UNITED STATES DEPARTMENT OF LABORFnawcss PxnrrNs, Sectetary

CHILDREN'S BUREAU KarsrnrNe F. LrNnoor. Chief

HABITFOR CHITD

CTINICS

GUIDANCE

AY

D. A. THOM, M. D.

Bureau Publication No.

(Rev i sed 1938 )

United States Goyernmenr Printing Office

Washington : 1939

For sale by the Superintendent oI Documcnts, Washington, D. C. - - pr ice 15 cenu

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CONTENTS

Letter of transmittal - - -Introduction-ti;bit-;di" p"i.on*t u"a- p roced r r re - - - -

Pago

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The psychiatr ist--- - -- - -- -i t ' " b'ycnolosist- - - : - - : : : : - - - - - - - - - - - - - : - - - - - - - - -The social worker------ -Habit-clinic procedure- - --Cooperation with other communt' ty agencies-----

The child and his personality--The parent and the home--------Habil problems associated with eating, sleeping, and eliminetion, - - - - - - - -

Eatine habitsHabits of elimination- -H e b i t s o f s l e e p - - - - - - - -

l . l ( :rntnlent torvards frustrat ion expressed in aggressive acts-------------\nger and temper tantrums-----Des t ruc t iveness- - - - - - - - - -Delinquency-

Ret rea t as a method o f nec t ing fa i lu re - - - - - - -Probleurs associated with the development of the chi ld's sex l l fe- - - - - - - - - - -Pcrsor re l i t l cbangcs fo l lon ing i l l ness and in ju ry - - - - - - - -Convu ls ions , t i cs , manner isms- - - - - - - - - -The c r ipn led ch i ld - - - - - - - -Mental-cief iciency----- - - - - -Conclusion---

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LETTER OF TRANSMITTAL

Unrtno Srerns DnpenuEnNr or Laeon,Clnrunen's Bonn,ru.

Washi,ngton, Nouember 93, lgSB.Mananr; There is transmitted herer,vith er revised edition of Habit

clinics for child Guidance, first published in 1928 as Habit clinicsfor t l re Clr i ld of Preschool Agc.-bv Dr. D. A. ' l 'hom. director oft l re l rabi t c l in ics of the Communitv Health Associat ion of Boston*nd director of the division of nrental hvgiene in the Departmentof Mental Diseases of Massachusetts.

The revision is an enlargement of the original edition. based onDr. Thom's exper. ierrce jn t i ie Irabi t c l in ics otel t l te ptst 15'vears. I trs believed that the rnethod developed by Dr. Thbrn and" here serfolth will be of interest to all co-ncer'ecl rrith the prrysicai andrnental health of children.

Respectfullv suburittecl.KerrrenrNn F. Lnunoor, Chief ,

Hou. FneNcns PnnKrns.Secretary o,f Labor.

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HABIT CLINICS FOR CHILDGUIDANCE

INTRODUCTION

X'ifteen years have elapsecl since the Children's Buleau publisheda report entitlecl, "Habit Clinics for the Child of Preschbol Ase It l te i r organizal iorr anr l pract ica l va lue." TI r is repor t r - r rs the f i is tof its kfnd ancl embodied what at that time r.eiresentecl a fairlvcomprehensive revien' of the organization and der-elopment of thbfirst clinic in this country to dealspecifically with the inental healthof the preschool child.

Sincd the preschool period is the habit-forming period, this clinicwas called a-habit clinic. ft was felt that there \ris

" r"ul need fol

this subject of the mental health of the child to be presented toparents, teachels, nutses, and general practit ioners in^a n-av thatcould be uti l ized bv these vario-us qroups in their e.r-ervdav contactn'ith children. It was tlrerefole rro.-t consiclered witl i in"the"scone oftlre publication to discuss tlre ps.1'chologicrl mechanisms wlricl i mo-t i r -ated the tvpe of conduct that br .ousht ch i ldren in to corr f l ic t wi ththe glorip oi

-rendered them rrnlrappi and inefficient. The author

has repeaieclly strcssed the rreed of i 'edtrcirig rneltal hygiene to termsthat would l ra le a pract ica l r -a lue to thoselndiv iduajs making dai lycontact rvith chilclren. Tire hst L0 vears have borne .witness*to th'efact that those mental-health clinics which have rendered a real serv-ice to the communitr'-tliat is, to the home, the school. the hospital.the medical c l in ic , ahd organizat iorrs concenred wi th c l i i ld rve l fare-har-e survived. They have created for thenrselles a place of im-portance in the fields-of parent edncltion, rledrgoqy. anci medicine.

