The Investigation and Diagnosis of Behaviour Disorders in Children. By at

Lucas, M.B., Ch.B.

a summary of two lectures the Secretaries' Course in February, and is

[The following paper is

Hospital,

R. Evelyn

given by reprinted

Dr. Lucas, of the Maudsley at the request of those who

attended the Course.]

Behaviour disorders in childhood and adolescence are of more serious import than is usually recognised. Too often are they the direct precursors of neurosis and of crime in adult life, yet it is only within recent years that this fact has received any recognition. To-day the subject of juvenile delinquency is attracting considerable and increasing attention in other countries and here, also, public opinion is being aroused to the necessity of more adequate and efficient treatment of the young offender. It is perhaps well, at such a time, to make a brief survey of the former theories as to the causation of delinquency and to consider whether any of these theories now suffice for our needs, or whether in the light of our present knowledge of the subject, the previous hypotheses need some modification. 1 he attitude of society in general towards the anti-social behaviour of delinquents and criminals has altered considerably during the past century. At one time, the criminal was considered to be a fixed and unalterable type, presenting in inherited disposition and physical characteristics the stigmata of indubitable and irremediable degeneracy. Lombroso showed us in portrait after portrait the facial types which we have since learned to associate with feeble-mindedness and constitutional inferiority, rather than with criminality per se. It is small wonder that a wide-spread belief in a criminal type produced at the time a

completely

effect upon constructive efforts towards the prevention of crime, the attitude being that life-long incarceration was the only means of controlling this

paralysing

menace to

society.

At a later date, environmental conditions came into prominence as a causal that many, perhaps the majority of lawfactor of delinquency. It was realised

30

MENTAL

WELFARE.

breakers lived in degrading surroundings under circumstances which provided no stimulus for the formation of decent habits of ideation and behaviour. The view was taken that a period of training in a correctional institution would suffice to eradicate the delinquent tendencies and give the individual a new start in life. Reformatories and training schools were therefore founded with this aim in view and delinquents were put under a systematic and orderly regime and given education and training in various types of work, in the hope that they would seek and obtain honest employment upon their discharge. This method, though started on a more rational and hopeful basis, was doomed at least to partial failure for the

following

reasons:

place, the duration of institutional treatment was often very short, short indeed that it could not be expected to correct those fixed habits into whose formation the experience of years or even of a life-time had gone. Secondly, the attempt at habit correction was made mainly through the exertion of a repressive form of discipline and little was done in the matter of providing substitutive interests in thought and action. The fact of recurrent or persistent ideation along former lines was totally neglected and attention was paid only to what the delinquent did (and this under strict supervision), while his ideational processes were entirely neglected. The attitude was somewhat akin to that of the old time physician who caused his tubercular patients to wear masks, thus protecting them from direct contact with the air which had originally borne the infection, while neglecting, at the same time, the hidden disease which was making its progress within. Thirdly, the delinquents were treated en masse, no attempt being made to understand and remedy the personal difficulties of the unit individual. It was not realised that a few months of systematic training could not alter the whole trend of a psychopathic personality or cure the innate suggestibility of a mental defective, any more than it could satisfy the intellectual thirst and urge of a supernormal offender. The treatment was, throughout, as uniform as possible. To use again the previous analogy of the patient, it was as if a physician, finding that one person suffering from chest pains and cough, needed sanatorium treatment for tuberculosis, assumed that the next patient with similar symptoms would benefit by the same treatment, neglecting to consider the fact that a slippery banana skin, a hard kerbstone and a resulting fractured rib could produce the same apparent results. Fourthly, the delinquent, after a shorter or longer period of detention, was permitted without further investigation or constructive effort, to return again to his past haunts with a resultant reawakening of old associations and renewed contact with all the earlier temptations. In the first

so

It is not to be denied that these flaws in the method were recognised, to some extent at least, by a few far-sighted individuals, but the fact remains that the system as a whole was, and indeed is now, permitted to remain unaltered in many

