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MALADJUSTMENT IN CHILDREN.*

By ROBERT THOMPSON

W ITHIN recent years, largely perhaps on account of the ever in- creasing numbers of adolescents brought before our Juvenile Courts, maladjustment in children has received a good deal of

study, and has assumed a position of considerable importance in our national life. So far has this progressed that the majority of civic authorities in England have now established Child Guidance Services, which, in the main, consist of out-patient clinics where these children are examined and treated, and various types of hostel to which certain cases are admitted for, as it were, in-patient treatment. The account which follows attempts to give a brief survey of the more usual types of case encountered in child guidance work, their response to treatment, and their probable future development.

Normal Mental Development Before attempting to understand maladjustment in children it is essential

to have a clear mental picture of what ordinarily constitutes " normal " mental development in a child. The well-known " landmarks" of develop- ment, e.g., taking notice, sitting up, walking, talking, becoming "d ry , ' " afford a very rough sort of historical guide to what has happened, but it is essential to bear in mind that wide variations from the usually accepted times of these landmarks may betoken nothing abnormal. Sphincter control, for example, may " normally " be attained in the second or third year, but, on the other hand, enuresis may persist in a perfectly normal boy or girl well into the teens.

Much more important, however, than these " landmarks " is our con- ception of normal intellectual and emotional development. The toddler should be insatiable in his curiosity, and only physical and mental fatigue should put a stop to his efforts. He should also, at this stage, display strongly the instinct of self-display, and always look for an admiring audience to witness his prowess. Mistaken attempts to restrict the activity of a toddler, often from abnormal fears for his safety, or failure to recognise and pay due attention to his "triumphs," are both, perhaps, unwitting forms of mental cruelty (akin to the strange rSgime fashionable some years ago of never lifting a baby from his cot except for feeding or toilet requirements), and may cause deep mental frustration in the toddler's mind, usually followed by restless nights, negativism, tantrums, refusal of food, enuresis, etc. I t may, I think, be briefly put that normal mental and emotional development should always--certainly from the point of taking notice--be a happy and exciting experience for the child, and that such symptoms as crying, (except when hungry or in discomfort), refusal of food, negativism, tantrums, sleeplessness, " nervousness " and fears, inability to concentrate, undue shyness, unsociability, avoidance of games, all betray that something is going wrong and needs correction. Moral lapses, such as lying, stealing and playing truant, may also point in the same direction, and usually do, but it has to be borne in mind that all children are naturally selfish, dishonest and

*From St. Crispin Hospital, Huston, Northampton.

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untruthful, and that these tendencies are only overcome if the parents, at an early age, implant in the mind sentiments favouring unselfishness, honesty and truthfulness. Pilfering and lying may, therefore, be present without any basis of maladjustment, and may depend simply on an almost total absence of the ethical sentiments.

There are, of course, other aspects to be borne in mind. The selfish child, tha t is, the child who from gross indulgence or complete lack of training has no conception of the rights of other children, or of " give and take," will meet with a sea of difficulties on beginning school life, and these difficulties within a very short t ime may produce very considerable maladjustment. Also it is easy to say tha t a child should be taught simple ethical principles from about the age of two onwards, but how few parents are qualified to carry out this task ! In the first place it can be done only if there is a strong bond of affection between parent and child (cold-blooded " lectures " avail nothing), and the parent must be sufficiently intelligent to choose the right moment for the talk (hardly ever in the presence of a third party), and to use simple illustrations which the child can grasp. Put over in this way the teaching is accepted by the child, who thus begins to build up a system of altruistic sentiments with a corresponding increase in his happiness. (The "spoi led " child is notoriously unhappy.) I t can thus be seen how irequently this tuition fails, and how difficult it may be for foster-parents (especially childless foster-parents) to strike the right note, apart altogether from the difficulty of forming a bridge of mutual affection between parent and child.

Apart from any tuition which the child may or may not receive it should be borne in mind tha t there are three essentials for normal mental develop- ment and that absence of any one of them may have far reaching results. These essentials, (stressed by many writers, but especially by Cameron 1 and Adler 2) are security, affection and freedom. Security includes, of course, proper provision for security against physical accidents in child- hood, but it also has a much wider and deeper connotation, and implies that the child must never doubt the permanence of his home life and background. I t is easy to see how this " security " can be swept away, and not only by such obvious things as parental discord, separation and divorce. Discussion of financial difficulties in front of a child, an obvious degree of anxiety displayed by either parent, illness of a parent, irresponsible conduct of a parent, mental breakdown of a parent, all tend to shatter the illusion of permanency which a child builds up, and must build up, regarding his home. Only if this sense of security is unbroken can one expect the normal development of self-confidence with all the happiness that tha t implies.