It has now seemed.wise to revise_the leport i i i ord'er that it may bemore useful to those interested in this field.

In the revision the name habit clinic has again been used rtrtherthan child-guidnnce clinic, as the publication is concerned p'imarilvwith pr.elcfool childr.err and_ml'y-o.f the problerns of older'children,deal t wi th in most ch i ld-guidancscl in ics. are not d iscussed. The {o l -ln.ving discussion will be open to the criticjsm of being rather srlper-ficial and lacking the precise techniclue necessary for"tlie solutioir ofmany of lhe i irole complex problerns with whieh parents are coll-fronted. It may be said, howe.i'er., that in dealinq

^with these obvi-

ously more involved situations, parents must nec-essaril v seek helpfrom Lhose n'ho hrve had training and experjence in this narticulu.field. Fzlrents do not treat fractures or ierious infections. nor dothey attempt surgical procedures; neither are thev equipped'to solvethe more serious problems pertaining to the m,Jntai lie^atttr of the

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IIABIT CLINICS X'OR CIIILD GUIDANCE

child. Experience, however, has led us to believe that the parent, theteacher, th^e nurse,'and the leneral practitioner are in a iosition torender valuable fir'st aid. TEey can irevent the clevelopment o{ manyserious mental problems if they are equipped rvith such knowledge ofmental hygiele^ as falls well ri i thin thefr'grasp.

From a fractical point of vierv there is a-larg-e group of cases whichwill benefit from the understanding and guidance that can be givendirectly in the home, where the pro*blem oliginates. lt is recogirizedthat there are exceptional cases so complicated and ilvolved that theywiil tax the skill and ingenuity of the specialist. The outstandingquestion is how the clinic can best serve the community in which itis located, the health agency n'ith rrhich it may be affi l irted. ald theschool and social asencies whiclr are tlenendent l l l)on it for advice an,ltreatment. Its fulction is not limited to the tleatment of incli-vidual cases but should include. for educational pulposes, the dis-semination of such knowledge as has been acqrrired^by'experierrce.

In the organization and der.elopment of clinics if is iecessary tobe practica[ ancl this requiles tha^t one eva]uate the total situaiion.A plhysician, a sociai rtorJiier, or a nurse may complicate a home situa-tio^n instead' of helping ib irnless the family rdth"" than the indi-vidual is kept in mind as the unit. For example, it may be mucheasier for the mother of five children to rvash extra sheets three orfour times a week than to bring a youngster alflicted with enuresisto the clinic the same number of times. On the other hand, muchmay be accomplished s-ith only the mirrir irum of inconvenieuce to themother if a weekly clinic visit is made. lVithout minimizing thevalue of intensive li'ork or implying that one method rvill be ap[licr,-ble to everv case. it rnav be pointed out that manv of the problemspresented at ttre habif dinics have been treateil successTully bymerely directing attention to something that was obviously wrongin the environment. In other words. there rvas no need to use apick and sho'r'el when a rake would'do the work. An importantcausative factor mav easily be overlooked by parents, a nurse, oreven the family physicianl and yet be quite ipparetit to a well-trained nsvchiatrist.

Inasm-uch as the behavior of the child represents the resDonse whichthat nalticular individual mahes to his erivirorurient. the clinic musthave

^ first-hand knorvledse of this environment.