both in England and in other countries. Much more recent is the doctrine, still fashionable in some quarters, that delinquency is due to disease. For a time, the medical world was so attracted by the discovery of the effects of auto-intoxication and of hidden foci of sepsis that it is not surprising to find these conditions blamed as being the causes of abnormal behaviour. Some still hold that the delinquent individual is a diseased individual and that, with the remedying of his physical ailments, one can cause also the disappearance of his delinquent trends. There is a sufficiently large grain of truth in these beliefs to make the theory apparently work out in practice providing that the cases are carefully selected, but wider experience shows that this one factor alone by no means suffices to explain the origin of delinquency as a whole. One has more than once observed a physician expressing surprise at the fact that most

large

areas

MENTAL WELFARE.

31

delinquents are not subnormal in stature, development and physical health, this surprise being, no doubt, due to the fact that only those cases in which ill health is a prominent factor would ordinarily cross the path of a practising physician. One might also mention in passing the view held by a small group that delin" " moral centre in the brain. The theory is that quency is due to an injury to criminal tendencies are the result of the impaired activity of a special area of brain tissue which subserves the functions of morality. This belief rests upon very insecure foundations and leaves unexplained so many important facts that it is unnecessary to deal at length with the numerous arguments against its acceptance. Now most, if not all of these theories have a certain amount of truth in them but fail in one important respect, in that each theory so far mentioned has explained delinquency by reference to only one possible causal factor. It is evidently necessary to widen our conception of the nature and causation of the delinquent reaction, a matter in which modern psychology may give some assistance. Most psychologists of to-day, whatever the school to which they belong, hold views that are to some extent deterministic. That is to say, they consider that no thought or action occurs accidentally or without a definite cause. Just as a solid object, which is acted upon by two forces, will move in a direction along which the resultant of these two forces acts, so are our actions determined by the resultant of the forces which are and have been acting upon us, both in the present and in the past. These forces, as we will call them, may be split up roughly into three groups. First there are our hereditary predispositions. It seems probable that children inherit to some extent their temperamental characteristics and are born with a tendency to react in a certain manner to certain situations. We know, however, that these tendencies, particularly in the early years of life, can be considerably modified. It is very unlikely, both on theoretical and on practical grounds, that a child is ever born with criminal tendencies, but the reason for this statement to discuss in the present paper. have what may be called the previous conditionings. This includes all the experiences to which the child has ever been subjected, whether remembered or forgotten. We know now that past experiences, particularly those of early life, affect our behaviour and our emotional attitudes to a far greater extent than was formerly realised. A person, who in childhood was badly frightened by a dog, may grow up with an unreasonable terror of all dogs, even though the original incident may have been long since forgotten. Many of our apparently irrational likes and dislikes have their explanation in incidents long buried in the past. In all people there is a tendency for the reaction to a present situation to be influenced by the previous reaction to a past experience which the present one to some extent resembles. This tendency has very important bearings on our dealings with delinquent children.

would take

too

Secondly

long

we

Thirdly there is the present environment. It is necessary to know something of all those conditions which influence the child at the present time. His own physical state, his home and people, his school or work, his intellectual interests, his companions and his hobbies. Furthermore, we want to know the child's distinctive attitude towards these. To the outside observer there may be nothing wrong with the home or the parents, yet if the child feels some cause of iinor discontent, his response to the situation will be unsatisfactory. On the other hand, the home, or some other section of the child's environment, may fall far below our standards and yet be in no sense a causal factor of the delinquent reaction. The investigation of the specific individual response of the child to various situations is of paramount importance in the examination of a case and unless great care is taken, it is sometimes surprisingly easy to lay the blame in the

happiness

32

MENTAL WELFARE.

