonly overoontrolled themselves and undemonstrative of their att'ec,tion. Hysterical conversion sycptoms also occur in older children, but behind wbateve~ precipitating causes are found there is found to have been a disturbance of emotional relations with the parents during the pre-schcol period, so that at tention to the mental health of this period is the best preventive measure. Schdzophrenia in Children. Two types of schizophrenia are gene+allyrecognized in childhood, but one of these occurs usually in the ratter part of childhood, towards puberty, and does nct seem to differ appreoiably from the dementia. praecox of early ,onset seen occasionally in very young adolescents. The schizophrenic disorder occurring in v, ery young children has been called by Leo Kanner, early infantile autist:l. Al though the illness has its origins in babyhood its seriousna.ture is sometimes not reoogniseduntil the child is sovera.l, years old. The outstanding oharacteristics of these oases are withdrawal and loss of emotional rela.tionships with people. In contrast to his marked detaohment from human beings, the child may show an interest in objects, but these are few in number and the interest is of a fixed and obsessive kind. These obsessive characteristics are BO marked that the ohild may be thought at first to be suffering frcm an cbsessive-compulsive neurosis, and he usually' reacts badly to any changes in the arrangements of his life or even in the order of the objects surroundiDg him. Speech regresses and develops a number of peculiar characteristl.cs, partly aile to the child's autism and lack of any real need or desire to oominunicate, anil partly because of a loss or alteration of the symbolic value of words. These are often given their literal rather than their metaphorical meaning, wi'th curious ' results on the ~ehaviour of the child. Sometimes these children become nearly or quite mute, but they are likely to utter suddenly quite a well-formed sentence.' In other ways, too, one finds unexpeoted peaks of residual abilities projecting out of the eroded plain of their general deterioration. •

•

They are often pre-oooupied by abstract concepts' aild pseudo-scientific ruminations but these are elementary,rc!,otitioooand obsessive. The speech and the art productions of such children show a highly sadistic fan'tasy life, but again these ~inAtions are stereotyped and obsessive. An autistic child may be impulsivel~ aggressive and destructive, but he is often quiet and immobile with occasional outbursts of erratic and ritualistic acti~s. '

Hallucinations and delusions have been described but are unusual. The histor.y of such a child usually shows that as 0. baby he W~B quiet and selfcontained, did not react or show interest in those caring for him, and may have been so unresponsive to stimuli as to be thought deaf or blind, like the child Christine in "Maternal Deprivation". Like Monique in the same film, the child does not adapt hie posture to that of the P'l rson pioking him up, but remains rigid and "hangs out" so that he is hard to hold in the arms. He does no'!; extend his arms when a gesture is made to piok him up. Intelligence tests during tho sohool-age -years: show him to be functioning ustllally at the feebleminded level and probably institutions for mentally defective oJiildren 'contain mo~e of these cases than is generally realiEled. , ' Most s:\.gnificllllt'and oonstantfeature iF.:l. certain family pattern. The ohildren's parents a1'8 usually of superior int(;lligence, often,professiona.l people, and thamother" in partioular, has usually' been oonscientlous - often' obsessionally so, but deta.ehed' and lacking in- warmth and J:lla;rfUlness with the baby. Both parents are often intellectuals with doctrinaiNiGI?,9,s about bringing up· ;children and have sometimes been attempting to bring up ~'the idcial child" by rigid and intensive IIJI)thods of training. The results of 'r.:'lis .is often an emotionally neglected buy, never :r;emoved, from its oot except for :Leeq:i.ng or toilet purposes andsu:ffering ~parent~l ~eprivation in its o~~ home. , One frequent characteristic of 'the'autist!io childTen whom I have seen is the possession, of Po very distinguished. grandi'ather(or eVen two ~f them!) and

- 86 intelligent but undistinguished parents who have grown up under the shadow of their parentsl fame. It may be that the sohizophrenogenic qualities of the father or mother are related to this situation and are due to the peculiarities of their own childhood experienoe at the hands of unusua.k parents; at any rate, I report .this phenomenon to you in the hope that something of tho same sort has been observed elsewhere.

----------------------------REFEREliC ES • 1. 2.

3. 4.

Arthur, Graoe (1937) Arthur, Grnce (1950) Guertin, Wilson H. (1950) Bender, Lauretta (1952) McCarthy, Dorothy (1946)

Bowlby, J.

(1951)

10.

11. 12. 13.

Spitz, R.A. (1945) Goldfab, W. (1945) Spitz, R.A. and (1946) Wolf, K.M. Powderma.ker, Levis and Touraine (1937) Cleckley, Harvey Tredgold,H.F. Ophuijsen, J.W.H.Van, (1945) Freud,· Anna Ribble, Margaret A.(1945) Ribble, Margaret A.(1943) Freud, S. Freud, S. Crea.k, Mildre.d Kanner, Leo (1926) (1933) (1951 ) (1943) .

Am. J. Ment. Def. L 11, No.2, 131. Am. J. Ment Def. L IV, No.4. Am. J. Ment. Def. L.IV, No.3. Child Psychiatric Techniques Charles C. Thomas, Illinois. Language Development in Children in' Manual of Child Psychology (Ed. Leonard Carmichael) John Wiley & Sons. Ino. N.Y. Mate.rnal Care and Jlental Health W.H.O. Monograph Series. No.2. The Psychoanalytic Study of the Child 1,53. Amer. J. Psyohiat. 102, 18. The Psychoanalytio Study of the Child

2, 313. Amer. J. Ortnpsychiat. 1, 58. The Mask of Sani ty. Mental Deficiency •. Primary Conduct Disorders Modern Trends· in Child Psyohiatry (Lewis & Pacilla) International Universities Press N.Y. The International Psychoanalytical Library. No. 30. Anxiety in Infants and its Disorganising effects in Modern Trends in Child Psychiatry. OPe cit. The Rights of Infants Columbia University Press. Inhibi t"ious Symptoms 'and Anxiety The International Psychoanalytical Library. No.28. New Introductory Lectures in PsyohoAnalysis. J. Ment. Soience July 1951. 408. Nerv. Child 2. 217-250. J. Pediat. 25. 211-217 Am. J. Psyohi~t. 103. Child Psyohiatry - Second Edition. Charles C. Thomas, Illinois. Am. J. Orthopsychiat. 19. 3. Amc·~. J. Dis. Child, 63, 30. J. Pediat. 35, 512.

14. 15. 16. 17. 18. 19. 20.

21. 22.

Ba.kwin, H. Ba.kwin, H.

~ ~

1944)

1946) 1948) 1949)

1942) 1949)

------------------------------

--'---

NERVOUS 'DISORDERS IN CHILDREN AND AN APPROAC,H

TO THERAPY. D.W.H. ARNOTT.

'-,-'W:JODW4~in the child, a:nd when the.y JiCUlOOur, seem to be of

lle:r'V'OU

~ lII4Ul_t$.:L~wns

as we know--tl:I.6m 1n the adult are relat;L?e~ a siml'lernatu.re. -

'the,ohil~ asa simple fear state and the adult depressive'.tate with mental retard-

The adult

~ety

neurosiB With its complex somatic symptoms is seen in

ation and idellos of unworthiness as a simple state of misery in the child. Children develop acute psychotio illneas with rapid intellectual deterioration, they may show acute regressions to inf~~tile levels, they m~ develop hysterical pareaia, but more oommonly nervous ,illness exhibits itself in changes of personality and behaviour, suoh as, undue oontrariness, irritability, loss of confidence, emotioD8l.ism, shyness, aggressiveness, temper t&J\.trums, lying, stealing and so on. ~

These variations of mood an.d conduct do not ordinarily conjure up a picture of illness, rather do they suggest a perverseness whioh the parent, teacher and , even the physician perhaps can be exoused for prescribing some punitive therapy. When suoh moods and oonduot remain persistent and unresponsive to exhortation and disapproval and seem to have become uncontrolled or irreversible, at this point the oondition must surely b~oome an illness of-mind and needing a medioal approaoh. The ou.~d S;y!IIptom in like the wisp of scokecoming from the ship's deck tha"i'; " gives,but little indication of the inferno raging below. The symptom is but'the or,y for help for release from the insupportable mental stress within. ,:Es _:\lherE'! any oommon ground in the 'basic meohanism bGluw1ouz:,di:sol'du~s1 ~

these persona.li ty and

•

There is perha.ps at leas'!; one and that is that ineaoh and ever,yone there, is a. rise of psychio tension which beoomes intolerable and for which relief must be found .• ,: A ,rise in psychic tension' occurs when any instinotual driV'e is frustrated or where fear, anxiety" anger and miser,y, self-consoiousness, 'interioritt,: jealousy or other nega.tive emotional states is a.roused to an abnormal degree. '!he tl!.reshold point at whioh psychio tEinsion becomes intolerable does of oourse var:y t:remendously 1ti different individuals. . Onoo psyohio tension passes its critioal level it spills over into intelleotual, emoti<>na.l, beha.V'ioura.l or autonomic (somatic) pathwaye, thus lighting up: its

partioular symptom syndrome. The types of rcasponso to an ab'normal rise in psychio tension may be either exoitory.or inhibitory. Examples of th9 exoitory, i.e. e~losive or aggressive reaotions, are temper tant~s, violenoe, soreaming fits, stealing and other anti-sooialoonduot, hyperkinesis, anxiety state, nightmares etc., and,of the inhibitor,y reaotions, undue shyness;' negativism, sooial ~~thdrawaI, regression of'speeoh and conduct, losses of oonoentr.ation and attention and depression. In the schedule attached is a table (inoomplete) showing a olassifioation of nervous reaotions based on this oonceptfon. The type of reaotion matters but little as the same underlying anxiety may oause suoh widely different reaotions ~B stammering or truanoy •

""', UL -

approach to Diagnosis

~nd

Therapy. - __ ~

The approach of the physician or psychiatris~to tha treatment of a nervously disorganised child must nocessarily vary according to his experienoe, ~r~ininlH' knowledge and temperament. It would seem superfluous to emphasise the fact, that the solution of any oase depends primarily on the acoumulation of sufficient faots regarding the ohi1d and his illness. .. The first deoision one has 'to make is whether we are dealing with: (1) or a normal child who is reacting neurotically to undue environmental stress, frustration or deprivation, a handioapped child who is reacting neurotically to the frustrations caused by his handicaps even under normal onvironmental stress.

(2)

The indic0tions that we are dealing with a normal child would be helped by the following findings, namely; a normal birth, the absence of disturbanoes of feeding or sleeping in the first few weeks after birth~' an uneventful infancy and no serious physica.l illnesses, the development €'.t the proper time. of. the motor skills. e~d' speeoh, and the finding of normal intelligence quotient, and the prosence in the child of a fair degree of friendliness and capacity for making human relationships. If by thiB~ we can sense that the ohild is normal or potentially normal, we oan look:more olosely at the ohild's environment for the oause of his illness. ~he environmental pressuros which may cause nervous illness in children are unreasonable parental demands for affection, for standards of cleanliness and oonduot, parental oruelty and parental discord. Continue4 frustration of the child's nonnal active living by over~~ious parents or. lack of proper play 1&\l1lUleB or of playmatlilB will also upsota normal ohild.C1.s willoontinue~ . 4eprivation due to lack of proper intellectual, emotional and sooial Bt~mu1us. This is the field of the trained sooial worker. The adjustment of these harmful enyironmental influences con8tl~te. the main therapeutic attack in these. nervously ill,. but potentir...l1y normal chl1dren. Once' this ia.done, the child's conduct tends to return to normal andth.e nervous symptom!,! to . gradually dissipate. One could postulate perhaps that a normal ohild in a normal environment will behave normally and remain in good mental health.

.. , '

11. One can suspect that we are dealing with a handic~pped child if, after a oarefUl survey, we sense t hat his environment is a reasonable one. Again the careful history generally gives some hint of i ts:.possible caqse, such as, the. ocourrence of birth trauma, or anoxia, of early £eeding and sleep disturbances or unusual'scre~ing in the first few weeks of life, of catastrophio illnesses and brain injuries in the first year or two. of life. We may also suspect some permanent emotional warping if the child has beon subjected to prolonged separation from its parents, or, after having suffered prolonged emotional stress or deprivation. Dolay in tho development of the motor skills and of speeoh may point to mental deficiency. Handicaps m~

be:

(1)

Gonor"l Defects; There may be a general warping or immaturity of the personality such as in John Bowlby's children, who are shallow and affectionless, whose interests are restricted and who have not developed the power of mnking relr...tionships with other people. ThOBe who conduct is consistently inhibited or in whom tho total response to most situations is consistently disturbed r...nd abnormal. Those in whom tho Ego is restricted and undovolopoa ....nd woak.

I'.~""

(2)

Speoifio Defects whioh may be..-.~ __ (~J

Intelleotual hanqicaps, eto., general mental deficienoy, speoific reading and spelling defects, lack of speech facility, auditory imperception, word blindness •. Emotional handicaps, such as, undue sensitivity, undue shyness and tliose who easily develop emotional swamping. Social and psychomotor handicaps. Some ohildren just seem to la.ok much "outgoingness" and drift into a withdrawn seolusiveness in spite of efforts to help them. Sooial inoapacity can also develop through lack of proper stimulus. Motor olumsiness is quite a frequent ooourrenoe in'handioapped childronand can oause muoh incapaoity and frustration.

(b)

(d)

Visoeral inforiority may be significant but as yet is an incalculable factor. Other physioal faotors such as ohronic illness, vitamin and other defioiencies.

(e)

It is diffioult in many instances to decide whether or not handioaps are oongenital, or acquired and it matter~ little frOm the therapeutic point of view. A handicapped child is generally made conscious of his defioiencies by his environment and is unable to cope with its normtl.l demands and this le ads to' a rise in inner psychic tension which may express itself in nerveus illness and disordered conduct. Many children are only handicapped in one or two faculties, but these may be severD enough to disrupt the total functi~ing of the child. Treatment is aimed at trying to build up these immature qualities to somewhere approaching average performance. Once this is aohieved, it is safe to apply normal environmental pressures. Apart from other basic needs for personality development, the child needs some successes to achieve maturity and happiness and the demands of his home and school environment must be adjusted to his capaoities to ensure such success. The d~,gnosis of these intellectual and personality defects is the field of the trained psychologist. Even acceptance of the handicap by the parents will remove most of the psychic tension and with this a diminution or cessation of the disordered behaviour or nervous illness. This type of approach may be termed an ecological one. Although, I have emphasized 0. factual approach and hinted at the many factors that a physioian should determine and try to keep in mind in forming a total pioture of the child and his illness, healing s~ill remains much of an art and the healer must be able to turn on m~ny taps of knowledge and feelin~, and at the right time. I have not mentioned the intn.ngible gains that come to tjlo child and parents from the sympathetio oontaot with the doctor, social worker and psychologist. Even if no dramatiC effects are apparent, the situation is never as bad again where understanding has replaced confusion and hostility given way :to friendly tolerance.

------------------------------

T H "~_~Jt_._.l.

THE PSYCH00Xn.9.A1.lRQE~S OF THE RAJ!DICAPPED CHILD

~~DIG~J~,SPECTS

He.rrlicapped r;hildren are not to be thoug.l1t of as entirely different from. other chuaretL Evo::r,)' child h ho.niicapped at birth, unable to walk ard talk or-·even ':.ohbar and see properly. The effect of physical handicaps is to prolong; the infar,tile si~ua~io~ of.. the chi?:ct. ""The MinLtry of Education in England recognises eleven categories of handicapped p!lpils. Blind Partially sighted Deaf P<..rtially deaf Delicate Diabetic Fi..uc,~tionally

sub-normal

E?~.leptic

M",ledjusted Ph,y::;;i.callJ hal'ldicapped Spbech defective

T;-,is is;· perhaps, nota logic'::l list for the maladjusted ari{ the physically handicapped C&I;.E.'go:·ies i1"1elude a niimbe= of varieties and disfigured children and thos~ with spe(:.ific learning ..difficulties are om.i~ted. The effects of a handicap depe~s gr~tly on whether it is present from birth or acquired after a year or. S0 irl which the cliild I S personality has made a good start, There are some observations on animals whiCh suggest that our impression that the events""of the first years or so are of :tasting impoi:tance for the child IS personalitJ'- is only a specific example of a general of a gen6.ral biological rule, e~g. the behaviour of t.he grey..gosling and ~f the lamb. Handicaps pre~ent

from early life a!fect the

~ldls'pe~sonality:-

1. 2.