' An irreducible

minimum for an investigalion should be outiined and carefully fol-lorved in every case in or-der that important environmental sitnationsdirecth' afiecting the conduct of ttre child may not be overlooked.This part of the clinic program should be cairied out by a 'weil-

traine'd social worke", wlio, bi virtue of her training, is in i, positionnot only to describe environmental situations but also to interpret tothe psybhiatrist holv these particular situations.are affecting the child.She-must be in a position to evaluate the social, economic, cultural,and intellectual level of the child's home and the surroundinq condi-tions. the personalit ies with whom ihe child has to deal, ancl theadjudtmeniof these personalit ies to one another. She musi bring tothe attention of the^clinic the facilities in the community that canbe utilized in helping the child to rnake a better social adjustment.

In order to unclerstand the behavior of the child, an appreciationof the intellectual differences in chilclren is also necessary. This

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HABrT CLTNTCS FOR CHrLD GUTDANCE 3

part of the progra-m is in the hands of the psucholoqisl. who obtainsthe ullormation relatir-e to the child,s mentai

'equjpmenf. his attitude

to*-ard .rvork, hil..abil i ty to concentrate, and. his iar.t icri iar inierestsancl aptrtudes. Thc psychiatrist must take all the^available infonna-tion, together rvith tlie material gathered from

-hls diloJ ne^otrat

contact with the child and. the pi-rents-, interpret this infoimation,and utilize it in making a plan. this pian mu^st taku into consideralt,o*,,o,,On,y,tlre lrari icl l]qi nroblem for which tne ctrif a *rs

-n"orght

to the clrnrc but t ire clri ld-s._a_djustment to l ife in general., ,

A l ,holgh a c l i r r ic {or .ch i ld guidance is concernEd wi th the chi ld ,tne-ramrly must be consr(leled as a unit. where there is a problemchrlcl, not infreque'tly the mother, father, brother. sister.

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other,relatrv€ rep.ese.nts the offending asfect of t ire environment.rt ls rrr(ery that certaln palental attitudes neetl to be altered. per-lraps the beha'r'ior of a p'oblem brother or sister must be treated.A charrge, in sclrools rnay-be rlecessary. Foster parenti *av i iao. tobe ur t rot l r rced as a tempo'ary expedient . possib lv help"must besought {rom. soci al agerci-es int"erested in rel ief , pracdment.'a nd'obser-vation of children under supervision. rt is noCunusual to find thatthe child '-ho has bee' brought to the clinic is

"oi lir" o""

-*t o i.

most in need of treatment. T)ie shy, diffident, well-manneieilchilcl ingrave need of help may lrave been 1'eit at home rvlrj le his much bet ter-ad.;usted, tempe-stuous brother who causes his palents annovance hasbeen, b.ouglrt for help. .rt freqrrently happeils that t*o or t lrreemembers or the same famrly receive clinic treatment at lhe same timeor that several members of the same family benefit by the treatmentn-hich one maladjusted membel receives at" t lre clinicl

I lental hygierre has made great strides during (he last 10 years,and the general public is ve'y much better infoimed about th"e imjportance ancl value of nrental health. The time has rlreadv arrivedwhen the^Jrrger social agencies a_re. t intl ing it necessary to htve upontheir stafls sorneolre rrell t lained iu clri ld-guida-nce_ ri 'ork. Alreadysuch age.cies have clinics for both childreil and. adults. rt has be"-come an absolute necessity for all organizations dealing with theproblems of _h_uman beings,,whether iiis with reference-to diruu.",poverty, or.delin"quency,.to have some kno*.ledge of mental hygrene.'rhe necessity of recognizing the importa'ce 5f mental heafti i hasbeen slressed bv the leaders in the fields of sociology, penology, in_dustrv. and edricatiorr.

.Theie is still a long way to go, horvever, before parents in generalwrl,l be 'a; qeepJf concerned over defects in perionalitv ant overundesirable habits as they are over physical ailments.