wrong quarter. This, of course, renders our treatment of the case correspondinglyineffective. We have thus three factors which influence behaviour and determine the type of reaction which will be produced by a given situation. These factors?the hereditary predispositions, the previous conditionings and the present environment all need investigation in any case of delinquency. The majority of cases are somewhat complicated, as there may be many factors more or less equally operative in producing the delinquent reaction. I cannot recall a case in which heredity alone played a part or even one in which it was the most important element. One becomes very sceptical at the fatalistic doctrine that the tendency to crime is definitely inherited. Experience of children, whose family histories contain the most appalling combination of mental defect, insanity, prostitution and crime, shows that the offspring of such families need not become delinquent, provided that, at a sufficiently early age, they are removed from their degrading surroundings and are given a decent chance in life. Inborn tendencies of one kind or another, the individual must have, but if too great a stress be laid upon these, the result is a hopeless and unhelpful attitude towards the whole problem, since that which is inherited must remain there throughout life. We can and must leave the hereditary predispositions and innate characteristics to take care of themselves, but we have no right to throw down the cards, until we have given due consideration to other possible causal factors. This is the only satisfactory basis upon which we can hope to formulate and carry out a constructive plan which will ultimately be for the benefit both of the individual offender and of society as a whole.

In dealing with behaviour problems in young children, one always has to begin with a recognition of the fact that no child is born with his morals ready made. This seems an absurdly obvious statement, yet the truth of it is often overlooked, especially by parents. The very young child is dominated by the pleasure principle. He finds that certain actions produce pleasure and others result in pain. The former tend to be repeated in order that further pleasure may be obtained, while the latter are checked, owing to their previous painful effects. This is the earliest and most primitive type of learning and one which, though modified by other factors, remains with us throughout life. Now, with repetition, the pleasure-producing action is each time performed more readily and easily until in time it becomes more or less habitual and a slighter stimulus is required to cause it. At length, a certain pattern of behaviour is laid down, which is facilitated by constant use and which will not cease to exist until no further advantage can be gained by its continuation. If misbehaviour is allowed to result, as it so often does, in the attainment of desired ends, there is a tendency for it to increase until the child may become definitely delinquent. So-called uncontrollable tempers are often explicable along these lines. A child shouts and cries until his wishes are granted. After this has happened several times, the mother decides to remain firm, whereupon, the child, being disappointed, cries louder and more lustily until, for the sake of peace, the mother at last gives way. The child has again become master of the situation and, moreover, has learned that if a little naughtiness will not bring about a desired end, increased The tempers become steadily worse until the misbehaviour is sure to do so. mother at last takes the child to a doctor, saying that he has fits or in some other way blaming the child's nervous system for a condition which is, in reality, her own fault. When a child has once learned to dominate his parents and his home environment, irregular and unsustained efforts at discipline will only drive him into further excesses. In his desire to retain his command of the situation, the child may

33

Cental welfare.