By limiting the Child'3 expecIe~c6 of his environment By th~ reaction t~ey induce ih t:he child I S parents

Limita_t.iI?Li......'?f Expe:r:~.

The··deaf child hea:os""less; the blind Chi.l.d sees nothing;" the cerebral palsied""and theblU6 cor\ge~d.tal h,:::!!;;· -jj.sord."rchildren get inadequate opportunities or explorI'1g the world. As the child does not toucli or see things he does not learn their nru"Jee; his vocabulary is smaller and he may not. be ready to learn to read the usual time. • .. at' -. At age 5 to 7 chiJaren begIn to a~ with their fellows. The handicapped child has difficulties in this and turns to his mother who may not encourage him to grow ilp and away fT'cm htiI". If the c.hild's mobility is limited he may be unable to be c.ggr'.ls3i VIOl when he Is a".noyed with his cOlilpanions which will iaiply a limitation of noi;;ual emotional experience, He"may assert himself by increasing his demands on h5 s mothuo The frustrated normal aggressive feelil'1gs may be revealed out in the pictur-es that physically haiidicapped children draw. Quiet and friendly chHdrengiven the cfiance can put "more blood and murder to the square inch on tnt> }laper than one would think possible". The ha,.,di:;,,) IT,P.;,' nec€.ssitate prolonged periods of hospit.alization in the fir~t fe", years_.with th? da"gers of. separation. 2. Parent:;.tJl.~a.ctioi'1s

t oJi.1:.t!di caps ,

A parent may fear tha.t he or she has been the direct Cause. He or she may hate the other parent rlS being responsible. A parent may feel -. dist.aste and miiy be ashamed of th.is reaci:.ion in himself or herself or in the other parent:· Such reactions may be tho expression of previously controlled personal or mentc.l difficulties. Conscious or unconscious guilt "'I

- 91 or hatred .ma"ybe1:.elt-#a)'ld sbow the!l1sci V'ElS as aggressive blame at' doci.ors" . involved • 4 ,

. , He or she may be disturbed oy the failur.: to reproduce perfectly. ". The normal difficult.ies of bringiY1£ up a child are increased and tfie parent lIlI1Y be less able to... cope with ... extrablU'dens •. The parents' reactions . _. .., .. , may be

(a) (b)

outmioken rejection lead1. ng to cold treatment or placement in reactions produce separation. ... an .... institution. .Both ... _. .., unconscious re jection leading"to overProtection 1Itlich may limit his e3iploratIOri" of his Gnvironment. The child becomes' t.iJn.orous"and givGS up' easily and"may grow up with gross social inadequacies despit-e a !!linor hamicap. Hard work for cerebral palsy societies may relieve anxiety causes fram feelings of guilt or rejection. _. -. Acceptance without unreal expectations. This gives the best chance for the child to"hB.V6 zest in life ani an adaptable personality. Same parent s accept without help; sane need specialist help. .. ..

( c)

The indlcence"ormajor maladj4stments in handicapped children ls" no higher than i", unhandicapped children, 'but "many handicapped children are "apathetic" o~ give up easily> retiring into dreams. The Blind and the Partially sighted Child. :c s~ted children. ~a new disorder of

In the U. g.A. t.here are 0.3 per 1000 blind and 1 per 1000 partially , The: origin"is"usually prenatal but in the last few years premature infant,s, retrolental fibroplasia has been a maJor cause of blindness. Blind children are not bitter about tfieir hatiiicap; their"persotlalit:y·'troubles arise from parental reactions to the blindl'l6SS. "Blind children need opportunity to JIlove"abou1::j they need •. encouragemen\:; •. 1' :.rents have to rememb6r to put things into 1;ne children' a hands, aescribing them so that"'the child learns"his surroundings. Blind '''.:.:" ,:,' 'cfiildrel'1 have to be tidier than sighted children bUt they shOUld meet ,•.. ',I ,,;' .','. and mix with th~. Over half of the blind children become self-supporting~, :;,,/ The Deaf and the Po.rtiaJ.1v deaf Child. u In the U.S.A. there are 0.7 per 1000 congenital deaf mutes.·' The il'lcidence"'of acquired deaf,.,ess is much less since the introduction of pel"ticillin. Deaf children are commonly liable to tantrums ana. aggressive befiavlour~ From being treated as stupid, deaf children canmonly became COl'1.vinced that they are inferior and give up trying. Delicate Children. Ttis E"lglish category iriclude~ chiIdren unable to attend an ordinary school for a variety of reasons; l'0CUnent respiratory infections; debility after il.l.ness; malnutrit:,oD from pov"rty or mismanagement. It JIlay oe that a psychiatric survey would disclose IDn1Y tc have emotional disturbances which perhap,';lreduce .. their ... resis':.ance to infection. -. .. ,: '","

\ "

',"

Asthma is a condition i" which 'a child is so made or Clonditioned that h~ reacts to"stress by ctevdc2J5..n,'; astlliria, The stress iiJay be " inhaliiig a substance to which he is hypersensitive, or an infection or" . emotiol'lal disturbance, esfiecial:l.y supprG,lsed anger, hatred or fear. In" ol'le investigation, emotional factors were .iJn.portant in 30 of 50 children. Tfie mothers tend to be"over eonsdentiouso The children are of Rormal .. lntelligence~' but often fearful"'of failllre"and afraid to try. Anxiety in the parent and child is a COlllDlon age:r~wD.ting factor greatly relieved by learni"lg that asth1lla in. childhood usuaJly does not persist into adult life.

Heart Disease, 21

- 92 -

.,,' Under the age of six years congenital heart disease is more common the.~' rheuma~icJever.: . As regards the latter it; is worth stressing the importance-of explanatwn of the disorder to the child. "Children with cyanotic congenital heart aisease - blue babies - often fail to walk a8 soon as they'might because they have be~n ,overprotected. .. ~. ~.

Some childreY! with the milder forms of congenital"heart disoroer and some with mHd" rheUmatic fever have been made lastingly hypochondruca1 by over cautiousness on the doctor's part. Epilepsy. "It might be considered an advantage to have a disorder which affected Alexander the Great, Mohammed, Lord Byron and both Napoleon and the Duke of Wellington. It is difficult to assess how common epilepsy is. 0.7 per 1000 sChoolchildren in U. S.A. are saia to have it:. Behaviour disorders occur il'\.,50 per cent of epileptics being sovere in 10 per cpnt. They are either the result of restrictions imposed on the child because of his fits, or manifestations of epilepsy. Some of the latter, the temporal lobe epilepsies"may prove amenable to surgical treatment. Petit"mal attacks are less common if the child is kept occupied. In some children attacks are coamoner When"they are alarmed. "The behaviour problems seen are the same as seen in non-epileptic children. A great deal can be done by drug and oth.er triatment •. Unfortunately, sChools and employEt'lS' tero to refuse adliifssio,: to epileptics which greatly increases their problenis~ The Mentally Defective Child • . , . Two 'per cent of the popul,ation are mentally defective. been u~ue pessimism about these people • There has

~Q.s 61 to 72, "of whom it had been prophesied that they were liablellto recruit to·'the ral'1ks of vagrancy, alcohOlism, prostit:ution, ., de1in~ency and chronic dependence, reproducing without care and handing over to"others their defec.tive off2pringll, Ir fact, "the picture was· dIfferent. tlf 122 traced, 4 had illegitirn.A.te children, "5had court recorC{s and 9 were in relief. 95 families out of 122 were financiail,y indeperoent.. 50 of ttie1r"'children were tested; 3 had I.Q.s under 70, 4 over 120 aro the rest bet.ween 90 and 110.

chilcii-e"n of I

.Hi 1933 a follow up after 17 years was reported of a group of 166·

Except where mental deficiency is associated·'with cerebral ~alsy, emotional problems are du.e to parental attit.u.des and are more ensIl:Y avoided ,than curea. "Scnol".stic aEricu:Ltios tilly make thE) child anti-social. Placin'g a child in an insLitu.tion m~,y save a family"from disruption; may be tobe best way of training a child. 'rhe work of training defectives requires no special skill bu',:, " u nlimited·'patience, good will and common sense". The' reward is in the child!s hecoming socially adequ.'1te. Cerebral Palsiod The f. _. • . •_ _ . _ ... _ - -Ghild. ,--~

In England tl:Ol"e is abcu.t 1 child. with cerebral palsy in every..lOOO children of school age" A comprtihensive c,}'pi'uCLch is very necessary. Genera.l intellectual ilIlpair:nent: is" cOr:1.'"1or;; 50 per cent are below I.Q. of 70 as cOJIipared with 3 per cent' 1:1 the normal pop~llaticn, Specific disorders of thought are common. Matt' athetoids are deaf, epilepsy is"common. The assessment of intelligence is difficult. Educability is not correlated with intelligence~ . . , It is said tl,c.i:. associated damage of the hippocampae part of the .. ' .. ; brain makes athetoids emvtionaLj labile, but the parents' attitude is of

- 93 . over-ridtiig importance for these, children. VerY early treatJneht of cerebral palsy is not always practical. tn the early months it"is difficult to"tell , how much of the disorder of mobility is que to motor and how much to intellectual disorder. Treatment of Children with Handicaps. Thehandieap itself requires treatment. _. If a choiCe is possible between treatment at Iioms or in the out-patient department of a hospital,: and.treatment as ~n inpat~ent,_.the fo~er is much to be preferred. Repeated cOt"lvalesce,.,ce interferences with progres/l of de"Jelopment and with learning in the school age child. Paret"lts need to be taught"to be kind but not to be more kim than the degree of handicap justifies, am that to do more is unkind. . .:: .C i-· ,-, \

THE

HANDICAPPED

CHILD

AND

HIS

PARENTS.

Mrs. Georgia M. Travis. In this p:,.per I wish to extend some of Dr. M8cKeith's remo.rks r.bout mento.l hygiene in rel?tion to modico.l care r)f tho physicdly ho.ndico.ppod child, with ospecic,l reforenco to the role sf the fo.mily in the s.uccoss of hos.lth meo.suros nnd. tho sntisfo.ctory adjustment of the child. With the improvoment o.nd extern ion of medicel care pr.ogrr.ms whiqh enr.ble m~r~ of the world's physicc.lly h1~ndicc.pped chilq.ren to Secure better mod~cf'.l c8.ro, dnngers ere encountored in the very benificence which s.ecks to S~.ve them •. l'ledics.l cC'.re is by necessity pntient focused, wheroC1.s hum8n lifo is fc,mily focu sed. Modico.l Cf'.rc concentr.o.tes UDon the body, "herons the child is ['.n insepo.ro.blo unit of mind c.~d body. As Dr. MncKoith ho.s indicf'.ted, the modern physicic.n is seeking w[~ys to to.ko into consider~.tion tho wholeness of the child in modicr-,l trc '~.tmont. I wish to oX:Jlore some of the wo.ys We cnn further nvoid the drmgcrs 0f sepf1.rr.tism by toking the family into acoount.

The child with congonitC'.l dofects or birth injuries, the child with o"'.rly crippling, c.nd the child who undergoes hospitc.lizc.tion, constitull3 groups with some CX"cricnces which nre different from the others rmd from physic~lly norm~l' children. However, there r.re certnin principles which :;,p'lly to them ~.s to 0.11 children, nrmely thr'.t ec.ch humnn being is difforent :'.nd unioue from ell others, th .... t ench child's life is inextricc.bly wClven with ths.t of his fr.mily, o.nd th~t the stc.ge of psyoho-soci~.l dlwclo1")ment 0f the child will determine the character "f the imprint left by T)2.inful exneriencos. They share with ::1.11 ehildren rl :arim.~.ry need for mrtornnl love 8.nd for em extra por tion of thr.t l0vG when the world inflicts pc.inful nnd frightening experiences .. utl;m them. Matern::'.l love, despite its extrc.ordins.ry durnbility, exists only as' the m0ther is nourished by 0. well-spring of childhood so.tisf<:'.ctions, mnrital support, rclc.tive henlth, c.'.nd freedom from ovorwhelming stress. The physicf'.l hnndicC'.p of her child mc.y m:'.ko hor invest even more of hers8lf in him, but it ;-.lso mc.y provent hor from loving the child or it mc.y c'1ll f'Jr c\ mobiliz::\tion of inner resources which da not exist be 0,". us 0 they hfwe boon too erontly sc.ppod by other concorns. Dr. Dads he.s pointed Qut in his pr.9cr on Pre-n:'.tc.l PcidC1.t:cics thct c20ch mother ho.s her own peculiar re[',s ons for r.nguish over tho birth of c. hrmdico.ppcd ehild, 2nd thc.t thoso reasons mc.y h::we little to do with tho intellect but with the emotions, or tho heo.rt. The specific meaning to the individuc.l mother should be undorstood if she needs hel;? in giving freoly of herself to the child, c.nd in tnking ndvc.ntc.go of whc.tcvor hc::.lth me[,sUI'OS ';ro :wi\ilr:-.blo in tho child's bch . . . lf. Evon the best ndjustod mothors with evary soeming C\dv['.nt~.ge bow under tho tr8.gedy of ['. defective b~.by. They dcsorve Qur D18st c.cutc percoiJtion of their feolings rmd our best help. The quality of love they 'TO c.ble to give the child is im:oroved to tho extent \lO undorstc.nd 2.nd r.llevir>.tc the specific C:lncorns :If the individuc.l mother. THE MEANING OF A CQEGENITALLY DEFECTIVE BABY TO THE MOTHBR. The ntti tudo of the m'Jthor townrd her bc.bydocs n:)t begin on the, day (If the child 1 s birth but long beflre. Ho\, she perceives and rencts to fncts of ::my kind will h~'.Vo be on determined by hor culture c.nd her own eXl)orioncos in life. Her feelings n.bcut the bn.by will be colored by h~w her community 100ks nt defective children, her religious nhilosophy, >:'.nd the ccttitudo Qf her fr.mily :".nd relntivos. They will be r.ffectod b" tho u.egree to which her potcnticcls for r. mc,ture outlook on life wore built in ~'.nd. c')ns()lid~.ted by r. hC'.PllY childhood of her own. The h:'tlT1inoss of her mrrriC'.gc r.~ncl the circumst . . . ncos she is in c.t the tir·1e cd: her nrcq:n".ncy will set those prcdetcrmin"'.nts into C'. p::\ttorn which will b,; fin".llv clotormincd by the ldnd elfC', hr,ndicr.p the child ~

-'• has. Mar'~ta1' u.r:ihapp:'ness or excessive environmental pressures oreating an unw.elcome pregnar..cy obviously predi-spose against love f9r the baby. ,The amount of phys::'cal burden, frustration, unslght.. . l1ness or humilia'Uon the handicap itself imposes "in that partioul.ar family further o.i:;>f-erentiate the kind of feelings the mother will have. In sho!'t ,the birth of a handicap1:ed baby is but one spoke ,. •in the wheel 0+ the mother's life, and it operates in relation to the rest of the wheel • . ,-'"

I 10,ok 1'oI'\lyard to learning during this seminar about the' cui tural , of the east on which psychblogical patterns toward handioapped children are built. In the Judaic Christian culture of the west, the ps~"chologica:" heri tage of an all-·seeing wrathful God who p~nishes l1S for our sins would seem to account for wide-spread reactions toward congenitally-handicapped children. These cultural vestiges ?nd an accepted myth that all mothers love their children create the base for an iutricate and devastating psyohologioal pyramid. " influe~ces

When catasti'ophe of any sor't visits the westerner, he instinotively ories to himself,. "Whatheve I dane to deserve this?1I Who can search his soulw:Lthout finding something he has done which he ought not to have done or something ,he ought to have done which he has not done? The iridivid,ual ptilI'ent in whom guilt 11es olose to the surfao~ for, let, us l3ay. marrying against a.dvice of his parents, or offending the - moral C9de. grieves that he should be eo punished, or that the child is having, to suffer for "his sins 0 Or t.he parent may proj ect his feelings onto h:l.s mari tal partner because he cannot bear to take the b.lame hi,rna!;}lf,. creating angel' or bitterness against the spouse. Suspicion may be roused between the two parents, .each thinking that • the other blames hilT!> du1lt :Ukewi.so haunts mansr mothers be'Jause they believe that all.. mothet'>S are, expected to love their children, and they know in their hearts tha't ,they do not love this child. Perhaps the baby is very l"epulaive to look at, or. very burdensome i;o care for on top of all the otber ,buro.ens ,this mother has. Perhaps the baby is a 11 ving rem1nd,erof somethingehe considers a sin , or of a disappointing or brutal' spOUSC" Seve1'6l contn'on reactions spring out of guilt. The mother may wish to hide the child. or may neglect it with at least ,an unconscious hope it will die. Or she may be'inconsistent in her handiing of the child,' first treating the bab~7 rO'L1ghly or neglectfully and then trying torr.ake up to :i. t b:r an eXGossi VG. and remorseful over1ndlllgencGc Or she .may fee'l that this cross which has been ,given her must be,borne, in order to atone for her guilt. Or she may so constantly try to prove to herself and the child that she does love hiiTl that nho depri v 08 the Other children and the well-being of the whole:t'amily to see thl':t this defective baby has every material need. Poor outcomes of pr-:gnapcy tirc ",OPe often seen in older mothers who have had lilany pregnsncieo and who have b,.;,:lO subject to health hazards 0:t"eett1ng anoxia or disposi t:l.rl1 to infectiono Women who are wow out and have big falnl lies to 100:: 8fter wi th less money for each as the -number of children inc.rc8se? and whose h!J5bands are less interested in them and more in other' t.hings, are depleted in psychic and ph;ve1eal en.e.pgy. ::t tas been our experience that these mothers :freQ.uently have very pressing Concerl1S in regard to ill health of other children" themselves or their hu:::bands$ and that poor housing and finanoial stringency ,;ibY make aacn dey an effort; There :I,s not room in their heartn 'fora full. measure of ,:c ,,'~ern over the handicapped child until SO";) fJ"~- :;thcr' >30LiL'OCS h",s been relieved. In tbeir'weighing 01" valuea1>toM.'Y or despair over something else may well come first.