" There are

advantages in snrall, informal clinics .theiever they ern Ue estaUtist-,earr,r. the commrrnity as an adju-nct to highly organized mental-healthct rnrcs \ \ ' t l tc l r r re a lwavs avar lable for serv ice. The ideal n lace forone of these clinics cohcerned with the mental hellth of ireschoolchildren is in association with other services for children, .l;p;"i"il,yg_eneral le_alth clinics. A c.ljnic_servi-ng preschool children uid .o-uolder children can be assimilated easilfb'y a health

"unt"" "rrJlt "un9pe-r1te as part -of the medical routine. -

There must be some morel]g'11{

organrzed mental-health centers here and t!ere, with oppor_tunrtres for research work and training. A medical bacl<ql^.o'undis absoiutely essential to clinics interesteE in mental health,

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4 I{ABIT CLINICS I]'OR CHILD GUIDANCI!

child must have a careful physical examination, and all abnormalconditions having zr physical basis should be corrected before anyattempt is made to interpret the symploms on a psychogenic basis.There is no branch of medicine in which sleater cale is needed toprevent the introduction of aII sorts of qudcks and charlatans thanpsychiatry. The association of a rnental-heaith clinic with a recog-nized medical orgauization stamps its rvorl< as part of a well-roundedand well-qualifierl medicll prograln.

The simplicity of such an orlanization has much to recommend it.It has the advantaqe of ofierins to a communitv a service that is asvital to its welfar'5 as the sch6ol or the hospiial. ft ofiers to theparent. the nurse. ancl the teaclier valuable aid in developins ahappiei and more irfficient gloup of clrildren, It permits the iirdi;id-ual child who is momentarily out of adjustment with life the oppor-tunity of understanding himself as rvell"as being understood by ihoseupon-whom he is depen?ent for his rehabilitatioir.

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HABIT.CLINIC PERSONNEL AND PROCEDURE

In the routine clinical procedure of the habit clinic the close co-operation belween the psichirtrist, the psychologist, rnd the social,rlorker t-il l be stresse,f iepeatedlv. Al?hbrrsh e"acli has a specificjob in which he excels, theire is rro sharp lirie of denrarcatioi. In?act, an occasional invasion of one into-the territory of the otheris to be desired.

It is the function of the clinic and the purpose of the combinedgroups to make a careful investigation and study of the child's6ehaiior', his mentrl attitudes, and Iris persottrlitv deviations. and toer-aluate his assets as rvel l as hjs l iabi l i t ies. I t is (he purpose ofsuch an approach to understand and eventually to straighten outasocial and undesirable tendencies before they become a fixecl part ofthe chilcl's personality make-up. If this is done many chilclren willapproach atlolescerrb

-nnd adrrlf l ife ulhamperecl by the crippliug in-

fl-u-errces of their earJy trainiug artd unhapipy experiences.' There rsreason to believe that a relationshin exists between the emotionalinstabilities and conduct disorders 6f early life and the problemsof delinquency and neurotic disturbances later on.

TIIE PSYCHIATRIST

The psvchiatrist is the logical person to act as the director of anyclinic ihbse function is to "study and treat behavior problems. H;is a medically trainecl person v-ho has specialized in

-mental health.

Hence, he not only is concerned rvith behavior as it afiects the in-dividual's conduct in relation to the communitv but is also seekinsthe rrotir.ating forces n'hich lie behind those inner conflicts leadinlto unhrppirress and irrefrciency. Only a medicnlll trnined personwho has also had training in ps;'ciriatry is qrrnlified to decirle rthichcases need physical treatment and ri-hich cases can be helped onlyby ,psychotherapy., I{e must also sec tlizrt cases needing both typesof trertment f l r 'e adequatelr cared {or ' .

The psychiatrist is'clepeirclent upon others of the clinic group forcomplete"understandins^of the cliild. IIe needs intormaiion iromthem jn order to outline treatment and see that the child is properlysupervised.. Q*!oil: of therapy may be carried on to advaritage Uythe ps5rchoJogist, the social n'orker, or the speech rrorker, but thefurai decisiori shoulcl rest rvith the'psychiatrist. A rvell-organizedclinic grorrp will have no tlifficrrlt.f in detelmining just rvheie eachindivit{-ual

-fits in best if the prelaiiirrq spirit is ore"oi cooneration.