eventually end by making himself and everyone else unhappy by aiming at an end which he cannot be allowed to attain. If the parents are intelligent and co-operative, such cases can often be quite adequately treated at home, but with weakwilled and nervous parents, it is sometimes necessary that the child should temporarily be removed to more normal surroundings where no advantage can be gained by violent temper. The beginning of school life is often beset with difficulties. At home, the young child has received individual care, while at school, however kindly he is treated, he is, nevertheless, one of the crowd and is expected to take his place in the group without any special attention being paid to his personal likes and dislikes. The child who has been spoiled at home may find it very difficult to adjust himself to the demands of this new situation, particularly when an early dislike of school is fostered and encouraged by unwise sympathy at home. In such a case, the child's objection to school may increase until, instead of disliking one single teacher, his hatred extends to the whole system of education and everyone associated therewith. A single punishment may suffice to create antagonism and one has seen a boy of nearly 14 years, who had persistently truanted since the age of five because he was on one occasion exposed to ridicule by his teacher. Though of supernormal ability, he was unable to read, write or do simple sums and was, indeed, sent to us to be certified as mentally deficient. He had developed violent temper tantrums and was untruthful, suspicious and extremely self-absorbed. His hatred of school had been encouraged by a devoted but unwise mother and it was not until the boy was persuaded to work out the whole situation for himself, that his resistance could be broken down. He then asked to be sent away from home and removal to a specially selected school resulted in a rapid and complete change in behaviour, the development of normal interests and excellent progress in learning. Another common cause of misbehaviour is the unwise attention which childoften receive from adults. Most parents cannot help being proud of their offspring. This would be quite a satisfactory state of affairs, were it not for the fact that parents are often proud of behaviour which should really be checked and, what is more, exhibit their pride in front of the child. A very young child learns to make a pert remark and the parents laugh at his cleverness. The father smacks him for some fault, the child hits back and the mother smiles indulgently at her son's spirit. Time and again, one hears a mother ostensibly complaining of her child's escapades, yet all the while, her pride in his originality is only half concealed. Most children love to be noticed by adults and the root cause of a great many misdemeanours is this desire to attract attention. This may occur in large families, where a harassed, over-worked mother has no time to bother with the children unless they are naughty. It happens with the only child, who is shown off to an admiring audience of relatives and friends and it is, perhaps, particularly frequent in children brought up in institutions, where the discipline is more or less uniform and the amount of individual attention is small. In this case, it is the naughtiest child who is the most noticed, and a child, who is really craving for love, may adopt most bizarre behaviour in order to be different from the rest. One has met many lovable and affectionate children, who were quite unable to fit in with any institutional regime, for the simple fact that, as they themselves have " sometimes expressed it, they did not feel that they belonged anywhere. Such in foster do well where children often very homes, they can feel that at least one person has an affectionate interest in them.

ren

"

On the other hand, children may be driven into delinquency by too strict Some parents treat their offspring as crosses which must " don'ts." grudgingly be borne and line the child's path with an" imposing list of Now a child who finds that everything he does is naughty," soon begins to

treatment at home.

34

MENTAL WELFARE.

think that, as all actions are equally reprehensible, it does not matter what he does. The young child should constantly be finding out how to deal with his surroundings and how to acquire more perfect muscular control. In the process of this learning, he is continually doing things in relation to some one or other aspect of his environment and the results may sometimes be unfortunate. Nevertheless the mother who, instead of repeatedly checking the child's actions, sets out to make them serve a definitely useful purpose, can usually enlist the child's co-operation to the advantage both of the child's temper and of her own nerves. Uncongenial occupation and lack of opportunity for recreation are often direct causes of delinquency. A child living in a crowded slum, with no facilities for out-door sports, will sometimes start thieving or damaging property, merely for the sake of getting a thrill out of life. Adolescents, with some specialised ability for which they have no outlet, will often use their powers for anti-social ends. This was the case with one boy who had quite an extensive criminal career. He was an expert safe opener and his propensities in this direction were never checked until his remarkable mechanical ability was recognised and he was given work in which his manipulative skill was of use. He had burgled for the sheer joy of using his hands rather than for any definite gain and his criminal tendencies ceased to exist when he found work upon which he could exercise his powers. A bright boy may become delinquent because his ordinary routine of school or work does not provide sufficient challenge for his capabilities, whilst a backward boy may commit the same offence for totally different reasons. In the first place, defective children are usually more than normally suggestible. They lack foresight and are thus easily led on by craftier companions. One often finds in group activities, that it is the backward child who does the actual work, while the brighter members of the gang avoid suspicion and share the spoils. One must remember, however, that suggestibility can be used for good as well as for evil ends, and that, in better surroundings, dull children are often equally responsive to training which is directed towards the development of a law-abiding attitude. The child who is somewhat backward, without showing any pronounced mental defect, is frequently very sensitive. Too often he is reprimanded for poor work at school and is the butt for his companions in the playground. In such cases, a pronounced feeling of inferiority may arise and the child may endeavour to assert his superiority in other directions. Not infrequently one meets with a backward child who steals money in order to buy flowers for his teacher or objects with which to impress his friends, the real motive being to re-establish himself on terms of equality with his companions. The same thing may also occur with an unwanted or neglected child, even though not backward in intellect, and one sometimes finds that an ill-treated step-child will both steal from and give presents to the step-parent, the underlying motive being a curious mixture of antagonism and desire for affection.