,'.

AND' SIBLI NGS. THE MEANING OF LATER ORIPP L.Illif TO TIDJ PARENT§

haza defe ctive ch.l.ld J.~ that he {;sca ped the exce ption al a~e bette r for ces dhan mate rnal love durJ. ng his firstYQar~ His . Howe ver as hia being able to trus t and rela te to peop le ·ther efore the hou~ehold' in es 'moth er may be. pr~gnant or there may be new babi not be able to secu re by the time of hJ.s il1n8 6s or accid ent, he may whic h he· need s. from her extra atton tion and mani festa tions of love wher e the moth er was T~e old~r child , havin g passe d from the stage to gain from or cope udes hlS enbr e, v~or1d,. has two. paro nts' attit indi rectl y beca use rtant with . In nJ.s baby hood , hJ.s fathe r was imro ty to give love 11 abi s er of the father~ s influ ence upon the moth much awar e of verv is five to ana care to hJ.m. The chi ld from two cy of the isten cons the and his fath er, as Dr. Peto has indic ated , th and grow gical holo psyc fath er's love is esse ntial to his norm al deve lopm ent. ~~n f~thers ~ometiJ!ljjfil. ' Dr. MacK eith ment ion?d t.he disaP IJoin tmen t...west is' natu ralfQ 'r pa:t\e nts It 'feel over the cripp lJ.ng of their child ren. . Par:t icula rly ldren chi r thei to see. thei r own fulf i llme nt throu gh of 1s own life , me outco the in if an indiv idua l has boen disap poin ted t'he boy will he may lnve st, his dream s in his son, thinl< :ing that that he want ed hero beco me-th e doct or or the lawy er or the athl etic forw ard to look may to be'. Or a heav ily burde ned man of the :'and in his him ing help , the day when t·he sons will do the hard work on the nding Depe age. m1ddley~ars and susta ining him in his old er's fath the of re natu re of .the chil d's cripp ling and the natu Altho ugh we dream s, the illne ss or accid ent may wipe them out. hand icapp ed the rd towa often see grea t tend erne ss and comp assio n feren ce, indif see cpild on the part of tho fath er, we come times t. tmen poin ba lefu l or bonig n, whic h rises out of this disap when this occu rs. Infe riori ty and anxi ety are crea ted in the child ers and siste rs, The ff~el1nFs the hand icapp ed child has for his broth riva lry ral natu and theii> 'i'eel ings towa rd him, rise out of the the hand icapp ed child child ren heve for thei r pare nts' atten tion . If use of his illne ss gets more atten tion than he woul d norm ally beca by inse curit y or accid ent, his devel opme nt is at not leas t marr ed he is given spec ial and jealo usy. thoug h it may be b;:r spoi ling. When othe r child ren 'food s to eat, sllch as an orang e or an egg, and the cann ot atten d er long ingly watc h him eatin e them , or when the mothtake the cripp led an olde r chi ld' s schoo 1 part,V beca use she has to usy and reta liachild to the clin ic, foun datio ns are laid for jealo go fishi ng child tion .' Or conv ersel y, if the fathe r lets a well riori ty, infe , with him but the cripp led child must stay at homeway. Chil dren " r jealo usy and reta liati on are laid down tho othe e shap h whic life attac h mean inZs to these littl e incid ents of home of extra ordin ary thei r pers o:ml ities . ParG nts must be poss essed ly relat ions hips fami in wisdo m and ,"1a·~"_":-. t~;" .f,r they avoid imba lance one of the in rs, when a serioL 1s and lone time hea 1 th haza rd occu c~ildren.

defe cts afte r the T~e child who incu rs senso rYr moto r or cosm etic cong enita lly the over li~e has a grea t adva ntage fJ.rs t yea!!.' rd to

O!'

•

SEPARATION DUE 'I.'O HOSP I'l'AU 4A'U. QQ.

suffe ring of the Dr. Jenningsar~d Dr" MacK eith have ,liscu ssed the zatio n and the itali hosp chl1d upon sepa ratio n from his fami ly for 'furtj ler what .' ider cons to afte- r-eff ects upon his char acter p "Ie need medi cal , As ly. fami sepa ratio n for hosp i taliz a'vlo n mean s to the for' lable avai es becom tion progr ams impr ove, ond spec iaUs t atten own r thei from ved remo be hand 1capo cd child ren, they al'e ~,')t to , ialis t has his home-t~J..i;pry and talwn to a CJ. ty vlher e the speC ial faci li ties. spec with ped prac tice 8 ',ld ~Ihere- -h<'~tals arc equip '

..... -

Seventeen years ago when the Unite~ States ~irs~ b~gan a . nation wide pro:;:camme in its 51 States and terrJ. torJ.es for ~edJ.cal care of crippled children. we learned through error how easJ.ly family ties can be broke~ when this situation exists. In rural communities in a few of the states where many children badly needed expert medical attention not available locally, parents were persuQded by zeQlous health aut~ori~ies.to permit their children to go away with them for hospJ.talJ.zatJ.on. In Bome ,instances the p:".rents hnd never s.een the cities to which the children were tieken, and for le.ck of money could not possibly go there. The faJ:' away medical centre gave the child the very best in medical care, but i.t did not occur to the busy doctors and nurses the.t the p-::.rents were grieving at home for lack of news of t he child. :.lnoners had not yet been appointed in many of the hospitals. If the parents did not know how to write, or . correspondence was difficult and awkward for them, they had no way to initiate inquiries as to how t~e child was getting along. To the parents it we.s e.s if the child had been los t through death. As the day nnd weeks wore on, time the gree.t healer, filled the wound and the family readjusted to what seemed to them the total loss of the child. They porhaps moved' away to another community, the mother or father might have died and the family was scattered. Many months later, perhaps years later, it was time for the child to return home from the hospital, and then the search began for the parents. When the PQrents were found, it was as if a stranger had ~een returned to their midst, a child older and ~'bigger and with d:!. ffi cuI t ways and food habits, and often a child who was frightened by his uncouth parents and miserable in their liv:i:ng conditions after the regular neals and the clean sheets and the p~rties he had received in the hospital. Although we are thankful thct this problem w~s c~ught, and happened in only a few are~s, I felt that the errors Lade should be pointed out as something to bo considered and taken into account by those setting up new medic~l care programnles for children. IMPLICATIONS FOR A MEDICAL.. CARE PROGRAlVlME.

Those associated with p:::,oviding or giving Lledical care to children are frumiliar with the many ways in which conflicted feelings rise to the surface to interfere with medical manageLlent. Defec~ive babies born in a hospital may be left there, the parents refusing to come after the child. In larger communities affordi.lg the opportunities, parents may exhaust their Tesources and w~3te the tine of doctors indulging in IImedicnl shopping", hoping i1" vain for a different diagnosis, and IiU1.y end by taldng the l:·~by to a quack. Parents may want to place their baby in an institution or a nursery out of sight, against the Llodol''Il doctor's advice, or conversely, they may refuse to place a defective child when the doctor feels that the welfare of other children J.n tho fnmily and the Llother f s welfare demands it. NUrses or other health personnel may lecture mothers in vain about proper c."..rc rcndnu·:;ri tion of a handicapped bF.;by, only to find tho notho:::' fil1..~d with oxcus6s, or pretending not to be at home when the nurso ·c~::l..ls. Parents .J:lc.'1.y refuse to bring the child to clinic for sup~rvision, or fail to make tho child wear an expensive brace, or fail to conduct his exercises. The child who needs activity limitation or special diet or medicine at home may not receive it, or only sporadically. We also know the excessive cost of hospi tf'.liza tion and wF',steful use of valuable hospi tnl beds· o(~ur '-'lhen (' . . . 8 charge is delayed through a lasthandic~ppB~

1'.

- 98 f

minute recall. that a child is a member of a family. . We must acknowledge that problems created by parental conflicts or CJ.rcumstan"es are not always dealt with by medical care personnel in the manner desirable. "Uncooperative" parents may be angrily dismissed or met with attempts at coercin. Thoughtless, harassed or rigid personnel who vest the institution or teaching or research purposes with priority over patients, probably exist everywhere. We do know that medical care is a precious commcdity, the world over. It is expensive and scarce. We cannot afford to use it extra·vagantly. We have subscribed generously in this seminar that mental health is precious, knowing that the world's stability rests upon it. We cannot afford to damage it mare than necessarily in thehundreds of thousands of handicapped children who are having or will have medical care. Conservation of both can be achieved, obviously, though at the cost of careful planning and the use of funds for certain essentials, and also at the cost of some reorientation of medical care programmes. Several items have proved important in working toward our goal in western community, the United States. They cannot lave pertinence for many communities, but they perhaps deserve mention for such use as they may have elsewhere now, or in the future. 1. Individualization - The individual variations in parental attitudes and circumstances merits a conscientious attempt at understanding the meaning of the child's disability to the parents and their capacity, emotional and social, to give him the care he needs. Individualized h(llp ~o parents at time of q,iagnosis is an investment in their. future care of .the child. 2. . , Understanding individual parents is expensive in time and rron~y, but seems to save funds, hospital bed space, effort and human values in the long run. It cannot be achieved by wishing, but only by training personnel and staffing programmes adequately and by coordinating existing social resources with medical care programmes. As one author has pointed out, the student cadaver relationship is different from t he bilateral animate relationship ~.n the practice of medicine. Medical 'students have' to be taught how to deal ,with emotions, parents " patients', and their own, i f they are to be readied for the critical role they will play. Just as Pld.1..OQ.l o~tioh JllllSt :1ntegrate the teaching that patients are people, so for obvious reasons, must education for the ancillary service s, wit:,. special reference to nursing. Almoners, upon whem rests much of the bistory taking and sharing with other personnel of individual parental feelings a~~ circumstance, need better training and srnl1er caseloads. The socia~ agencies of emaIL or'large communities form resources of great value in securing an understanding of parents in their cOlllJllunities, when they are drawn into a cooperative relationship, ,.. Aid, not advice is frequently needed by parents of handicapped children, both in emotional support and aDeviation of stress. Maternal love, the chilcl f s basic need, cannot be forced~ but we can feed the fuel of acceptance and sympathy into the mother,so that her own generator can give out more. Frur.ily circumstances are often at bottom of seeming lack. of cooperatian.

...

'. 99 ., The mother preoccupied with worries and diff±culties needs help with tho~e things tha.t deplete·Ler inner resources. This is often hard to snr;r1 y, or it :requires sensitivity and.akill, and willingne.88 to come ..o gri~g ·with [l, C0m:"")).l1'!.it.y·~ la.o.k in·meeting ba.sio nee(ls of \lIaD7 people.

.- #

4. Adaptation ·of clinio services; Specinl cliniO-B· for frail or h'Uldico.pped babies offer some opportunity for avoiding the difficulties inher&nt in large programmes. Mothers of babies seen on the appointment system in speoial clinics need not sit in the waiting room unhappily comparing their inf~..nts with norree.]!. babies, and oan avoid the embarra.ssed or pi tying glances of O;hor mothers. Select ion is permitted of physicians.and nllrses best equipped by personality and traini~ for the work. Personnel learn through experience not to bottle up the mother! s _~iety through prema.ture rea.ssb.rance~ and to plan for the tilr.e necess3.1.'Y to . iisten to conflicts and hearta.ches. Mothers receive sufficient oonfidenue in such personnel to admit laok of love or revulsion for their children, if they have such feelings. Finding acceptance alleviates guilt a.nd thereby r,lduces tensions which f.re responsi'ble for inconsistent handling. A well trainod alwoner attached to such a olinic can extend the physicip...D' s services in this dirac ',ion and secure resource.s necessary for reducing environmental or family stress. Adaptation of hospital services Dr. MacKei th ha.s mn:do us all e.ware of the importance of daily visi tina- of the llOSpi talized child. Poor peopla living at a. diatance or mothers of Inrg~ families often bannot visit, unless special help is ,glventhem. Fa.res and provision for lodging must sometime·s be suppJ.io,l; Correspondence though an inadequate substitute .for visiting, helps a .child to know that he is loved and not forgotten, even though. the latters may bo written for an ili terat.E>. parent by someOne else·. ' Lettors to the· pA.rents are an· eSllential corallary. Planning forhospi tal discharge must be begun early i f eft·er-care. arrangements· are complicated, which they oftena.re. Childron needing seveNt cperations should be sent home or placod in a foster homo during .the interval·; ro.thorthan being kop.t in the institution. . ..