Strange as it may seem, the second essent ia l - -" affection " - - i s the one which is probably most often at fault. I t is not that parents are usually harsh or cruel (fortunately, only a small minori ty are), but unfortunately many parents, who are most affectionately disposed towards their children, fail completely to convey tha t impression to the child's mind. Many of these parents believe tha t rigorous attention to all the wants of the child should convince the child tha t they love him or her, but nothing could be further from the truth. A child does not reason things out in this manner. All the child knows is tha t some deep need remains unsatisfied, that it rarely experiences real happiness, and that it is frequently the subject of nameless fears and dreads. With many of these parents it is not easy

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to convey to them just where they have gone wrong. Some are naturally undemonstrative, /some pride themselves on being so), but merely being " demonstrative " will not solve the problem unless the " demonstration '" is sincere and is actually felt by the parent. The parent must realise that somehow he has to build a bridge of affection between himself and his child before he can hope for a~y improvement, and this bridge must never be weakened, e.g., by nagging the child over unimportant details, unjust punishment or long " lectures," but that by countless small and unobtrusive ways, little surprises and imaginative acts, the bridge is continually being strengthened. Once a strong bridge has been formed the child will respond to correct teaching and correct discipline in a remarkable way.

The third essential for normal psychological development is " freedom," and this has an application from the earliest days. We have seen how insatiable is the toddler's curiosity, and why the display of this instinct should never be thwarted, short, of course, of physical danger. In later years a relative freedom is equally important. After the necessary discipline of school and meals has been met, initiative on the par t of the boy or girl should receive every encouragement. They should be encouraged to plan their own hobbies and recreations and allowed to make their own simple mistakes rather than always having a constant overseer. Criticism of mistakes by adults should only be made if absolutely necessary. Nothing damps the ardour of a boy or girl more than constantly being told just where he or she has gone wrong; strangely enough, they readily accept acute criticism from their playmates, (which is one of the great advantages of the social play of childhood), but criticism from " grown ups " is almost always resented, being as it is usually quite Uncalled for or " priggish." (This is probably the cardinal mistake made by " well meaning " and usually " ambitious " parents).

Lastly, all parents should appreciate tha t there is a " normal " degree of being troublesome which should be exhibited by every growing boy or girl. Behaviour which approaches " perfection " probably betrays some- thing much more gravely amiss.

Symptoms of Maladjustment.

When the emotional development of the child is interrupted by any cause, symptoms of maladjustment will invariably make their appearance. These symptoms roughly fall into two classes (although most children will probably display some symptoms of the other class) : " withdrawal " symptoms and "aggressive " symptoms. The " withdrawn " child becomes hstless and apathetic, shuns company , avoids games, easily bursts into tears, often sleeps badly, is given to day-dreaming, is inattentive, is some- times enuretie, and may at a later stage display various " r i tua l s " of " obsessive " behaviour. Quite frequently he is pale, undersized and undernourished, with poorly developed, flabby muscles.

The " aggressive " child is given to outbursts of temper (" temper tant rums "), frequently with destructiveness, is often physically violent to other children, and lies, steals and plays t ruant at every opportunity. Punishment has little or no effect on his conduct (if particularly severe it will produce some " withdrawal " symptoms), but it only serves to make him more rebellious, more on the defensive, and to display more cunning

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in the carrying out of his schemes. Enuresis may be present, but is more common in the " withdrawn " child.

Treatment of Maladjustment.