The psychiatric intervierv rnust be so"c6ndricted thrrt the farent feelsat ease. (See case presented in section on Habit Clinic Procedure-Intervierv With Psycliiat,r'ist, p. 17.) The psy_chiatrist should try towin the confidence of the parent. This can be done onlv if the nai-entis convinced that the doclor is interested in understatttlins t]re'prob-lems confronting the child and those of the parents as ivelt.

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HABIT CLINICS F'OR CHILD GUIDANCE

fair to assume that if the parents are makins mistakes in the train-llg of their. children, they-are not doing soivittfutly and viciously.They are without doirbt inxious to disc6ver rvhat m"istakes tirey aremaking and why they are prone to make these particular errors.It tend"s to build'up a barentis self-esteem ancl make^ him feel capableof carrvinE out thi details of treatment if the psvchiatrist antl theother clini-c workers trert hin as a responsibje" beins. 'Ihere isdanger, at times, that the psychiatrist will take advailtage of hispositioir as the oire in autho^riiy. IJv I criticll. unsvmprtiretic atti-lude he wj l l huuri l iate parentdu' i th"al l rhe obi ' ious"mii takes whichthey hal'e made. He rrill send therl an-ly frorn the clinic more clis-couraged and less able to cope rvith their ploblem than rvhen theycame. It is a verSr clelicate

^piece of rrorli to cleal with a mothei

who has been a failure rvith her child (for this is often the problen).esp-ecially if_.o1e lias.to p-oint otrt-the_ seliorrsness of rhc dihicuiLl. idwell as the difficultv itself. It is in this respect that the habit ciinicdifiers from most agencies. Hospitals. schdols, ancl manv other or-ganizations have tiie larv beliind fhem,'or if noi the law, ihe fear ofdeath or destitution, or an actual and conscious 'want, and they afiordconcrete and tangible assistance. The irabit clinic' has no'definiteauthority blt l."l to,depend for its cooperation upon rhe parentaltnstlnct anct a rrtencuy contact, anct rts assrstance ts at tlmes ver')'subtle and intansible.

The psychiatrist examines all the infolmation whicli he himselfhas col lected from his i rr terviews l i th paler i t ant l c lr i l r l . to--et i rer u i t l rthat. obtained by tbe social rvorl<er a^nd the psl'chol,,s'ist" flrr,1 frorrrmedical reports. He then attempts to interpfef tlre clii lt l 's bchar ior.in terms of his personality mak6-rrp and hil environment. Hele isly\g{u the psychiatrist triei to applyto this child his knowledge aboutchildren in genelal. He is seeking to cletenuiue tlre hopes, interests,ambitions, lbve attachments, gnidges, fears, antl disnprlointnients'whielr have createcl conflicts'ujithin the child himself. Iie seeks todiscover just how these conflicts have a.ffected the child and hjs re-lationship wiih the u'orld in rvhich he lives. Tfe is concerned rvith'what can be done with those environmental situations which creatoemotional turmoil in the child. Parents are by far the most import-ant influence in the child's environment. ancl io it is their attiiuciesthat cause the psvchiatrist the greatest concern. The conditionsand relationships in the school aird the neighborhood are likewiseimportant, as is the social, economic, and moial status of the familyin ?heir nirticular communitv.

The reiationship between tire psvchiatrist and the child is one thatrequires time, patience, judgment, gnd understanding. 'Ihe psychia-trtst has no inslmments wrth which to measure resentment. humilia-tion, fear, jealousy, and other less well-defined attitudes ivhich thechild mav be experiencins. We know that the child who is in con-flict with himseif and hiE environment is usually unhappy. He isnot satisfied 'with his lying, stealing, or truancy. Rarelv-ii it an endin itself ; it is merely "a n:reans of iScape froni some sit"uation whichis felt to be intolerable. It is with these intansible rrroblems thatthe psychiatrist has _to deal, using such rrnderstaiding as his exper-ience,

-education, and training permit. Perhaps his"success is due

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IIABI'I CLINICS F'OR CIIILD GUIDANCE 7

nore to his inherent wisdom and abilitv to understand the motivestl,at actuate human behavior than to"his psvchiatrie knorvledge.Ilotlr are essential if one is to succeed in being'helpful to the childin trouble and to his worried, harassed parents.