SUMMARY: Medical care and psyohologioal ttnderstandinghave each reached a high· degree of proficienoy.. Tho oa.re of the.,physically hd;ndicappod ohild requiros that they be brought to~etb.or. Thofr correlation in his .. behalf is not accomplished easily, becaus.o mediolll.'car.e i!i! prima.rily centered on the body of anlndi-.ridual, whereas, menta.l hygiene ·demlUlds that the cl~ild. be considered <!l.S a whole· and as a member of a family.·Tho·p!iy:sically handice.ppo(l child shares: wi th all children a primary need for matermi.l love. His handicap and separation from the family for medical treatm~t create hazards. The mother's ability to accept the chil(i and give him .. tho care he needs are influenced by her. freouom from guilt over his hc.nc'.ica:;,', llnd freedom from exoessive environmental and emotional pressures. Medical progr~s are called upon to help her when theyrecognizo problems in her accept~noo and oare of the child, because poor attitudes·and poor home oare.m~ ·defeat medical treatment itself, and becauso they defent it', larger aim. Succ0ssful helying is 'built upon a fottndation of ttndel'standing the undcrlying:1.iffioul tics in eaoh oase. It frequently requires the· use of social rosouroes in the corrununity. Widening the scope of medioal onre l'l'ograms to mnke these thingS possible rnises the. original cost in money and time, but without them w:1.ste OCC1Lrs of moc:'icl~l resources and huma;tl v:<:j.lues. ... -~";''''''-'--''''':''------

100 THE:ME VI. PLANNING TO MEET TIE 'PSyarosOOIAL .NEEDS OF CHILDREN .......... _. --- . • ;-'=""-~-

1. METHODS OF MASS COMMUNICATIONS n MEN'[,AL EEALTH PRINCIPLES.

Elwyn A. Morey. Increasing awareness of tho importance of tho "whole individual" in the field of health has operated in two rather conflic.ting ways. Firstly, it has led to'closer rela.tionships between the related professional disciplines, and seoond, in stressing the need for mental health to be considered positively, and as one component of total health, I think, paradoxically enough focussed attention on this one component to such an extent that the "man in the street~J is vaguely disturbed by it, somewhat apprehensive of all this new emphasis, and not at all clecr Vlnat is meant by mental hel'llth or mental hygi".me. We have even had evidence of this in our naminf'.r. The first problem of mass oommunio?tions would seem to me to be in tho field of multi-disciplinary agreement on termin~ ology and principles. People have come to rely on public health services, not only for ourative physioal treatment, but also for preventive advice and pract-:ices. Public sanction in matters of physioal health is medically direoted, and the ol(I wives I tales of the past are being replaced by SCientific medical knowledge. ' In the matter of mental ill-health, also, modern psychiatry has added greatly to increased understanding. But danger signals are not enough, and a positive mental health, approach mllst go further. Here, I should.like to quote from Profession Willi= Line, in the WFMH IbJ.letin, August 1950:' "With our realistio technique of group participation, our inoreasing qampetenoo in understanding the dynamios of human relationships, surely we oan do much more than we are doing to bring the John Does into partnership in positive mental health. There are two symbols of action in this field ••••••• The first is one's own Na t1:ol'll~l Mental Health Assoc.iation, 'which, specifically through local branches may hope to enlist the active partnership of citizens, under the stimulus of ~edicnl and social science leadership, ••••••••••••••• Secondly, and in my opinion, even more important, the Foderation is end~avour ing to institute a world forum on mental health. By 'the stimulation 6f groups allover the world, whorein mentD.l heD.lth matters may be discussed undermulti'.disciplinary social science leadership, some consensus of understanding maybo brought about. Think how wonderfUl it would bo if the John Does/lRe world really unclerstood what is involvod in tho universal faot the.t a child is born younger than his socioty; the hitherto universal fact that when individualisation is folloWOQ by urbanisD.tion,.houses are built largely under oconomic value standards, and have less regard for the meaning of home; that teaohers of young ohildren need social science .training; and so on. In this way, oan we not build up an ever incroasing weight of public opinion, based on science, in the realm of effective ar.c. satisfying human rel~.ticnships?" The first two steps I should like to propose then, as leading to mass cDmmunications of these ideas are:1.

10-

E:lqlansion of National Mental Heal th Associations. Inc'~.)ased

mul ti-disciplincry cooperation, such as, we have enjoyed in this seuinar.

At this level, howevor, the main problem of incorporating the prinoiples of mental hygiene into practices o,f I1.ny community has not been c'"irectly faced, and one must also consider some of ·the commonly used techniques for group communication. It is important that we stress communication, rather than mere dissemin,.tion of inform.:1tion, for the principles of mental hygiene need to be appl ie.£-.: as well as, acqui:::oecl. As in individual learning, mass learning, depends on cortain f"c1tors, the most important of which e.re:1.

Me,o.ningf:J.lness of the matorial

101

2• 3.

Motivation, of the learner in the situation The learner's roadinoss to learn The associations which con be made between different facts The amount of pra.ctice and use which can be mn,de of the material.

4. 5.

Methods of Communicating, Trhough the training of professional workers in ~ number A. Indirect! of different fields, mental health principles Dassed on indirectly when other advice is sought. This is particularly true in public health work, through maternity and infnnt welfare services, teachers and school medical officers and the like. As the WHO expert committee suggests, such training may consist of:1. 2. In-sorvice courses Inclusion of mental hygiene in tho basic training of all types of public health personnel, to aim at giving'e::'broad understanding of human behaViour Training of specialists in mental hygiene for public health services. These workers would study psychiatry, psychiatric social work, clinical psychology and psychistrio nursing with particular r'eference of the application of these to public health. (In gr'oup disoussions emphasis was given to the resistanoo that develops in many seotions of the population when mental health or mental hygiene ~s mentioned. It must be recognised that not only tho lay, but professional groups develop resistance. The indireot approach is the method of choice to prevent this resistance). ' Direct: Obviously a wide variety of tEChniques is neoessary, if a vast number of people of different interests, and abilities, are to be reached, and it will be expect'ed that methods require adaptation for different communi ties. In general, the moro personal the approach the mo're successful the teaching. Techniques may be classified as mainly dependent on sight OJ;' S9und,. :B.

(1)

Me.inly Visual (See "The Heal thy Village" Unesco Monographs on "Fundamental Education" V., 1951.)

Films and Filmstrips havebeen shown by several research workers to effect significant changes in attitudes, even when thSJintent of the film is not predominately educational. Films which bear little r~_ation to the particular community (e.g. School in the Mailbox to the natives in N~w Guinea) are of little value. The best teaching technique with :fHms is to uso them in conjunction with an introductory commentary, and later discussion, whon the intent is educational. It seems, however, that in tho field of mental health much could be accomplished by inoorporating m,ntal health practices in numbers of general type films ( e.g. prinoiples of child development, Pop-eye and spinach, etc.) where the ideas 'WOUld be assimilated gradually. ' Posters are usod very offectively in nu.rilbers of related fields - whY not in mental heal th?Postors, well presented, can be sim:ple ancl forcefUl. Comic-,stripsan'd comics mc.y be used in the same way. Pamphlets (SUCh as, Parents' News shoets) m<1.y bo prepared to suit a.lmost any level of Ii teraoyand comprehenaion, but' probably need to be slanta,d 1iowards particul3.r cultures. Other reacling mo.tte:;:'L such as, llrc::ll or, journal articles and comments also afforel

102 important media. (ll) Mainly Audio. S01m;} :films h:J.YQ v'll UC,S si~~·'-l:,.r 1;0 t.hoac me:lti0nec:. above, but are core restricted in their 1l.I>plica+,i.on, I1S tho commentary raay net be vp..riod.

Ra.dio t_ probably the most important sound medium. llGl.'C the communication m3Y be either direct, through talks, advertising etc., or cirect, through the inclusion of menta.l health i~eas ih plays, stories, etc., The l~tter is, in man~ ways, the most effective. Television is a mediULI which will have to be consic1.ered soon. Ta.lks ~d the ~iving of advice c.re the techniques :JO[,1 cvlmnonly in use. Preventive praotices J.n physical health owe a great deel to ti18~e- it is likely th~t in mental health the most importo.nt effects will also con~c this way. 'I'his stresses the need for consistenoy of information and advice. Again, direot talking is better appraoohed through related servioes than threugh mental hygiene experts. Dangers of Mass Educ~tion: Mass edu~ation techniques applied to mental health may sometimes do more harm than good. This is particularly likely if tho information given is uncertain or inconsistent, when even gre~,ter confusion is likely to arise; or, if the information is too dogmatic, .not allowing fOI individual variations. Over omrhasis on the import{Ulce of mental health may create anxioties and disturbances which hitherto have not existed, thus undermining the principles it soeks to develop. Thoughtless transfer of principles and toohniquos from one culture to another will obviously be unsatisf~~ctory, each grauo needing to develop variations to suit its particular needs. Diversity opinion or approaches botwoen disciplines similarly would cause confusion rotard development.

very

of and

_MENTAL HYGIENE

PUBLIC-HEA11H ?RACTICE,

Mental hygiene enters, directly or indirectly, into all phases ef publiohealth service. The committee attemllted to illustrate how knowledge derived from clinical psychiatry can be applied to public-health practice and to stimulate those engaged in practico to an incren.sed awareness <:!.nd understanding of the'montal hygione im:!}lications of t:1eir worl~. (The group meetings made tho point chc.t in planning programmes it was important to beCin where there V:'1.S an Gxprossed n08d ~or help). Family services Maj;erni ty~ In (lealinG wi tn pros::?Gctive parents, p'.lblic-heal tb workers tend. to overlook the emotionn.l sign]_ficcmco of tho eX1Jorieywe. The f.;ri.rs, natural "nel. unnatural, o.nel the " ambivalonco" (i.e., changeable feelings) of the pregnant woman and hGr husband, concc:rning tho oxpectec', child may give rise to s.erious (listurbanoes in f=ily rel'J.tionsh1;1s. Authori tative advice from, ahd an understanding attitude_en the part of) the he11lth '.Vorker cando muoh to aid the prospective parents in mi1kin[;. satisfactory enotion111 adjustments. !!!.fantsan.£..E'c-sohool children:· Many ini(1.nt "!teal th" practices - such as, rigid feeding schedules, into1..ereut 2.:1" :':"2-C','.ture toilot trainir.g, and restriction of infrmtilo movemol".t - m2.y b0 c!.:.'.Lla.,si'1G to th" c.hild's uovelopmont and to his subsoquent mentEl h,al tL E\t~liC'-~0al·t:i 'i..)1,1'.';:;:'3 who deal with infants shoulc. try to !'lake parentsav"~ro of this dangor, Of primary imllortance in tho enrly yec.. rs of [1. cllilc1' fi }'.fo is thQ. mo1;hcrohild relationship, and hoal th workers dho1JJ.d try to ;?r8SerVo, strengthen;· and stabilize thisre111.tionshir. Separa'~ion of a child from i'~s mother, J?"rticularly durine the first throe ye['..rs, s~.lOul(' bo nvoi,lecl, except as an omergency measur.o. Tho committoe d.ilHlussud in detail the situr:.tiors w;1ich neoossitate. separation of infants from their mothers, the omotion,'.l consequencGs, =d the difforenttYlles of pl:'..colwnt in .1.10[.10& or j.nsti tut 4.ons to which the chil(~ may bo subject. lIighliChts of t:,is ('.i:'Gussion follo\{~

103 1.

.. 2.

It was pointed out that governments which establish day nurseries or creches in order that mothers of pre-school children may undertake productive work outside the home should'be made to realize the implications of such a policy, from the standpoint 'of the mental health of the children. "Holiday homes" for whole families are valuable, but those which separate pre-school children from their parents may'· do": as much harm as good. In choosing a foster-home for a child, the primary concern . should be the emotional atmosphere of the new femily, and the foster~other's understanding of the child and its problems. In institutions. and special schools, an effort should be made to create a homelike environment and to supply some sort of "substitute mother" relationship. When a child is hospitalized, the mother should be permitted to visit thebospital as frequently as possible, and the hospital staff and health worker should try to help both mother and child through what is a trying emotional experience. The welfare of the child should be the determining factor in adoption, and for this reason it :i.s highly desirable thattwhcn'ever, possible, adoption should take place during the first .six months of life. The motives of the adoptive parents should.be closely investigated; a desire for a sense of fulfilment on the part of both husband and wife is considered the soundest motive.

• 3.

Sohool Health: School'medioal officers should be concerned with the mental, as well as, the physioal health of the pupils when they examine, and. they should assist the teachers in creating a school milieu favourable to, the present andfU~e mental health of the children. . ~

Handicapped ohildren: ~he handioapped ohild is often a problem referred to public-health services. The psychological mutilation which may result from.a physioal handicap may be more orippling than the physical condition itself. In addition, the handioapped ohild presents a psychological problem for its family. Provided the health worker himself has a satisfactory reactio~ to physical handicaps, he can contribut:e greatly to successful adjustment of the child and' its family. Care of the Aged; Another speoial concern of publio health serVices, is the ()are of the aged and infirm. It is important to realize that financial support of the aged is only one of the factors to be considered; it is equally essentinl to kelp them achieve ahd maintain a sense of usefulness to SOCiety, through suitable social opportunities and some sort of productiv8.activity. Oommunica.ble dise,,,",sos: The fears and s1;igma which are often associated with communicable disea~ and the segregrction which the diseases impose, give rise to many mental health probl-ems. Leprosy, tuberoulosis and venereal infections may be oi ted as speoific examples. In leper oolonies, the incidenc'e of psychologica.l disorders is such that psychiatric hospitals have had to be provided in some of thom. In tuberculosis sanatoria, the psychological effects of prolonged sogregationand loss of a sense of purpose in life cnn greatly hamper succes of treatment, tuberculosis patients also suffer from these effects when they attempt to adjust to "normal" life n.fter discharge from ac.natoria. With regp.rd to venereal. diseases, the chief mental health concern is the psychological factors involved in sexual promiscuity. The mental hygienist is also conoernod with the psycholog-' ical implications of educational campaigns associated with anti-venereal-d~sease me a.sures ; he oan assist publ ic-hc~l.th_ .we-rkoxa-in mcki.ng such campaigns affective.

- 104WAYS ANll MEANS OF IMPLEMENTING THE F:rirDINGS OFTHESEiI[NAR-

Dr ..

F. lJulsara

1. Effective plannin~ to be of value.has to be done necessarily on the spot in relati:n to the' context of existing situation and therefore need~ fi~st and foremost, a quick but close survey of a comprehensive character in order to allow for the int0r-action of physical, biological and social forces in the community or society concerned. Pla~ning must further relate to the available resources of the cummunity or country in finances, in trained pereonnel, equipment, training facilities and young recruits of the required calibre to feed the training. institutions. The instructions for planning should emanate from properly constituted ~uthority if the plann~rs are to be saved from frustration or the unnecessary wastag6 of energy in pushing forward an unwanted plan or project. Those a~tually engaged at the field level will be in a much better position eith,;r to plan or help in the preparation of a Workable or effective plan. The plans should s at targets and time schedules for each phase. An evaluation has to follow to see that there is no undue wastage in the execution of the plan and the objectives arc kept steatily in view and unhealthy repercussions or developments avoided. If these aspects of effective planning bo conceded, it will be seen why a s ominar like ours cannot undertake to produce a specific plan appJiQ1ble or acceptable to a dozen different countries at different levels 0 ..: devolopment. 2. A questi·'n that my be pertinently discussed is "how far can we spread this useful knowledge of a wise upbrir.-,ing of children with a respect' for' their developing personality, not only among the profess ional people, who arc responsible for the care and treatment of children, but also among communities al\d i'amilies~ and particularly among actual and prospective parents, who are> most intimately concerned with a balanced growth of their children, phYSically, mentally, morally and SOCially? In short, how can we promote on a limited proi'essionaland wider nation-wide basis "mental. hoalth in childhood", so that children growing up with. the foundation of a healthy mind and body may create h(Jalthy SOCiety, .capabloof \vitpstanding the inevitable stress as and strains of a complex and dynamic ciVilisation, and of enjoying the kaleidoscopic life that is man's heritage. To poso tho problem in this way is to' faco the realities' of the situation in our respective cultures with their specific social mores and miliau, their economic and political structure, and patterns of family life.

3. The findings of genet ics, human enbryology, of. eugenics, pediatrics, psychology, psychiatry and psycho-analysis can bo applied 'in tho practice of tho respective profess ions in every country irrespoct ivo of cult ural differences. For, the proved facts of science do not ultimately admit of cultural barriers for their diffusion. This aspect of the univHsality of proved scientific knowledge, which can be tested and appli€;d with expected ~osults, is very significant for technically and SCientifically less dovoloped countries, for, we can adopt it with relatively little cost and great advantol.<!.e in proportion to the expenditure involved in its importation through original books, translations or technicians. In your consideration of plans to mc"et the psychosocial needs of children you might wish to consider .the following quostions. ). 1· How comprehensive should the Report of the Seminar be to bo u,seful"to the . members of the various profeSSions, to the administrators and legisla.t.ors. How far would a s6loctive or compn,hensivebibliographyof literature and a catologue of films with details u.bout pric\Js, producers and availability on loan or purchase bo useful. Can such a bibliography or lis~ be usefully included in the Report. Can W.H.O. or U.N.:r.S.C.O. or any other international organisation be induoed to keep the bibliographic and film lists up to date.