When a clear picture has been formed as to the causes of the maladjusted state, t reatment becomes a relatively easy matter, although some considerable t ime may be required to undo the harm of the past and to build up a healthy system of sentiments. In some cases, where home conditions are unfavour- able and cannot be radically altered, t reatment may be quite ineffective until the child is removed to a hostel. On recovery, of course, the problem of the home conditions has again to be faced, but sometimes fortuitous incidents have conspired to improve the home conditions while the child was absent. In all cases the parents must be educated as to why things have gone wrong, and their new att i tude and their rSle in the recovery of the child must be clearly impressed upon them. The child must then be interviewed at frequent intervals and a quick check-up on its progress made. In all recent cases I do not like these intervals to be longer than two weeks; long intervals tend to break or weaken the bond between psychiatrist and child. An essential plan is always to interview the parent first to find out progress and setbacks, and where, perhaps, the parent ia still making mistakes. Only when fully armed with this information should the chihl be interviewed. My practice with all younger children--roughly those under l~)--ds to see them in the company of a parent, to get them (in the case of the aggressive child) by a very mild probing to admit a few of their major " errors," and then to elicit the old promise " t o be a better boy or girl." Only a little should be a t tempted at any interview, and the att i tude of the psychiatrist must be one of the most obvious friendliness and encouragement. I f the psychiatrist fails to make contact with the child he cannot hope for any benefit to be derived from the inter- view, and this contact should become closer with each interview when, as a rule, the child will readily admit all the " slips " of the previous two weeks. (Censorious "lectures," probing or " analysis " are all fatal to any progress). Any point of improvement must be duly commented upon, and the reward of a toffee at the end of the interview is usually much appreciated.

Bigger boys and girls, who require more reasoned argument, are bet ter seen alone. One can then point out many things, which could never be said in front of a parent, but other general principles remain the same. The boy or girl must quickly be made to feel tha t the psychiatrist is only out to help, and that, if they t ry to follow his advice, life can become immeasurably happier. I t will, perhaps, be helpful to consider, in more detail, the t reatment of some individual symptoms.

Lying, Truancy, Pilfering, Tantrums. These, the four common symptoms of aggressive behaviour, are dis-

played in all varieties of combination by the aggressive type of maladjusted child. Lying, t ruancy and pilfering may, of course, be present without any maladjustment, and it is important to remember that all boys and girls will naturally lie and pilfer and perform other selfish acts unless and until they have built up strong sentiments favouring truthfulness, un- selfishness and honesty. Therefore, it may be apparent at the outset tha t the latter sentiments were never instilled into the child, and that what is

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required is simply a process of re-education in which the psychiatrist, can give great help to both parent and child.

I t can be said at the outset tha t " aggressive " s y m p t o m s of maladjustment do not present the same problem as " withdrawal " symptoms. Very frequently the child has .been "wi thdrawn " for years and no notice taken of it, until it decides, on account of the almost unbearable nature of the .symptoms, to hit back and assert itself. Then and only then is it labelled "maladjus ted ," but in many eases this can be seen to be the process of natural cure, and only a slight modification of the aggression is necessary to effect complete discovery. One, therefore, often welcomes the appearance of aggressive symptoms, and one should be particularly careful not to a t t empt to squash them, but merely to redirect the energy. In such cases the psychiatrist does not align himself with the parents against the child, but i f anything appears to take the child's part. Once good rapport has been established with the child success is rarely in doubt in these cases.

The " Withdrawn " Child. In the case of the " withdrawn " child (who has not as yet made any

a t t empt to hit back), progress will generally be far more tedious and require much greater patience and perseverance. These children (as the term implies) t ry to efface themselves, become generally " nervous," fearful, solitary, given to day-dreaming and often obsessional rituals, burst into tears with little cause, avoid games, find concentration and lessons difficult, and though often gifted slip further and further down the class. Physically, from both their usually poor appetites and lack of invigorating exercise, they become pale and thin, with flabby musculature.

I t is essential to establish a good rapport with these children at the earliest moment, but this will usually be found much more difficult than in the case of the "aggressive " child. Above all, these children require affection and encouragement, and criticism of any kind, from either parent or psychiatrist, must be taboo. The first duty is to educate the parents into the correct method of dealing with the child and to impress upon them the necessity of dropping all criticism and " lectures," and again the necessity that in some way they must " g e t over " their affection to the child. This " change over " cannot be done in any crude or dramatic way - - t h e child would immediately sense its ins incer i ty--but in countless small and unobtrusive ways the at t i tude of the parents can change to one of sympathy, understanding and encouragement. The psychiatrist can render invaluable help by pointing out, usually in the presence of the parent, the progress of the child, and by minimising and putting in a better perspective his many shortcomings, e.g., refusal to sleep in a room by himself, inability to concentrate in class, etc. Not too much should be a t tempted a t any interview, and it is absolutely essential to see these children at frequent intervals, weekly in severe cases and then fortnightly until recovery is practically complete.