In the maioritv of cases t'he results are good. fn some the im-provement is"quick and very rnarked-in the-mother)s eyes-a miracle.in othels the broqress is slorv and the coldit ion is complicatetl andnot fully appr:ecilted by the mother, who takes the atfitude eitherthat it ii udbiess to com6 to the clinic as the child is not improving,or that the problem is too unimportant to bother rvith. In either casethere must^be frectuent cails dt the home in order to educate themother and insure fhe ploper follorving out of the treatment. Sooneror later these children^ sh6w the efreci of the 'work done upon them,and the mothers expless their qratitude. It is in these cases that thesocial services are most inrportant, as the resttlts depentl rtpon carefrrl,persistent, tael lul rvoll< that means not merely a series irf calls buta plocram of education.

i t is essent ia l thab the r rsychi r t l is t n 'ho det ls rv i th the bel rav iordisordels of childhood sltoirld be optinristic as well as patient. Alltoo f requet i t ly manv of t l te problerns rvhich are brot lg l r t ' to the c l in ichave been in ihe making foi a long time. These habits have becomefirmlv fixed, and they are very mttcll a part of the inclividual. Atti-turles" l-,tr i i t up as th6 resrtlt of lottg-continued, unhappv expeliencesare rrot eratl icated easil.y. The psvchiatrist must ds-ote l-eel<s,months, and sometimes ;'ears,to the lreatment -of a single case. Aitimes he rnnst even acknowledge failule. Yet he must always thinkin terms of the future and in terms of success.

THE PSYCHOLOGIST

The duties of a psychologist in a clinic devoted mainly to the prob-iems of presclrool

^children-are many ancl laried. What-they are rl i l l

t lerrerrd irnon the problems of the individtral children seekirtq clirricrlhelir. At^one tim-e his function mav be to determine tlie levefof mem-tal-develooment that the child has ieachedl at auother. to throrv somelight upon the reason for slow langtrage developmerrt; or yct ag:-rin,to'give^aclvice upon some school pircbl:m, of l'hich there are many.Sirice the contacl of the psycholtigist viih the child usualy coversa long per iod, he is in a posi t ion to observe any specia l handicapthat the child rnay have.

^ Loss of heat' ing, defective eyesight. ir i-

articulate speech ii sornetimes d.iscoveredl ;?;;^;;;otil"* o-*titt.t-ism mav so-metimes serye as a clue to some more obscnre difficultyrvhich leads to the child.'s beins directed to the risht sources for careand tleltment.

When one seeks to recorrstruct the behavior of a child bv the for-mation of correct habits, much depends upon the child himielf. Oneof the first ouestions that confronts a rvorker is the native nbilitr ofthe child, oi in other rvords, ho'w much may be expectetl of

'him

in the reeducational process. It is to the psvcholocist rvith liissnecia l ized t ra jn i r rq th l t one looks for an ansnler to This r t r rest ion.'T l re

var ious st r r t i ies nrade in lecent yeafs l l l )on the t levelopinent ofchi ld l i fe ind icate thnt menta l develo l rment proceeds in ar i o lderJy.continuous way. A chilJ must attain the lorver nental levels before

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g EABrT Cr,rNrCS FOR Crrrr,D GUTDANCE

gojng on to the higher. By administering and interpreting manyJtandardized tests nbw available it is possi5le to deteririne d"ifierentage levels. Has the child reached a level that one of his ase usuallvri:aches, or has his mentai growth failed to keep pace-with hischronological years? On the other hand, has his lnental age gonebevond Fis chronolosical vears? It is essential that these"fu-nda-mental questions be afrswered first, for many problems arisc throughigrroranie of these facts alone. To expect L ctrita to functjon on alevel of which he is not intellectuallv cipable onlv brinss stlain andstress to both child and parent. Ori the other hand. minv problerrrsare often created bv failure to recoqnize that a cl-rild's mental cle-velopment, is beyond his chronologicai age. A few cases ivillrllustrate tIus.