3. 2.

3. 4.

Would the holding of multi-discipHnary moetings of persons interested in mcn~al health and hygiene, someWhat on the lines of the seminar bo of assistance in arousing professional interest in the subject and help create public opinion.

- 105 -

•

Would a National Association for Mental Health and Hygiene prove of value in devoloping programmes for mantal health in each country? The danger of multiplying associations of a nation-wide rangQmay however, . be guarded against. Whore there arc already professional bodies in the individual fields or disoiplines, whioh troat of some aspect of mental hoalth;1t may bl, oonsidered whethtoF it would not be \vise sometime for these bodies· to meet together to sccur.., a total approach to the problem of the mental hGalth of adults and children. In some of the smaller countries, this is particularly important because·of the very small numbers of interested profossionals or specialists available there at present. 3~

What assistance can the United Na.tions and its Sp<lcialist:>d Agencies and other international organisations like tho various Foundations render to individual countrios in supporting local or rogional conferenoes by providing literature, specialist p.srsonnel, undertaking or assisting in country-¥ide surveys and rosearoh; the provi$ion of partial or complete small libraries of selected books and films and the award of Fellowships or ScholarShips in neoded fields. Foundations like the Rockefeller, Carnegie and Ford, which are eager to help may be persuaded to take up .specific activities or projects which the other international organisations cannot help, care boing taken to prevent duplication. Whereas testud and provon sciontific knowlc,dge can be adopted and applied in different cultural milieus, the question naturally arises, what techniques have to bo followed whure the daily life· of . a substantial group of p(lople and their mores, customs, beliefs and IIIOral and social values may bt: affected by the adoption of practices, so far,ioreign to them" What is the best way to use the services of social workers and social scientists, such as sociologists, anthropologists, psycholo~ists and social educationalists when projects are boing planned, with a view to eringing under caroful invostigation and consideration people's reactions to the injection of the new activity ~ong them and further with a view of enlisting thoir cooperation~ publ~

3. 1.

3. 8.

3. 9. 3. 10.

When is a preliminary survey of tho local community, as a means of arousing interest and as a fact finding project justifiable?

Similarly taking tho local community into confidonce by a proper approaoh through its olucted or s "locted leadors has proved of inestimable value, wherever it has been employed. This not only· facilitates the work of those going into the community from outside, but has lead to whole-hearted support of the community, resulting in valuable assistance by way of donations, workers and free labour. This is an aspeot of tremendous significanoe in Asian oonditions with poorc,r state resources and such vast idle or under-employed man-power throughout the year in urban and industrial areas. C," ..,nyt'·ing be done to brine the cOnQepts of \IKlnta.l health to the masses of the people? Telescoping methods and techneques for the solution of such mass problems as illittoracy, provision of medical and public health services, social education, application of the achievements of soienoe to improve agriculture and rural life arc being triod out in a large number of Asian and oth~r lOSS w$11 developed countrieil. Those interosted in the problem of mental nealth of ohildren and ()f tho oommunity in general may well stu"ly thelJe movemonts of CQmmunity organisation and devolopment that aro going on in their

3. 11.

- 106 -

countrios such as CODmunity Contres, Family Welfare Centres, Maternal and Child Welfare Centres etc. Can the same forces be harnassed to put across the fundamental or basic knowledge of mental hoa:lth? To ''That extent can the 'keyworkerc .such a.. public. !,ealth assistants, la .' health visitors ,. nurses, ·midwives, teachers, multipurpose cOmlunity workrs at the village level.be used, providing the appropria.te training of these personn~l can· be carried out. These workers are in contact with the people through the country.

3. 12.

The underdeveloped coun"r10S who faoe the basic problems on which (!ood mental health depends viz. adequato nutrition. sutficiency of clothing and sanitary housing, medical care, eduoation and Bocial security~ Thoy will, thereby, both direotly and indireotly oontribute to a much greater measure to the montal health of the oommunity. Continuous lack of nutrition, ignoranoe of tho ordinary ways of living and functioning of the environment, are conduoive to constant anziety and neurosis. A few yoars ago much of the sciontific knowledge was oonsidered abstruse, difficult, and above the head ~f the average lay oitizen. To-day in many spheres of higher scientifio knowledgo, populnr books are explaining thoso abstruse and difficult subjects and their implications are being'worked out, in various types,of apparatus. Similarly psychologic~l matters andpr6blems are not somothing extraordinarily abstruse and can be understood by tho average citizen if presontod to him in ~ suitflble form. ,basic prinCiples of mental health for Can 1'10 simplify their inclusion in ~chool and oollege curricula? How can this be dono in advanood countries immediately and how eanit bo done' in' underdeveloped oountries and when? . ,I

3. 13.

•

.:) ..

•

..... . .!

. ~ .. 1, .'

~UW'ARIES OF CONCLUSIONS' OF DISCUSSIONS

- 107 -,

ON PLANNtkG TO IlEET THE PSYCHOSOCIAL NEEDS OF CHILIREN

Tbe-f~~WWing conclusions were reached in the group meetings and plenary session devoted to the consideration of this theme. 1.Gen~ral

principlos /

For its practical application the nee~s for me~tal health should be interpreted in terms of the everyday living of the people, and each worker on the tield of health, education and' welfare needs to be able to interpret these prinoiples accordiag to the needs of tho enviroonment. It optimal.eonditionlt tor manta! health are to '\e obtained tft the community thay must come largely through ~ protessiotilal

. cballnels. pos.i~

To this end it is necessary to e~sure,.as tar as sound personality dYVolopment in those profosaional . workors eng.agod i,n the field of human relationsbipa. .'

."~

1. 3.

be mot as they arise;

The needs of the community with respect to mental hygiene ahQU!d evory effort should be made to avoid lU'ouriq anxiety by stimulating action which the oommunity is not aeekiag.

1. 4.

Unwise publicity, which suggests evils that do not Gxist, thereby creating anxieties or cures that do not exist, thereby raising falso hopes is most undesirable. fI2grammes for maternal and child health.

2. 1.

A sound programme of mental hygiene should begin with adequate pronatal care, lollowed by sound natal aDd post natal supervision. adequate prenatal care impliess(0.) good obs.tetric practice based on sound training both

of dootors and nurses; this will lliniJllise toxaomia ot pregnancy and prematurity; (b)'the guidanoe of the moth~r throughout pregnancy to a tull understanding of. the development ot the foetus, her own emotional reactions to hor family situation and to her partioipation in labour. This knowledge will help minimise .physical and psychological damage to the moth~r and child and should reduco the incidence of cere.bral trauma to the infant. In postnatal supctvision stress should be laid on the need for the establishment of breast feeding with the avoidance of rigid programmes· and for the necessity to re-examino the mother some weeks atter the birth of h~r infant. It was agreed that the teaching of the personnel engaged in the cc.re of the 0 - 6 years old group was of basic importance. The public health nurse, (the health visitor, the intant welfare.nurle) have the most diroct contaot with the home, when ohildren are this age, therefore adequate training in tho tiold of mental-hygiene 11 necessary. '!his also implies the inclusion of mental health prinoiples in general nursing training. ' The criteria of selection of public health nurses (health vis itors, infant weltare nurses) should be reviewed to make sure that only the most suitable are employed. Muoh damage to the mental h&alth ot mothers can be done by unsuitable personnel.

- 108 ..

3. 3. 1. 2.

The incorpor~tion of t~e er~n~l~s of m~ntal he~lth i~ tho ]:Iasic traihlng .of nur.~, . ---, In ordor that a nurse's basic training may better prepare hur for modern neods tho following are desirable: A broader psychological approach to the teaching all subjects on the curriculu..m, including the help needed for the trainee nurse to understand her own feelings and reactiona. The integration of aspects of health as well as sicknoss into thE) toaching. In training programmes for obstetric nurses more recognition l'let'ds to be giv(')n to the ,!!ghrniiY pationt as a mother and to th.e bobyts emotion~l noeds. A bro~dor considera~ion ~f brca.t feeding problems with less emphasis on rigid routine; " In tho training progr:mrrne of, nurses in paediatric hospitals and wards considerable emphas'is should be given to the characteristics 'ot'the growth and development of children, with explanations 0:C ·,'normal" or expected behaviour under a variety of conditions, inciuding hospit:J.lization. " Ih paediatric nursing tho ~hild should be considered as a whole pllrson and due emphasis placed on his individual needs. The hospitalization of' chil~ren.

3. 3. 3. , 4.

3. 5.

3. 6. 4.

4. 1.

This problem ':las approached in two sections: (a) To what extent can ohildron be kept out of hospital? (b) When they have to bo admitted v!hat can be done to minimise the harmful cflocts of separation?

4. 2.

Avoiding unnoces'3ary hospitalization is particularly important with Children under 5 years of age; many operations can be duferred, e.g. tonsillectomy, hornioraphy. ' When hospitalization of the yo~g child is unavoid~blo, great care should be given to the preparation of both parents and chiid:.and greator undorstand ing shown of the child's emotional neecj.,s during tho p0riod of separation. Bettor trained dOlilicilary practitionors who are ablo and willing to treat patients at home and better liaison between hospitals :md these practitioners Vlould reduco the need tor hospitalization and allow earliur discharge of children from hospitals. In the Asian~Pacific cO'.mtrios, owing, partly to pressure on beds, there seems leBs,unnecessary hospitaliZation and 'we 'would'urge things to be kept that way. It is bettor for tho resources to be used develoiJing home services rathor them elaborato hospital development. Thero are. two types of adnissions, acute and elective, which pose rather dif,feront problems. Most of the points made here reter to elective admissions. Explanation is neoessary at home, ~t the hospital during the admission phase, on discharge. Bold explanation \oIetoro ,admission can do much harm and it is folt that much of this risk can 'be circumvented if admission techniques are improved. In tho admission routine mother and ohild need to moet someone who inspiros confidonco. The teChniques must be el.stic allowing

4. 4.

. . .... ~

4.7.

- 109 for vari~tions according to circumstancos. This requires oducation ofthcpal:'sonnel. "It might be. done as you woultl approach a child with -!ts--mother coming to stay in your own homo". 4. 8. Whether a child for operation should have 24 hours in hospital first to get used to tb~ plgce or come in on the same day was diacussod, without reaohing a d.ofi·nite answ~r. Tho child's itihIoduction to the ward is considered ihe mast important time of all. What happons to the child in the ward during its waking hours? How often do nurses know the child's familiar words f~ toilet actions or ovon his own familiar name? 5urelythese should be added to the admission questions. Ward activity, cleanors, ambul:l.tory child ron all help to interest tho child but there is tho danger of the quiet ones and some conscious effort is necessary both by staft and ideally,by spocial staff for the purpose. A broad generalization is that 4 year olds can be occupied and intorosted by materials but 2 year olds need Reople. In countries where mothers arc habitually admitted with. tho ohild, there is a tendency for nurses to become mere distributors of drugs. How are -'we to recognize the children Who neod the, mother in? This can be loarnt by observation, but in teaching the principles wo must convence nurses that such a nedd is no reflection on their care. What about other children in the ward? It was generally thought that they. would not be upset if they know their own mother will come __ later. Who should make the decision as to visiting? "Discre'tiQn . It must be made by the paediatrician in conjunction with tho sister. of the Sister" does not work.

4. 9.

4. 10.

4. 11.

4. 12.

4. 13.

4. 14.

A set time for visiting each day tends to be difficult top hospitals. Reasonable and convenient staggering is preferable.

fr2!2ssiona~.training of teachers to better eauio them to !!"ntrlbttte to sound mental health programmes.

In the past, in general, too much emphasis has been placed on the acquisition of professional techniques for the teaching of srecific skills, with too little provision on the devolopment of the pers onality 01' the teacher or ofun<ierstanding the needs of the developing child. Since one of the principles of IIIElntal health is that a child should integrate all his experionces, there should be tho close,t co-operation between home an4 sqhool at all stages of a ohild' slife. achool teachers, as a well-informed group in the commtll'lity, should help to interpret the needs of children to the community. The contributions of psychologists to a mental health ~~.

5. 2.

5. l. 6. 6_ 1.

The best contribution of tho psychologist is in a mwlti. disciplinary team.

- 110 &. 2. The psychologists ca:: r(,ndcr tho following ar:Jac. ' scrr'·~ c,

in this way, in

6. 2. 1.

Lqucation (a) TtrClChcr tr:lining, basic and in-service; (b~ Social and vocational guidance, (c) Remedial servicGs, in respect of specific cducat:;,blo (d) Adult education, Community Welfare Servico; (a) Maternal, Inf:l.nt :;.nd Child Welfare (including training of personnel), (b) Hospital sfrvicos. (c) F:unily gllidancc (includit1.'; child and marriage guidance); (d) Institutions for childron (e.g. orphanagos, hOt~es for dolinquonts and handicapped children), (e) Courts (including probrttion); . (f) Rccrc.'ltion servicos; e.g. clubs, playgrounds, holiday camps, de. Indust ry. (a) Employment services; (b) personnal relations, (c) Accident prevention.

6. 2. 2.

ft. 2. 3.

An understanding of the principlos of Mantal Hoalth enunciated by the SocinClr is basic in tho training of lIocial workers.

7. 2.

Social work educators should bf. aware of this, and there is now a trond to include these principles in all schools of social work • Although social workers hMo long b'ci'n aware that evory buman is a distinct personality 'll'td that this fact has been demonstrated scientifically, they :uso need to understand specifically tho principles cf dynQmic psychology. It is unfortunClte thclt in the p"lSt, the principlos of mental hoalth have fr:.quontly 1::(hJn ignored when policies for ehild caro WGre forr:l'.llaicd • S ocial wor.k.._aduo~ors htWl- le,:rnt that the incorporation of principlos of cont:..l health in tr3.;,ning courses for social work(;rs is -frequently fraught '(lith (liffi~ulty be cause at anxieties aroused thl:rf'1::y in the studer.ts thoPlsolves. Practical experienoe under supervision of the application of these principlos is necessary to allay anxio1;3' arousod', and should apply tho p:>:'inciples only Vlho'(! ;.he 3"t;.tdent is roady to receive them and to experience tho validity 0"' tho principlfls. It is important th:L t'lis kno'.lIhJgc: should permeate the administration ef: all :J.goncics dCllin:o, with the care of young children, and it i'3 the r:s,Jonsibility of social workers to interpret thv principles to ~dministrators ~n1 legislators. The concopt of fost.er family CQre instuad of institutional care of depondent children should be onColtrar;8d, and where substitute parental care of children under the ago of 6 years is necessary,

.,. 3.

7. 4.

.,. 5.

'I. 6.

'1. 7.

.. - 111evf>ry ettort should be made to place them with toster parents. This is more economioal, and has better results than institutional care.

7. 8.

It is a healthy principle whorever pouible to aftord the mother ot dostitute children such financial and other assistance as will enablo her to keep her children in her own care. High priority should be given in all countries ~p programmes which will allow this to be done. . .

/',,7.'.• 2.,' .' Social workers make a major contribution to IDOntal health -;.... ;'.. Qt·· ch ildrenby et torts to alleviate pors ontil, soc ial and . "econ:)mio streues in the home • • lid:', •. .10., .All tamiliEls, irrespective of economic need, should havev·!:.:rc;; ~:;r .i~: ~~

In this connection PIJ.I""ft't1l comill8-;j.'. ;ititocontaet witl1 intant welf'aJ-'I'J..e&ntTos, pre-sohool oentres., ·.'sehoO'ls and .other social agoncies. .', ,it. .is important to 'reaoh tho social prob.loma of .- . , ord~rto .