Enuresis. Enuretic children form a very considerable percentage of the work of

any child guidance clinic. We have seen that enuresis may be one of the symptoms of maladjustment, and as such will require the appropriate t reatment , but, on the other hand, it may, and often does, exist independently

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of any maladjustment. Again, there is unquestionably a tendency for maladjustment to arise in normal enuretic children as a consequence of the enuresis. This is not surprising considering the many and varied efforts which are made by the parents to cure these children, the not infrequent coarse jokes of other children, and the considerable physical and often mental distress which the habit of necessity entails. I t is, therefore, appro- priate to consider enuresis separately as a single symptom, always bearing in mind that i t may form only part of the symptomatology of much more serious conditions.

Whether or not other symptoms of maladjustment are present, there are a number of cardinal points to be borne in mind in the t reatment of enuresis :

(1) The parents and the child must be made fully to understand that complete bladder control is often attained only in the teens by quite normal children, and that enuresis is an extremely common condition. This at once releases a considerable amount of tension.

(2) The parents should be instructed never to apportion praise or blame, but to t reat the whole subject with calculated and lighthearted indifference. (Obviously praise given will act as a boomerang when " failure " occurs).

(3) The object of all the above is to rid the boy's or girl's mind of all tension and anxiety regarding the condition. This is a pre-requisite of any treatment. (The increased kidney function caused by tension is familiar to everybody and should be explained to the parents and to older children). For this reason the giving of any medicine or tablets or rewards only serves, in m y opinion, to keep up such tension and is better avoided. On the whole, I think one loses more than one gains by such methods.

(4) I t is important not to give any meal, beverage, milk, fruit, sweets, etc. within two hours of bedtime. (Water may be given freely). I t is agreed I think, that sound, restful sleep is much more likely to occur with a relatively empty stomach. A restless sleep with much dreaming is much more likely to increase kidney function, and it is probable that the boy or girl just succeeds in getting into a really deep sleep when the bladder is almost full.

(5) For similar reasons I always ask parents and children n o t to have any excitement, indoor games, horseplay, etc., a f t e r the evening meal. I do not think television is particularly helpful, but sometimes one has to compromise. The ideal is to send the child to bed in a quiet, restful frame of mind, in which deep sleep should occur quickly. (Angry scenes or parental discord are, of course, equally harmful).

(6) I always advocate " raising " 2-3 hours after going to bed, which should be 4-5 hours after the last meal. This should be regarded as a purely routine business and carried out without comment. I f frequently wet when raised, the t ime must be shortened. I f never wet when raised it is sometimes an advantage to raise a little later, although obviously the habits and needs of the parents must be considered.

(7) Charts and notes on " dry " and " wet " nights (kept for the psychia- trist) should be written up when the child has gone to school, and should be given to the psychiatrist before the child is called in.

(8) The psychiatrist 's interview, in cases without maladjustment, should only be a brief sort of " pep " talk. He must never appear discouraged even in the face of a long succession of " wet " nights.

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Diurnal Enuresis and Encopresis. Diurnal enuresis is less commonly met with than nocturnal. Sometimes

it is present in children who are enuretic at night, but it may be met with in children who are " dry " at night. Encopresis (soiling) is less common still and may exist alone or in company with enuresis.

Diurnal enuresis and encopresis always betoken some maladjus tment , sometimes of a considerable degree, but occasionally only sl!ght. The type of maladjustment is almost always that of the " withrawn " child and will require the t reatment for that condition.

In m y experience both these conditions rapidly respond--of ten after one or two interviews--to correct treatment. Very commonly both are based upon a slight anxiety hysterical state, rather than on any deep- seated maladjustment and all that is required is encouragement and re- assurance. (They are akin to such conditions as hysterical vomiting, hysterical fainting, hysterical tenesmus, etc., so commonly met with in adolescence). When the diurnal enuresis is linked with nocturnal one often finds that anxiety hysterical frequency is at the root of both conditions. Fear of wetting himself causes the small boy (or girl) to rush to the lavatory more than a score of times daily, with the result tha t the bladder becomes contracted down and almost incapable of holding anything above a few ounces of urine. One cannot therefore in such conditions hope for any improvement in the nocturnal enuresis until the bladder has been re-educated. I have found that such children (and their parents) quickly grasp the necessary explanation and usually relate with pride, on subsequent visits, how few times they have gone to the lavatory during the day. Teachers frequently ask if the children should be allowed to run to the lavatory every t ime they make a request. In most cases the answer is definitely " N o , " (the explanation of course must be given to the teacher), but in other cases, e.g., the " withdrawn," very shy child, enuresis will occur only if there is some obstacle to his getting to the lavatory in time.