Sylvia is a chilal whose mental development has not kept pace with heryears of living. At 6 years 8 months she was brought to a clinic primarilyfor her many fears. n'ears of animals, of strangers, and of school \vere amongtliem. There were other problems of stubbornness, temper tantrums, and toomuch dependence upon her mother. She had entered the first grade in thepublic school but was soon excluded because of her peculiar behaYior. Shegave no attention to the subjects presented but wandered around aimlessly,talking to herself.

Careful study of Sylvia shorverl a high degree of mental retardation. Inmost respects she was capable of doing no more than the average 4-)'ear-oklchild is able to do. Expecting her to hold her place r!-ith children some 2 yearsin advance of her mentally, necessarily led to diffictlties, X.urthermore, inthe treatment of any of Sylvia's probiems one will have to keep in mindthe immaturity of the child and expect no more of her than she can attain.

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Jean represents a child whose diffficulties were due in part to advancedmental development. Poor adjustment to kindergarten, a strong desire todominate, and resistance to authority were some of the problems for lvhichher parents sought clinical guidance. Although Jean's chronological age rvasonly 5 years 8 months, tests indicated that she lvas oyer 8 years in her mentaldevelopment. She 'n'a recognized by both parents and teachers as a brightchild, but at no time had her true ability been recognizeal. It can readliybe seen why Jean did not find school work on a kindergarten level interesting.

Slow speech dcvelopment is a problem which usually gi r-es a part,ntmuch concern. Many chi ldren are brouglrt to a cl ir i ic"{ol ' this r.ea-son alone. \ \ ' i th such a- cas_e, the role of the psychoiogisr is ver.yimportant. _ I t may even be that the_problem is sblved by'the psyclro-logical strrdy alone. for tests rnav dater,mine that the ;hi lal has nobrerclred the mental age at whicl i speech develops. The sneech re-taldation mty provt to be only a part o{

^the chi lci .s ger}eral

reterdatlc)n.

The services of the clinic s'ere consulted in regard to Celia's slow speechdevelopment. She was 6 years 3 months of age and had. begun her flrst-graclework in school. X'rom this she was soon dropped. Two older sisters werespending much time trying to teach her but with litile success. In spite oftheir effort Celia had only a few rvords at her command. Her oroblen wassoon solved, for all tests showed that Celia had not retched the mental aeeat which specch develops. I{er slowness in talking could be explained by amental retardation below the age at n'hich a cliild begins to use language.

^.Thg"*" ry&y !e other reasols why- a child is not learning to talk.Chief of these is deafness or loss of'hearing.

Grace represents such a case. At 4 years of age she had acquirecl scarcelyany vocabulary. several tantrums at tirnes made it clifficult for the Darenrsto disciplire her. !n the tests tt'at could be giveu her at the clinic

-she re,

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IIAB1T CLINICS F'OR CEIILD GUIDANCE

sponcl€d like a ehilal of average intelligence. Ilowever, her behavior suggesteddeafness, and a hearing test was recommended. Autliograms showed that thechild suffered from marked impairment of hearing. Iu this case slowness inlearning to talk was due to deafness and called for very different treatmentfrom that of a child whose poor speech is due to mental retardation.

Proper school placement is of grent importance for the mentalhealtli of the child. School failire shouid be avoided wheneverpossible. Formerly little attention was paid to a child until he hadfailed two or three times. Attempts are now in progress to mal<esuch adiustments much earlier. witi the result thatihe*clinic servicesare often consulted when it l6oks as if the child will not make thsgrade during the first year. In this way, failure, with its emotionaleffects, is o{ten averted. More enlightened mothers are even bring-inE their children to the clinic to det6rmine their readiness and fitnessfoi school. For these problems the services of the psychologist arevery necessary.

Robert was a little chap wliose age allowed him to enter the first grade.His moUrer questioneil his readiness and came to the clinic seeking advice.A1l tests conflrmecl the rnother's suspicions. Robert was slow ln his developmentand was in every respect a much younger child than his chronological years.I-Iis poor ability in some special things gave everJr reason to believe that Robertwould fail if he began his flrst-grade work at that time.