.. 'a'ccl'es9 to caso wOJ,'k ass istaneo when needed.

advancethetraatrnent of tho child as a wholo,• ,': ". ." ~he'co-ordination ot all,community resources in dealing with sQc~ - .. ;... ' ' .. prol:ilems:ot all' kinds is regarded as fundamental. Effective 'Co-':i c1;,,:',Z':," 'o'rdlnalli{)n ,depen<!8 on a propf;r approciation of ' the respective' ,;;'. ,'J ' tol'Os of each disoipline, and it is the responsibility or each " ...'.' ·,ttis1oipline to adapt skills and techniques to the neods of'\the organization. . ":'.' t,·,

. ,.': '.,. :11.' -.~ In

1'r

7.:.12,

'l'Ite prevention ot social problems presents a constlin(;:' ":.,. dta11engeto sooial workers, and tho preventive tiold9.f"·:·· 80118.1 wort caMot be too st rongly stress ad. Preventi,on')' saves 'Gos\s 1ft ~th human suffering and economic pr!)Vljl'().rl and ., soo1a.l. workers have a res')onsibility to stimulato this·~ttitude. . .. ",,- ,":':, .'. '

\,. '"

-.. . .(.' ;.

.J,' :.

",.'

..... .' ..•.}1. ~

. .:.' i' -,'", .. . . ,'. ",

,-.:

·'.'i

, ," ; ~: '",

... '

~.;

...:..

\ .....

-I,; .,: ... . '! .... :'

..!.

- 112 ~g9NCEFl' OF :MEX,'J~_~_Jl:ND _?..~ BASIC PRINCIPLES ~~G

OUT OF THE SEMINAR,

•

DuJ:oing the sem!.nar there evolved a strong 'desire to devt:::op oOnCepts cf mental. health which oould be used by members and others as a guide to the develop:rent. of programmes to meet the psycho~socl.al needs of ohildren.

t '

1. Health is a state of complete pivsical~ mental and social well-being and oot merely the absence of disease or infu:mity. This state of general wellbeing is possible. only when there is abseJ:1..oe of want. .. 2. Mental health is an essential component of this ooncept of total heaJ.th.

We accept the definition of "Mental Health" as formula.ted in the Report on the SeQOnd Session of the Expert Colll!cittee en Mental P~alth appointed by' the World Health Organisation, which says "Mental health as the committee " understands it is inflw=ed by bcih biological and social factors.' It is not a statio condition b1,t subject to variations and. fluctuations of .degree·; '. theoommittee's conception implies thL capacity in an individual to form' ha.rnxmious relation with others l and to participate in, or contribute dO}lloIo" . structively tc, changes in his social and physical environment. It implies also his ability to achieve a harmonious and balanced satisfaction. of his own . potentially oonflicting instinctive drives--harroonious in that, it reaohes an • integrated synthesis rather than the denial of 'satisfaction to ce~!'!4.n ..' instinctive tendencies as a means of avoiding the' thwartiJ1g of, others. . It ' implies in addition, an inal,;-idual·.whose personality has developed in a wa:l~' . 'Which enables his potentially conflioting instiilotivedrives to find harmonious expression in the full realization of his potentialities, In considering this definition in relation to children, it is recognised that the potent.ia.lities of the child are continually developing, and that the mental health of the adult is rooted in the sound mental health of the child.

3..

Mental health is likely to occur 1..'1 a family and collllllUllity where the parents and other members of the family themselves are health3" and living harmoniously. For then they are better able to nurture the child in such a way as to build a robust perso!'.ality • Faotors whioh influence physical health ma.y directly or indirect+y affect mental health. These factors include genetic constitution; factors affeoting embryonic development; prernatu:;:e onset of labour; hazards of birth or the postnatal period. ,In ma.n.Y il.lStances by the application of present medical knowledge, these conditions can be prevented or minimised.

.5..

6.. The building of a robust personaUtyis assisted by an understanding of the stages in the growth and development of the child of the complexi.ties of inter-personal relationships~ 7. Children's potentialities will develop more fully when their individual differences in physique. intelligence and temperament at each stage of their development are underst~od and taken ~nto consideration by the adults charged with their Ctl.re and training" 8. The· best developIOOnt of the child is mad.e easier i f we deal with him as an1nili:;n.dual, for, i t is only frorr. the child himself' that we can learn by liste~ to and watching him what his especial personal needs are. Our comprehension of the ohild's individual needs is hdped i f we remember that he behaves meaningfully to himself .dUrin the limits of his ma.turity and . experience and that hw.an behaviour i.s a.:ffected by the intellect and 00011. ions, and also by continuous mental processes of which the conscious mind nay be una:ware. All, and a:ny of the child I s experiences may affect his later behaviour even i f the experiences a!'e not consciously remembered.

•

9. Emotional security of thd kind that derives from intimate relationship, with loving parents or 1:Arent sUbstitutes is one of the basic needs of children. Serious' character defects and unhealth;y ways of reaoting to stress in adults can be traced baok to excessive emotional insecurity in cb:i.ldhood. In the course of the child1s development conflicts are inevitable. These are often associated with desires for dependence or independence. These may give rise to emotions in parent and child which are disturbing to both of them. Either may temporarily feel hostiUty towards a person 'Who is usually greatly loved and this emotional experience may arouse anxiety. If th@ esseJ:rtially normal l'Iature of this reaction is UIlderstood by the parents they can better tolerate their own feelings and in their tu..-.n give help to the ohild. The satisfaotory handling of these oonflicts forms the basis on which the child lAtor handles his conflicts in other spheres.

10.

11. It is a matter of colllIOOn observation that emotional problems exist in every person;_group, coll1lllL1llity and society. 12. As ill-health from malnutrition and infection beoomes less -with technological advance, emotional problems become more obvious. This tenclency rray perhaps be counteracted in countries, where urbanisation 8J}d industriaJ.isation are in their earlier ~tages, by the applioation of the aocumulated knowledge of mental h;ygiene' available in other parts of the world and by avoiding the latter's mista,kIOlS. For, such laJOwledge and mental h;ygiene ~lread;y' available should mo..!::c it possible to modify wrl;oward trends of social dev~lOimmt. . ,

'T~ ..are i Qhil4,ren who are relatively .bandicapped from realis:i,ng their full development of' personality, au1. adapting adequately to the, demands of their life in the oommunity. It should.be realised that these baDticaps are not 1'i%ed states, but are capable of amelioration., - By proper care and assistance such children can be greatly helped to proper development and adaptation. _, ., ,

1'.

14.

In consideris:lg this concept there isneedfo~apprecl~tlon of the cultural patterns of cOIllllllmities. This should be borne- in mind. through theusllal phases- :of invest,igation, administration and application in the field.. . " .... . .... .

15.

Finality in knowledge of mental health is not reaohed yet, a,nd there is need of researoh and constant reassessment of our knowledge.'

..",.

'.'

. ... ., -

- .

. -

- 114EVALUATION OF TEE SEMINAR BY TEE MEMBERS.

...

. T~o evaluations were made 'of the seminar, its conduot and values. The ~~rs~ wqs k struotured and WI"./il made through a que.stionaire' distributed in the. rs Wee to be oompleted and handed in at the end of ~e first weck. EVALUATION AT END OF THE FIRST WEEK.

The results of the first evaluation made by 32 participants were as follows:Fairly good Not up to

Good

--I. 2. I feel the seminnr up to this date has been ,,30

Exp;c-M.tions ";

The plenary sessions have been: The group meetings have been:

21 22

5 10

4. (._,

That time plaIined for eaoh ha.s been:

of,~e

fOllOwing:

too long .~ust :i'1g,~t 's~g~t

.:' f.:

( a) (b) (c) ( d) {e)

length of working day time to explorethll libra:r.-y Talking· With other members Plenary sessions Group meetings 1

22 15

1 17 '.':.'. '

.. -\

24 .

8' 3

28 26

What oriticisms would you raise at this time: (a) About the general arrangements: Few answered this question, most of those who did asked ~or more time for sightseeing. Others made a veiled reference to this by suggesting that the afternoon should be free with sessions in the (lvenings. Most of these apparently wished to use this time for extra seminar activities. (b) About the plenary sessions, Most of those who commented on this asked for a longer time for general discussions in the plenary meetings followiDg the talks. This was done. One hoped that the material would be 'more practioa.l~

(0)

About the group meetings: A fow answered this, and asked the faculty members should be rotated. This apparently arose from a desire of all~embers to associate with some particular faoulty members. /

" - 115 EVALUATION AT THE END OF THE SEMINAR. The~0<~(md-'&valllation was conducted first in the group meetings, repcrts from ·which were' then presented to a plenary mea tingby group reporters. was followed by '" ganeral discuDsicn on evaluation. J

This

:PiSGus.sious wero stimulated al'.d perhaps partially structured by the distribution during the second 'Neek of a questionaire which was meant to aid discussiens.

1. There ,;ns a universal comm'mt that ·the time between receipt of the notices abcut th') semin0.r and the event was too sncrt for the selection of perhaps the mos~ sa -:;isf',:lctory nomine",s f~'om all ceuntries. Fer some pa.rticipants there was no time to gather the fa.cts suggesten in the Circular letter Ne.3.

2. :::t was suggested. tha.t a brief sumrnary (t page) of· the talks, together with a list of references and a programme should be sent te participants well in advance of the r'.eparture from the::').' own countries. (This is partly in oonfliot with the suggestion in paragraph 4, below. Ed.). 3.· These participants who. received Circular letter No.3 sometime before their departure, and had h&d time to meet with officials and experts from their own countries had found 'this set of questions most helpful in orientating .their thinking towards the main themes of the seminar. \

4. It W(1S generally agreed that there shou1(L be at least three representatives froll\ 0 ach country. (This was strongly expressed by these who were the Bole nomin00s ofthoir country.)

Some felt th~t th~ p=oeramrne should have been more flexible, especially in the 2nd an~. 3rd weeks, to allow more speakers from Asian countries to give factualta.lks to tho plenary meetings. (This would have been easier to organize if the names cmd cual:'fica'tions of -the Asian participants had been availa.ble much earlier than -they w';re - Director.)

6. It was said by seme, that there could have been more meetings of profassi.onal groups.

7. A recornrr:eJ:,l[', tion was made that .3. mee ti.ng of the groups should have been held before 1;;1::; ol't'J.ci~,~. opc,ning and rece11tion. This would have assured thi1.t everyone woulc_ hrN" rr.\.d; everyone e1 se 'before the mee ting.

8. General' tlIJpreciation

W'l.S ex:prcsserl te'3 programme content. The IlIl1l tidiscipl Lr,ry, mul ti-cul taraJ. charactor of t1::.e membership reaul ted in the presentation of rna:1Y f~.. : '._ to every questior,. l'his proved to be a moat stimulating experiol" 00 0

It '.... ,tS c:onsi'k:red by somo that too much time wns devoted te maternal depriva.tion (one ;It;.y) anc. th.J.t more time cou~.(l have been spent on the consideration OflCommon Behg.7iour Probh,mf1 cT Children, and Poyohologicd Problens the Handicapped Child.

- 116 10. The following subjects should have been included in the planned programme g i.

Mental health of parents, brief historical account of adult attitudes towards children.

. 1

ii.

11. Some. of the members from New Zealand and Australia, thought that there were too many pictures of Western cultural patterns., and not enough of Asian patterns in the papers presented to plenary sessions •. To some extent this was offset by the free presentation of local prQblems and experiences by the Asian members in the group meetings. In.this respect, some groups obviously were more fi'..vourefl. than others. 12. Some thought that there should have been'more organised meetings of, cuI tural grOl,PS This is a debatable· point •.. There seemed to b.e ample opp<;>rtunity fo~;g'z:pups to get together in the unplanned free-time, at meal time, and at the,.soc;:ie.l cLub. ' 0

13. C.

Some of the papers presented to the plenary sessions were too long. General Arrangements!

14.

Some reporters felt that they were often too fully occupied recording the discussion to be able to take an active part. It was suggested that in future seminnrs non-participants should be secured to do the reporting, advanced students or tho vnrious disciplines would be only too happy to do. this.

15.

The, sC:r'oerdng of films· had a mixed reception. They were screened in the room USed for plenary meetings, and all members felt they should see these. Scme were familinr to members, others were oonsidered unsuitable. It was agreed that a plan for the most satisfactory use of films had not been developed. The library came in for some oomment, mainly, tha.t there wns not enough time to usc it satisf?.otorfly. Perhaps, in part, this may have been due to the impression that the members were expected to read the books and pamphlets Whilst members were free to do this, if time permitted. The main purpose of the library wMtodisplay the books etc., that were available on this subject.

16.

Tho "Open" Plenary Sessionsl 17. These four meetings held at 8.p.m were attended by about 100 doctors, social workers, nurses et~., from Sydney in addition to the members of the seminnr. In theirevalu.ati;on of these meetings, the members of the seminar were of the _opiniont4'l.t they did not assist the semin!'!.r programme. Indeed some felt that on e?,ch .0ccaSion, they may even have retarded the even progression of the seminar • ." .Qnthe other hand there is ample evidence that they stimult'.ted intense interest in mental health in childhood in many Sydney groups, which is even now he.vinr, rc 81;1 ts. EVALUATION BY THE FACULTY. At tho c::mclusion of the semin1'.r the members of the faculty met to consider the w<'.ys b which the seminar might have functioned more smoothly from the admin:'str(',tivo point of view.

General consideration. ..

Appreci~tion w~s expressod of the courage of IVHO in organ1S1ng a seminar on this su-oject in this region n.t tho prGsent time. It was agreed th<'.t the

.. ll7 seminar wes successful in that it establishe~ a frien~y atmosphere wherein the members could exchange idoas, lear~ about the problems of other countries and generally obtain support for many of their own ideas and practices. 2. Time Schedule.

, It was agreed that the time schedule GOuld have been improved. The time between the deeision to hpld tho seminar (1st April), and the dates when the seminar had to be held in order to use the accommoda.tion (lOth August to 3rd September) at the University Colleges was far too short to ensure the most satisfactory planning. 'The decision to hold such a seminar sho~d be made at least twelve months before the date. A staff member ~f WHO, or a special con.ultant who could subsequentlY participate in the seminar should visit all oountIies in the region immodiately after the decision is made to hold 'the seminar. The purposos of this ~sit would be to asoertain the most pressing proble~s in each oountry, and help the authoritios select the delegates. This woUld permit ample time for oo11aboration between the delegates and it would enable more participation by-the delogateb in tho aotual planning of the programme. 3. Selection of the partioipants.

• ~

A te~ of at least three from each oountry or territory is to be proferred Although a good working knowledge of English was to a single representative. cons~ered a pre-requisitive, this was not observed in all cases. The seleotion of representatiwes from countries with widely different oultural patterns was a particularly happy arrangement. There was little or no evidence that the participants from the economically underdeveloped oountries were so overwhelmed by the magnitude of the physioal problems in their own countries, th~t they were unable to benefit by discussions with fellow workers from the more highl~ advanced Western cultures. In not a few instances, representatives of the former were able to tell of work they were doing in the fields of mental health that was new to people from the more highly developed countries. 4. Programme.

The faculty members reoognise that towards the end the time-table was too orowded. In part this was due to the inclusion of extra talks, in part by the nature of the subjects which demanded extra time for disoussion in the group meetings. Attention should be drawn to the reaotions of a number of members to the theme of Maternal Deprivation. Whilst most members of the seminar were prepared to accept the efrects of separation of a child from its mothers, these other members rejected the idea completelY. It is just possible that the soenes in the film were so anxiety provoking that they blocked acoeptance of the ideas. There is no doubt that the unrelieved sequenc~of the effects of separation in the films ''Maternal Deprivation" and "Grief" oould be lightened with a few brighter sequences. There was a suggestion that the theme "The Child and its Relationship to the Community" should have preceded the th.eme "The Child as an Individual',!, The decision to develop the programme as it was presented was to some extent tho result of a certain degree of anxiety amongst the Australian members of the faoulty who carried the major lecturing burden, about their ignorance of the oultural patterns and the problems of the peoples of the Asian and Western Pacific countries, from whioh the delegates came. In a future seminar of this kind. it would be highly desirable to include lecturers from as many oultures as possible, or failing th~t, international lecturers with experience of a variety of cultures. This is only possible if ample timeia given for planning.

-mUndoubtedly the group meetings were more valuable than the plennry sessions and it so far as is possible to in future seminars, two group meetings S40uld be held for each plenary session.

APPENDU TIME

TABLE.

DAY A.