Hysteria. I t is essential, in child guidance work, to have an acute appreciation of

all symptoms with an anxiety hysterical basis, otherwise hopeless confusion will result. Such symptoms respond almost immediately to correct methods of t reatment, which are essentially the same as those used for adolescents and adults, with the exception that one has often to direct the suggestion much more to the parent in the presence of the child than to the child himself. As I have pointed out elsewhere s the doctor must be certain of his diagnosis before at tempting suggestions ; i f he is not absolutely certain his suggestion will completely fail. In younger children suggestion via the parents often works much better than directly to the child ; frequently it is the ill-concealed anxiety of the parents that is keeping up the whole thing. The hysterical child does not fit into a picture of withdrawn or aggressive maladjustment (this does not, of course, preclude the presence of some hysterical symptoms in the latter conditions) but exhibits a number of ill-defined fears, usually of recent origin, plus frequently recently acquired mannerisms, fits, habit spasms, " r i tua l s , " etc. These fears may be of going to die, of having certain diseases, of wetting himself, of the dark, of small rooms, of fainting, of not waking up, and the habit spasms include all varieties and combinations of grimacing, head-nodding, air swallowing, and so forth. (In older children hysterical " fainting " and " vomiting "

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are commonly met with). I t is important (for diagnosis) to note that these symptoms are, as it were, set apart, and that otherwise there is no evidence of emotional disturbance, frustration, or " withdrawal " symptoms. Also, the symptoms are usually of recent origin, have arisen suddenly as it were " out of the blue," and have caused considerable parental alarm.

Epilepsy. I do not propose to go into the treatment of epilepsy in childhood, which

I have dealt with elsewhere, 4 except to consider what our attitude is going to be to those occasional cases which an E.E.G. examination reveals to be probably of epileptiform origin. These are the somewhat rare and inex- plicable cases in which the conduct is of such an unpredictable, sudden, impulsive or violent nature as to suggest something more than a psycho- logical cause. In the absence of anything pointing to a fit at any t ime during the lifetime of the child (which, with a careful history, I tlfink will be rare), I consider that the conduct complained of must be wholly unpredictable before an epileptic origin is assumed, but if, after further investigation, one is satisfied as to the correctness of this assumption, drug treatment should be consistent and adequate and spread over a lengthy period. On the other hand the response to drug treatment in itself should clinch the diagnosis. I f the assumption is correct the response should be instantaneous and dramatic. What I believe will only lead to hopeless confusion and despair is the growing tendency to assume a possible epileptic origin in a large number of difficult children, to give a mixture of psycho- logical and anti-convulsant drug treatment, and to expect good results.

Fate of Untreated Children. I t is interesting to speculate on what would be the probable fate of many

children attending child guidance clinics if no such clinics existed: A small percentage would probably make a more or less satisfactory adjustment, but for the majority I fear the future would hold considerable difficulties. Many would experience, in exaggerated degree, the usual difficulties o f adolescence, with violent emotional swings, withdrawal into day-dreaming, sexual aberrations and difficulties. I think for the boys one could predict that a "considerable percentage would become youthful delinquents, and later young criminals, and that for the girls many would become pregnant illegitimately and some would drift into a life of promiscuity or prostitution. The unstable emotional life which these people experience must contribute also to a relatively greater number of nervous breakdowns of the type of unxiety states, but I feel that by far the greater danger will lie in the fields of moral conduct. Good moral conduct, of course, is not guaranteed by lack of maladjustment, and this is probably where the most successful treatment of these children may fail, for unless strong moral sentiments can be built up, the future, even in the absence of maladjustment, must remain uncertain. But the building up of such sentiments, in the presence of uncorrected maladjustment, is well-nigh hopeless.

References. 1. Cameron. The Nervous Child. Oxford University Press. 2. Adler (1927) " The Cause & Prevention of l~eurosis." Jo. Meat. Sci.

(1930) The Science of Living. George Allen & Unwin. (1927) Understanding Ituman Nature. George Allen & Unwin.

3. Thompson, R. " The Diagnosis & Treatment of the l~euroses in Out-Patient, Practice." Practitioner. March, 1951.

4. Idem. "A Consideration of some of the problems presented by Epilepsy.'" Irish J. Med. Sci. March, 1951.