Sex misdemeanours in children

are

very

common,

and their

causes are

legion. They form an important problem in many cases, and well repay careful study. In the first place, it is well to remember that so-called sex delinquency often occurs without the child having any ideas which are sexual " in the adult meaning of the term. The very young child may discover that he can derive pleasure from touching or rubbing certain parts of his body, including the genital organs, the habit being, at an early age, comparable to thumb-sucking, nail-biting or nose-picking, and needing treatment by similar methods. Severe punishment or terrifying threats serve merely to frighten the child and to concentrate his thoughts upon a habit which he would normally abandon on growing older. "

During school age, a boy or girl is often introduced to the habit of masturbation by another child who, owing to the manner in which the subject has been treated at home, has come to the conclusion that there is something strange and

MENTAL

WELFARE.

35

wicked about the habit and that he or she is defying some terrible, though little understood, social taboo. Time and again, one meets with a little group which is held together merely by the knowledge of some trivial sex habit, which the children think is unknown to the rest of the world. Remorse for such actions is often accompanied by a hopeless and despairing feeling that no one else can possibly be so wicked. The child feels shut out from normal social relationships and his interest is therefore directed more and more towards himself, with a resultant increase of auto-erotic behaviour. A child often exhibits tremendous relief when he, at last, confesses his guilty secret and finds that it occasions no horror or surprise. A calm discussion will often suffice to eradicate the habit without any further treatment. I frequently explain it to children by saying that very tiny babies are interested in nothing but their own bodies. They desire food, warmth, nursing, in short, anything that causes pleasurable bodily sensations. As a child grows older, his interests change. He thinks of his toys, his friends, his parents, etc., and his thoughts, instead of turning in upon himself go out to various objects in his environment. The older one grows the wider one's horizon should become, and masturbation denotes a turning of interest back to oneself and a consequent reversion to a more childish form of behaviour. The child who realises that he is merely being self-absorbed and babyish, often finds it quite easy to direct his interest into more normal channels. Promiscuous sexual intercourse among adolescents is another condition which one must be ready to deal with and here also one's treatment must depend rather upon the delinquent's mental attitude, than upon any preconceived standards of morality. Heterosexual experiences in themselves may not be of more serious import than theft, lying or other adolescent misdemeanours. It entirely depends upon the motive and upon the child's whole personality make-up. Some people seem to think that delinquencies of this type only occur when the adolescent's sex desires are strong, but this is not always true. Curiosity or imitation are often far more important factors, though neither of these would be effective in provoking misconduct had the child received adequate sex instruction. Unfortunately, many parents cannot bring themselves to give the necessary guidance and they tend to put off all enquiries with a tissue of lies, with the result that the child obtains information from undesirable sources and feels that there is a sort of terrible fascination about the whole matter. This leads either to a desire for overt action or to a tendency to repress and avoid any ideas pertaining to sex matters. In the former case, delinquency results, while the latter state is productive of many of the nervous manifestations which are seen in the out-patient

departments of our hospitals. In conclusion, I should like to say that, whatever the type of case, one ought never to be discouraged by one's failures. The subject of the treatment of delinquent children is, as yet, in its infancy and we have a great deal still to learn. Each time a failure is recorded, it should be the basis of a fresh start and a new investigation. Were there any factors in the original causation which we have not yet taken into account? Have new circumstances arisen which are making the child's adaptation too difficult for him? It is only by patient, thoughtful and thorough consideration of each individual case that we can hope to formulate any really satisfactory plans for action. A scientific evaluation of all the factors concerned in making the delinquent what he is, can be the only true basis of any adequate and rational approach to the solution of what is, I consider, one of the most vital and pressing social problems of our time.

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