Monday. 10.8.53. Arrival, registration, official opening and reception. TUesday, 11.8.53 •. Plenary Session - Mental Hygiene - An Orientation 9.00 .a.m. Lecture - Dr. C.R.Gundry. 10.30. a.m. Plenary Seesion - The Technique of the Seminar Dr. F.W.Clements. 11.30. a.m~

DAY B

Group meetings Group meetings

2 •. 00 p.m. - oJ .1.

4.-qo p.m. Films THEME 1. DAY 1.

THE CHILD AS AN INDIVIDUAL.

Wednesday, 12.8.53.· 9.00 a.m. Plenary Session - Some Aspects of Personality Development in Childhood. - Dr •. E. 1(ol'ey

10.30 a.m. Group·Meetings 2.00 p.m. Plenary Session - The possible relationship of Bvent. and conditions oQourring in the pre-Natal peried upon personality deveLopment - Professor Lorimer Dods 3.l5.p.m. Group meetings Films l3.a.~

4.45. p,m. DAY 2.

Thursday, 9. 00 a.m.

Plenary Session - Some e~ents and oonditions in post-natal life of the ohild whioh might affeot personality development. Dr·, Ronald MaoKei th Group Meetings Plenary Session - The child's sooial development. Dr. Irene Sebire Group Meetings Films

10,30 a.m. 2. 00 p.m.

3.15 p,m.

4.45 p.m. DAY 3. 9.00 a.m. 10.30 a..m. 8. 00 p.m.

Friday, 14.8.53. Plenary Session - Psyohoanalytioal Theory of Early Personality Development ~ Dr. Andrew Peto Group Meetings Plenary Session - Summary of talks, disoussions and questions raised on Theme 1 - Dr. C,H~Ound;t'y ,THE CHILD .A1lDIT_S RELATIONSHIP TO THE COMMUNITY.

THEME 2. I

DAY 4.

I"'

Monday, 11.8.53.

9. 00 a.m.

Plenary Session - Family Patterns and Child Care • . Professor Raymond Firth

•

Monday, ).7.8.53 (Cont.) 10.30 a.IDo Group Meeting Group Meeting Films Plenary Session - Fami~y Patterns in respect to the training of ohildren - Miss Norma Parker Group Meetings Plenary Session - The Child and the Community in South East Asia - Dr.J.F.Bulsara Group Meetings Plenary Session - Changes in Authority and Conformity of Children in Australia Miss Gladys Pendred Group Meetings Plenary Session - Summary of talks, discussions and questions raised on Theme 2 - Professor Raymond Firth MATERNAL DEPRIVATION. Plenary Session ... 1, The effects of separation on young children - Dr. Alan Jennings 11. The effects of separation on young children Dr. Andrew Peto Group Meetings Plenary Session - Children in Hospital, Before during and afterwards - Dr. Ronald MaoKeith Group Meetings . (The films . Grief (Spitz) Maternal Dep'rivation (Roudinesco) A Two-Year old Goes to Hospital (Robertson.) were screened during the plenary discussions this day). THEME 4 DAY 8. COMMON BEHAVIOUR PROBLEMS OF CHILDREN, Friday, 21.8.53.

2. 00 p.m 4. 00 p.m DAY 5.

. Tuesday, 18.8.53.

9. 00 a.m 10.30 a.m

2. 00 p.m 3.30. p.m DAY 6

Wednesday, 19.8.53.

9. 00

~.m

10.30 a.m

8. 00 p.m THEME 3. DAY

7. 9. 00 a.m

10.30 a.m.

•

2. 00 p.m

3.30 p.m

9. 00 a.m Plenary Session - i. The Meaning of Children's behaviour disorders - Dr. Albert Ph' '.lips 11. Nervous Disorders in Children and an Approach to Therapy - Dr. Desmond Arnott 11. 00 a.m Group Meeting Plenary Session - Summary of talks, discussions and questions raised on Themes 3 and 4. Dr. John Williams

• ,

8. 00 p.m

THEME 5. DAY 9.

PLANNING TO MEET THE PSYCHOSOCIAL NEEDS OF CHILDREN - PART 1. 1

Monday 24.8.53.

00 a.m

Plenary Session - Planning to meet the Psyohospoial needs of children - Dr. C.H.Gundry Group meetings (Professional groups) Plenary Session - Methods of Mass Communication in Jl{ental Heal th Principles - Dr. Elwyn Morey Group meetings THE

10.30 a.m

2. 00 p.m 3.30.p.m THEME 6. DAY 10.

PSYCHOLOGIC A:' PROBI':EMS OF THE HANDICAPPED CHILD. 25.8.53.

Tuesd~y,

2. 00 p.m

Plenary Session - The Psyohological ProbJemB of the handicapped child i. ii. Medical Aspeots - Dr. Ronald MacKeith I~edico-social Aspects - M'rs. Georgia Travis

3.30 p.m 8. 00 p.m

Group Meetings Plenary Session - Summnry of talks, disoussions and quescions raised on Theme 6 - Dr. Ronald MacKeith ~ING TO MEET THE PSYCHOLOGICAL ~l.

THEME 5. (Continued) DAY 11.

NEEDS, OF

CHILDREN - PART

Wednesday, 26.8.53

9. 00 a.m lO~

Plenary Session - Planning within the Framework of 100801 conditions - Dr.J.F.Bulsara Group Meetings . Plerary Session -Reports from groups. EVALUATION.

2 0

q..m

2. OOp.m THEME 6.

9. 00 a.m .

Group evaluc. tivns of t he Seminar Plena.ry Session - .. Evaluntion . ------.--~.--

11.30 a.m

CONCLUSIONS.

•

2. 00 p.m

Plenary SessiC:1S .,. Conclusions.

WORLD hL.il.lTJ:l ORG,J.US.Ll._T}_~__-:-- COlll.'IONWEALTH GOVERlfMENT SEMINAR Ol~

MENT"J, HB1.l.LTH

Ii~

CHILDHOOD.

List of Members. ~rs.

Luisa Alvarez Phil ippines.

Supervisor Health Department, General Office Bureau of Public Schools, Manila, Philippines. Senior Honorary Psychiatrist Children's Hospital, Practicing Psychiatrist, Macquarie Street, Sydney, Australia. Far Eastern Regional .Social . Welfare Advisor, United liations Technical Assistance Administration, C/- E.C.A.F.E. Bangkok, Thailand. Deputy Matron, Royal Alexandra Hospital for Children, Camperdown, Sydney, Australia. Chief Division of Child Welfare, Social Welfare Administration, Manila, Philippines. Psychiatrist, Guidance Cli~c, Philippine Mental Health AssoCiation, 431 Paredes Street, Manila. Chief Psychiatrist, Male Se'rvice Depa.rtment, National Mental Hospi,tal, Rizal, Philippines. Medical Officer to Baby Health Centres and School Medica.l Officer, Canber~~" A.C.T. Au~tralia. Lecturer in Child and Educational Psychology, University of Hong Kong Lecturer-in-charge', Social Pediatrics, Institute of Child Health, University of Sydney. Medical Director & Physician to In:ptients, Children's Hospi tal, Melbourne, Australia. Director, Maternal and Baby Welfare Division, Department of Health, N.S.W. Professor of Child Health, University of'Sydney, Director of Institute of Child Health, Royal Alexandra Hospital for Children, (graduated from general practice to pediatrics) Camperdown, Sydney, Australia.

Dr. D.II.H. Arnott Sydney Australia. (Member of the Faculty) Dr. F'. J. Bulsara, Bangkok, Thailand. (Member of'the Faculty) Miss D. Bush, Sydney Australia Mra. Gertrudis R. Cabangon, Manila, Philippines. Dr. Jose M.Clarin Philippines

.. Dr. Edith Clement, ,Canberra, A.C.T. Australia Miss Marie F. Clements, Hong Kong Dr. Frederick if. Clements, Sydney, Australia. (Director of the Seminar) Dr. Vernon Collins, Melbourne, Australia Dr. Grace Cuthbert-Brown, Sydney, Australia Professor Lorimer Dods, Sydney, Australia. (Member of the Faculty)

Professor Raymond Firth, London. (Member of the Faculty) Miss Moira F, Gallagher. New Zeala.nd Dr. Charles Gundry, Canada. (Memher of the Faculty)

Professor of Anthropology, London University, London School" of Economics, Aldwych, London \/.C.2, England. Supervisor of Pre-School Services, Dep,utment of Education, New Zealand. Director, liIIental'Hygiene Program in Department, Vancouver, B.C. C~ad.:I. l~europsychi,::.trist at the local Beterans Hos]?i tal, and a lecturer in psychiatry at the Faculty of Medicine, University of British Columbia. In the fQll of 1951, he went to Thnil311d as a short-term consultant in Mental Hygiene for World Health Organisation. Social Worker, Maternal & Child Y'/elfare Department, Ministry of Heal th, ,jog jakarta, Republic of Indonesia. Assistant 'Professor, Ochcmomizu Women's University, Staff member of the Research Institute for the Care of Mother's and Children, Jallan. Director, Centre Child Guidu.nce CliniC, Hyogo Prefecture, Tokyo, Japan. Chief of Departm',nt of Nursing Nation~l Institute of Health, Taiwan, Chine. Technical Expert in Charge of Mental Hygieno Division, N;~tional Institute of Beal th, Taiw11.n, Chin?.. HonoraryPedi,1.trician at Royal North Shore hospital, Sydney, Australia. Research Fellow King George V and Queen Mary Maternal a.nd Infant ,felfare Foundation. Honorary Physician Mater Misericordiae, Chi,uren's Hospital, and ~ecturer in Podiatrics, University of Queensland, Australia. 217 W'ickham Terrace, Brisbane, Ql d. Psychiatrist, No.1 Child Guidance Clinic, School of Medical Services, Department of Public Health, Sydney. Australia. Senior Inspector of Schools, Department of Education, Christchurch, New Zealand.

Miss Hari[\ti, Indonesia.

Dr. Nobuyoshi Hirai, Japan

Mr. Junichiro Horiguchi Japan Miss Ai Chu Hsu, Taiwf1.n, China Mr. Chien liou Hwang, Taiwan, China. Dr. Clair Isbister. Sydney, Australia.

Dr. David Jackson, Queensland

Dr. Alan Jennings, Sydney, Australia (Member of the Faculty) Mr. J. F. Johnson, Now Zealand

., -

Dr. Margaret M. Jon9s, sydney, Australia • Miss Dorothy Tze Kao, Tdwan, China. Professor Estefania A. M.:;.nila, Philippines ~

L"cturer in Hygione, T.. acher l s College, Sydney, Australia. Professor of PLysical Eciucation, ~J.C.U. Principal, AfLiliated Primary School of Hsin Chu, Hsin Cbu, T4 wan, China. Director, Institute for Human Adjustment, Professor in Psychology, Chainnan, Department of Psychology, Philippines University, M.. nil:J., Pr.ilippines. Assistant Technical E~)Qrt, Nursing Department, N;.tional Institute of Health, Taiwan, China. Poliomyelitis Medical Supervisor, Victorian Hcclth D.. ?artment, Victoria, Australia. Research Social Worker, Department of Social Studie s, University of Sydney, Australia. . Dir.;.ctor, Divj.sion of Child Hygiene, D(.; .artment of Hc;alth, Wellington, New Z.. :;.laOO • Pediatrician, Guy I s Hospit.al, Lomon, England. H(';di of CJ:;ildren Section Out-Put-ient Clinic, M.. ntal Hos,. ital, lX;onruri, Thailand.

Miss Yun:..O-Lu, T.:-.iwan, C:-ina. Dr. Bertram P. McCloskev, Melbourne, Australia. Miss Mary McLelland, Sydney, Australia. (Member of tho F<~culty) Dr. Gordon McL~od, New Z",-"land Dr. Ronald MacKeith, Lomon, England. (M,;mber of the Fbculty) Dr. Subha M.:;.lukul, . Bangkok, Tl-.~land

Lecturer in P~chiutr.v, University of Medical Science, Thailand. Miss Leonie J. M~rtin, Hobart, Aus tralia. S~nior Psychologist to Division of Mental Hygiene an:! State Ps,ychological Clinic, Hobart T,:smania •

Dr. W. Barbara Meredith, Victoria, Australia.

Director of M<lt .. rnal, In.t:ant ani PreSchool WEoli' .:trc. DeJJurtment of Health, M~. t .. rnal ani Child Hygiene Branch, Victoria, Aust.ralia. D(';'A.l.ty Director, Scheol of Medical Service, Dapartme:o~, of Public H""J.1th,' Sydnoy, Auutr:'lin.

Dr. Edwin A~' Meyers, Sydney, Australia.

Dr. St.anlb;{ W. P. N€:1v ZcC!land.

M~,,;,s,

Deputy Dir6ctor of Men.t:l.l Hygiene, Dt;p:~r'rr.lent of Health, Wellington, New Zeslani • 1i edieal Director of Mothers & 132bies .H ",ulth Associ,'ltion, Adelnide, South Austr'11ia.

Dr'. Es t.ell> R. Mocatta. Ad~l~idc, Sth. Aust.ralia.

, ,

.' Dr. ElVf!n Mor..s:...r, Western i.us (,r"li2" , (M ember of the Faculty) Senior Lecturer in Ch:~.::"d :md Clinical Psychology, University of vVestern Austr1!1ia, Nedlands, W. A• '

Vo.rsit:~,

Stirling Highw:JY, Nedl:!nds, W.A. Dr. Hugh C. Muroh.y! .. Queenshrrl • Dr. Wilfred,1,. Nichobs, Singapore. Miss Audrey 1... R. Orbell, New Z(;'112M. Miss Nonna Parker, Sydney. ,(Membor of the, F'Icul ty) Miss Gledys Pendred, Canberro., 1... C.T. (Member of the F~culty) Dr. Andrew~,

Director Mnterrml ani Child Welf"re SUMCS, DO:,;1rt."ncnt of Health nnd Home Affairs, Brisbi',ne, bustr;\lia. senior Lecturer, Department of Social Medicine and ,Public He.?lth, University of MaLlya, Singo.pore. Nu.rse Inspector of Hospitals and Nurse Instructor, DcpartInent of Health, Wellington, Now Zodand • Director, Dcp"rtnont of Soci~!l StudiOS, The University of Syd~cy, Sydney. Chief Educational Officer of the' Australicln hssociation fo~ Pre-8chool Child DevalDpment c/o Institute of I.rmtomy, Canberra, i •• C..T. Australia. . Former~ Director of the Institute for Research of Juvenile Delinquency and . " Psychiatrist to the Juvenile Court '~riBUdape8t, Hungary.' Training-analyst and Secl;"etal}" of the Sydney Institute of Psycho-analysis. Private address: IIParkviewll '.: .... '. ,c"., Guilfoyle Ave., ;' Double B9Y. Australia.

Sydney. (Member of the F~culty)

Dr. Albert'R. Phillips' Melbourne • (Member of the Faculty)

Psychiatry Superintendent, Travancore De'·elopmental Centre and Travancor~Ql.ir9-,c)· Depe.rtment of Mental HygLene, Victb~a'~ Lecturer in Mental Health, Depll.rtJllent of Social Studies, Tutor in Psychopathology, Department of Psychology, University of Melbourne. . Matron, Torren's House, School for Infant Welfare Nurses, Adelaide, South Australia. Rangoon General Hospital, Rangoon, Bl;.rma. Pediatrician, South Australia. i.'

Miss Jean M. Parkinson, Adelaide, South ],tlstralia. Dr. Daw Popo. Dr. Bronte M. Pulsford, South Australia. Dr. Joan J. Refshauge. New Guinea. Dr. Naomi R. Ryan, Adelide, South hustralia. Miss M. Cl. Sarawak. ~

Medical Officer in Charge; Infant arid" Materne.l Welfare, Port Moresby, Papua, Nt-w Guin0a. Medical Officer, DepartInent of Public. IIealth, Adelaide, South: Australia,' .. '.

, ..l

:I.CI

Health Sister for Saraw;:.k. Address: Health Centre, Kuching, Sarawak.

I \ (./-", .

the Faculty) Dr. Basil F. R. Stafford, QUf?enslam. "

Child Psychiatrist, No.2 Child Guidance Clinic; School Medical Ser'iice, Department of Public Health, New South Wal~s, Australia. The Director, Child Guidance Clin:i.c, Dept. of Health and Medical Servo.c.;;s, Address: Dept. of Health & Home Affairs, Brisbane, Australia. ' Medica: Officer in Charge of Child Health, SenioT,' Medi.cnl Officer 0: Schools, Medi,cal Superviso!' of Infent Heillth, Western Australia. Addrf;.ss: "All Waysll lJ. Alexarrlra A,ve., Claremont, Perth, W.A. Direct.or of the Governmont Mental,Hospital, Dhonburi,Th~:;'land. Lecturer in ~sychiatry in Medical School. ' ' ' ' Sen;lor Medical Officer, Maternal and 'Child Welfare Depa.pt.:;ent, Ministry of Health, "Jogjakarta, Republic of IrAonesia. .Director Medical Social Services' and 'IrcStl'uctor, Dsparj::nent of MediCine, University pf Colorado; Fulbright Locturer, 'iJniversity vf-Sydney"Depar.Lment of Soc.ial Studies. Superintend€int Of the Field Branch, Child Welfare. Department, Sydney, Sydney, N. S ;\'{. Education Officer,lr.alay Wumen's Training College, Mdacca. Federation of Ma1a,Ya..• P eychiatrist Clinic, Children's Hospital, Melbourne, illlS tralia. AdviBp.r, Maternal and Child Health Services, vleste::n Pacific RegionalOffict:, World Health Organization, Manila.

Dr. Eleanor M. Stang Wes,tern Aus tralia.

DT.Arun B. Suwana

ITri -SoepannanT,ibkro-Atmodjo Republic of Indo~esia.

Mrs~ Georgia Travis,

. Sydney. (Member of the Faculty) "'Mi:~, Eric, Troy

_: :':; ,:s,drieyo, i~"

Miss Constance White. ,Malacca, Mal",ya.

Dr. Dr~

John F; Williams. Melbourne

A.E. Wimot, Manila.

COIvIMONVlEALTH OF 11.USTRALIA - HORLD HEi..LTH OitGl..NISATION. MENTAL HEALTH SmHN':i.R -.------CIRCUL~R LETTER NO.l.

Preparation by participa~ts during the pro-seninar phase. 1.

Introduction:

Circular letter No.3 pointed out that in the nost successful type of scientific neetings considerable preparation takes place in the weeks and nonths preceding the actual neeting.. So it has been for this seninar. 'The nenbers of the faculty have had nunerous neetings in which a wide rr:mge of sub-jects relating to the conduct of the senirh"!.r have been discussed. It is hoped that the parti~ipants will be able to devote. a considerable ~Dount of tine between the receipt of this lotter, and their departure for the seninp.r considering the several points outli~ed below. 2.

Purposes of prepa.ration by participant~ in-the-pre-seninar phase.

It is not proposed tht".t the !:lE'.teril:'.l you collect should be fomally presented as a paper, bc;..t that thereby. you shOUld be 'able to enter nore fully into the discussions in tho group neetings.

Methods of collection of naterial.

The ;ideal ncthodis for the dolegr.tes attentling :the. setlinar to neet, several tLDOS ifnccossary, with a group of people who are infonlod about the subjects to be discusseG ~t

the

sen~~~r.

Tho

;

group can discuss tho progrp~r:me of tho soninr.r and tho subject.s outlined in this Circular letter. ~his proce~ure has three advnntages: (a) ·it enables the delegates to the se:r.l:Lnar to 'be briefed on local problens by the people who are handling then as part of their daily work; it affords the delegates an opportunity to gather problens of particulr,r locnl inportance which can be discussed at· tho seninr.ori . tho delegates can neet the sru~o group on his return and present then with a report of the seninar, with a s~~ary of tho cOLw.onts n~de on tho local problens which were discussec'.. with hin before he left for-the seninar.

(b)

(c)

Failing the opportunity to have this kind of neeting be~ fore c.eparture for the seninar, it is suggested that the partiCipants .... where ther£; are r:'.Ore than one, should neet p..ud. cUscuss the progranno and this Circular letter, anJ that they should ?gree to collect the facts not jOintly known to then by personal interview with the appropri~te authorities. A single celegate can ['~so do this. It is not intended thnt the :preparation in the pre-scninar phase should bo spent re",c1in;~ stancln.rc1 works on the various subjects. Local infornation (',nel facts arc far nore inportant. '-

Collect...i.on o ...:L.E.eleva.nt Local Literature reports etc. ,

As part oft his preparation we s'trongly'urge' ... t~ou f$lould collect and bring to the'-sem'inar-repor~s, reprints, .:~~ pr'inted in English relating to any of the subJects to be.d~scu~sed. W-en-WOtt1~ to, put"these in the semim r libra.r.y where they w~ll be 'available all members of the semire r,. '

. ,',

t: i :

Films:

It may be that local e.uthori ties have made films a:eali'ng' with some of the·subjects to be discussed. If these are available in 16.m.m. size, and if'. it is possible for you to arrange matters, , WE? suggest you bring these films. We will arra''1.ge for t hem to be ,s,creened when you 'can supply the appropriate commentary. Certain fOrIllr'.li ties will have to be completed on entry, ,into Australia to enable the fiJ:r.:S to be passed by the filn censor. - If you bring filns with you, it is suggest<ad that you cooplete the attached forn rtnd have it available anongst your papers on arrival ntSydney a i r p o r t . ' . in the Pre-senin;-r Phase. 6.1. ~..,.sical _condi tions Jik.f'J:y to affect per_sonE'.li ty developnent 6.l.1. Certain noxious jnfluences ar€l now known to operate during tt1e first triD<:~ster of pr!:'r;:'.a:1CY, e. g. rubella.. '" . QUESTIONS: . . .. ' . Hp..ve the effects of ruoelle. or P.::.:y other noxious ihflU:~ice 9:eeratil1g during pregl'l.p.ncy been. recorded in your ,count:ry? . ,W"ha.t: are the recorded effects? . . " Are special efforts nade to help the child so affected, adjust. into the no:ml?~ life of the connuni ty'? If not, what Q.oes becone of then? Is p;nything kJl0wn of the subsequent socia:lbehaviour of these children? 6.1.2. Prenaturity. The question is often nsk€ld whether prenaturity,~erse, has any effects on personality developnelJ,t. This nay be d~scusf"~d during the sonine.r. . . . QUESTIONS: Whnt is ttt.!) prenatu.ri ty rete in your country? What special pI'ovision,~ !It'.de for the C:1re of tho prenE'.ture? Is there any eviclc11ce f\.vail8.blf:. frc:::l your country which.·night help answer the question whether prenatu::'i.tv does ~ff.ectJlc.l:!.S.o.na.li ty dcvelopnent? ' 6.1..3. Congeni tal nalfo rL18;t ions , if, severe, nay be associated wi t-h disturbance of the personality. /' QUESTION: , Arc there any' ligv.rcs fo:..' tho incidence of congeni tal.~ fo~ations? What are the cor~lonest. forns of congenital nalfornations? 6.l.4. A groulJ of diseases' ~c;,l' '}ntly called the psychoI:'l£!.tic diseases Q.re of int"r::;st to us in this H0Llinar. There is frequently n strong enotiollt'.l fE"ctor in thei.r etiology. Included in this list are infantile food eczema, asthma, . "

· "'.

ileo-colitis, intorference with vision. QUESTION.:.. Do these diseases, occur fro~uently in children in your country? (It is ,highly unlikely thE'.t thore w ill be any offici~l statistics of incidence, but you nay be 'able to get a general idea fron pe.diatricians or general practi tionors).' It would beintorosting to know if there has been ~ increase following ru~y najor social change e.g. nore intense industrialization of localities. During tho seninar the interesting phononenoa of why in some children the. Lluscles of tho bronchi (asthma) secra to be e.ffected aild why in others the colon (oloo-coli tis) is affocted. It v{ould be interesting to know what is the rel~tive incidence of thes~ . various disaases? Have you any evidence of a rol~tionship between psychosonatic diseases and fnnily,ettitudes or experiences (e.g. anxiety states assoc~~ted with war, nigration etc.) The QualJty of ~other-C~j,Jd Rel~tionships: During the seminRr fre~uont references will be nadc to the ~uality of nother-child relationships, so· that a knowledge about the following points would be helpful in the discussions. 6.2.1. Are childron welcome additions to the family? 6.2.2. Are thcrodifferent attitudes in different socio-economic classes? 6.2.3. Approxinctely what porccntage of childrQn arc breast-fod to thre;e T.1onths- to six months? :"ro thoro socio-economic difforencc.s?· 6.2.4. Is prQlonged breast feeding practiced by any group in tho population? Vlhe.tis the usual. age of weaning of these children? 6.2.5. What are tho feolingsc-of'--thoso Dothcrs who are not able to breast feed their children, arc thoy concerned about the effects of this upon the child? If so, what do they fear? 6.2.6. Whnt is the traditional p.ttitudc of nothers towE'.rds the care and handling of children? ( a) ensy, deDonst'~tive anc,- waru, asevidenced by constant attenti'qn, frcquvnt cuddling (b) remote, imporsonal, in the belief that cuddling is haruful. Whcn this is'the attitude the child is frequently left. 1Ulc'1ttendeG. for l.ong periocls. 6.2.7. Who looks after the; child, tho Dother T:lOstly, cr the caro shared by many people? 6.2.8. Have traditional practicos changed in recent times by the Iilntroduction of other techni~ues? 6.2.9. To what extent is tho young child handled and carried ~round by cithe;r the mother, siblj~~s etc., 6.2. ~ II

-'Why do wonen ,with young children work outisdc ihe hone? Borec..on, financip..l, CCi:'lt:irmationofa career?

6.5. ~,

Th.(~nedical g,ucsti.2!lI2..Esked by nothcrs of young children:

w~rc nothers, bring their infants and young children for ned~cal

All countri.cs now ha\Te Info.nt Wolf"re Centres or Poly6~ir.rles

and/or hOM th nclvico. QUESTIONS~

Wh'1,t ,1.1'0 tbo domrumt p:coblor.ls brought by nothers of infE'.nts ane.; yO~If-(~ ,~:l:ilci.r"n, attending these clinics in your country?, What "ro thcr.)I,.·TO},iJ:mte relntive proporti'.ns of: (e.) Ph'>'sical clisoas0, e. g. infc '~tious clisee.sos (b) feeding problens, (L1e~nutritioil) (c) beh.aviour problens, e.g. refusing food, nega.tivisn etc. Are. there B,ocio-economc differonc.es? ' Has there been a change in 'eripnasis in' recent t':i,nes?Can this change be rele.ted to any social ch'e.hgo? Do'es the training of the staff of Infant Welfare Centres, include the stuely of onotiongl and social factors as well a.s of tbe physl,caJ,.? Wha.t percentage'of info.nts attend Infant Welfar.e Cent-res? IS,a.tt~ndancc'regular?

\\ , \

... " ".

6.6; ,'The Attitude of the Cormunity 1,;owards young children: , The attitude of CO:r.lllUI.li ties towards young childrenvai'ies ;, f~n narked frecdon '~o one of' severe restriction to within well defi:p.ed :-L-i;:,'i.ts o The ai;titud.e children arc expected to show to':" wards adults," especially parent.8~ Varies fron one of an easy conpan:ionship toa ~estrictiveon(; in. which children are 9xpected to renain, "seen and not hee.rd". ' QUESTIONS: . Wn2,t A.ru the traditional attitudes in your eoun-pry? Are there eth.."lic or socio-economi8 differences? Has there been a change ill attitude in recent tiBGS? "

6.1. j ..

Social Stress: . .

'" · - A variety ,·of social' J?roblens, e .go poverty, poor houSing, insufficient housus lead.ing to IlP..rked overcrowding, chronic faJniJ.,y illho9-lth like Balaria, (:((/1. p:::ooc1uce stresses within the family , which nny [',ffect the develollnont of the personality of the .children. ,Frequent chanBos of pIece of living, nonac1isn is also a social factor in child developncnt. gUE§.TIONS: Which of these soci.a1 factors oPerate in your country? Have you or others observed any effects upon the pattern of dovcloprlOnt of the children?

s Behaviour Problcr.1s: During the seninar references will be nc.de to tho nomal. 'developrlont ofch:;.lc1ren,and it will be pointed out that some of 'the so-c.·l.llec1 "bohe.vicur prohlons" of children are in fact expressions of the nomal process of growing Uh At this stage, we do not • -·<think it wise ,to enunerato these, However f it would. help the dis'" cussions if you woulc~ collect a list of t hose characteristics of chilc1ren 1 s qohaviour in your countrY which thinking parents, or the " authori tiesconsidor al'e problens of behe.viour. In some ways ·thi.s ~, ,question .duplicp.tes the question posed in 6.5.(c) '",v': ..

608.

~hil(trenl

6.2.10. Wh::,.t is the attituc~e bwards habit training? (toilet, sleep etc.) 6.2.10.1. Co~nencGd early with fiTI~ desire to have the child "trained\! as young as possible 6.2.10.2. Flexible -allowing the child to "train'! itself as it~ !'lntures 6.2.11. Does the f ather play an activo rolc in t'ho he..n111ine of tho cp.ild during tho fir st year? . 6.2.12. Infe..nts and young chilGren at tines suck t~oir thunbs, handle their gonitals - What is the general attituce of parents to these happenings? 6.2.13. Vlhon is the childf-expo ct ed to show disgust and. shame in respect of body functions?· NOTE: It is highly unlikely th".t there is ono ·e.nSWer to any of those ~uestions for any country. It is noro-likely that thore arc a nunbor of answers for difforent ethnic, socio-econoroc or rclig-· ious groups. It would be helpful to Imow of those differonc~s. 6.3. Opportunities for children to play together: lllay in childhood has an inportant effect upon tho soci~l and. Gl.1otional clGvolopnen t. Opportuni tics for prc-school children to play with their o~uals depen~1s on a nur.1bcr of f2.ctors, e.g. sufficient chUarenin close proxinity in thesano age group, facili tios for plewing togother, atti tude·.of adults towards ilho group. playef children. .. In the nore· highly developec'.. countries the large nunbor of- . small fanilios has r<Jduccd opportunities for children to neet a 6uffici(mt nunbcr of children of the sane age. Attenpts to; ncot this deficioncy have lead to the establishment of kindergartens etc. However, even in well se.rveC'. COI:lIluni tics existing facilities seldon provL~c for as nuch 2.S 10% of the pre-school population. QUESTIONS: What is the traditional attituce towards pre-school children playing together in your country? What kind of play do they engage in ? i. e. froo - non-purposeful-play. or play that is essentially a preparation for their lifets work, i.e. playing at the occupations of their fathers? . At what ago .do children start to participate in activities outside tho hone? In your opinion, what function doos play have in doveloping the pgttorn. of 60ci/:.l development of children in your country?

The Child of the Working Mothor: The perccntage of women with chilr",ren who are gainfully employed outside the homo varies considerably fron country to country, and fron group to group within the sane country. In sone (countries or situations) the infants and childron acconpany the nothor when she goes about her work outside the hone, in others they are loft. in the care of re12.tives or older children, in others -, still, theY:?Irc put in croches or clay nurseries. QUESTION: What happencls in your country? Approxinately what percent ... age of wonen who lk"\ve yo1ll'~ children work outside their h o n e s ? i . Betweon whp.t ages [>,ro chilo.rem left at clay "nursories"? '}h2.t cloyo'J. know about the stanc1nrc1s of care in the creches? HOW Lluch "noth0ring" cl0 those chil(~rcn rece:i:Ivo? Is tho sickness rntc or nort2.11 ty r'1.te of these chil'lron higher than in chilclrcn froIj, the saDe socio... econonic groups whoso nothcrs /[0 not work?

6.4.

Informations clés

Organisation Organisation mondiale de la santé (OMS)

Type de document Technical Documents

Date d'adoption 31 décembre 1953

Source Organisation mondiale de la santé