Proper school placement was a matter of concera to Richard's mother also.She was a'rvare that he read well for a child only 6 years 3 months of age,but she questionecf his ability to rlo second-grade work without spending thefirst year in sehool. The clinic was consulted. Richard's advanced mental de-velopilent, together with the fact that educational tests showed his preparecl-ness for second-gracle work, justified his going into that grade. He wasadvanced to the second gracle, where he aaljusted himself easiiy and happily.

These cases represent only a few of the many problems coming tothe clinic in whibh the services of a psvcholosiit-are essential. Fur-thermore, because the rvork is varied^and dem'anding, it is importantthat oniy those who have had adequate training and expelienceshould assume the responsibilitv of dbinE the worL The qiralifica-tions of a clinical psfchologisf should c"omprise more than a mereknorrledge of the teihhique olf administeringithe tests and the abilityto complte the intelligence quotient. Determining the intelligencequotient js but a smail part of the ps.vchological

-study and means

little unless interpreted in lelation to good developmental, med.ical,and social historv of the child. Personality traits, handicaps, if any,and speciai abililies or disabilities also corie in for study.

-Only one

rvho ii familiar with these various aspects of a child's developmentcan ever hope to do justice to the child in such a study.

After the intelligence quotient has been determined, a questionrvhich one may reasonably ask is whether the intelligence quotientremains constant or relatively the same throughout life. Though theconstancy of the intelligence quotient has been studied extensively,the question is not definitely settied at the present time. The age atrvhich the psvchological stirdv is made wiil influence somewhai theintelligence-riting.

-To a clinical psychologist who has worked with

* your]c child beTore his lansuasd his devitoped to any extent it isnol sur'"prising to find that thE cliild has raised his rating perceptiblyat a later date. Also, a chirld from_?-poor _environment may changehis scoring when placed for a while under better circumstances.

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10 HABI'I CLINICS FOR CHILD GUIDANCE

However. an experienced. worker will recognize the potentialities of

clevelopment and dilTerentiate betrveen l-hat rnay be a permanent re'tardation and an undercler.'elolrment due to ltoor enlirotuleut.

The rvhoie subject of a psy^chological stldy might be best under-stood by poirrt ing out some of the matly interestrng flcts thrt l)] l t)come t6 i icht diring an exenri 'ntion. T1e first requireme-nts nreDroDer raD-port betrr:een the psychologist arrd the chilrl arrrl estnb-iislrinent of

" prop." attitucleioivar.d tle tests in general. Tle psv-

cholocist qets hishrst l inorviedge of i l ie child from the way il_s'hichilie siT"afon js met. With onE child rrppolt is quickly estrblish.e,l,Ele comes reaclily and alone rvith the examiner to the examlnlllgioo-. IIe mtv 6e a l ittte shy at the beginning but he sool lerrtrsthat the examihel is a fliend ancl not sdmeone to be feared' In a

short t ime he is r-ery much at cirse and complies rvit lr all rerluests.He works I ' i th cfioit and persistence and meeis the most diff iculti..t

"o.tt.though his elTcrt'ts-naY not be crolvned rvith success' His

attitude is onJot independence'and of meeting nerv situations alone

and unaided.iVith another chilcl the very _oppositg puy be true. His. mother

mav have to accotr rDl t rV | im to t l rc ixamining I 'oo ln; |e renrr i r rs ferr -ful"of the exrminei thi 'orrghout the exnnriuniionl he js never at erse:he responcls to tests larg'; ly untlcr plotest; his eflort is poorl anclwhen ire rneets ihe slig]rtesl diff iculty-he rPperls for,help.^ In 1'act,his-attituae is ot're of

'dependerrce and a corr-'{ rrrt seeli ing for rssi;t-

" r r " " . At r lo t ime does h^e meet the nelv s i t r l r t ion i t t rkpctr ' lc t t l11 ' r l r ' l

unaided. In truth. the response to the test siturtioll tllrrY often be

an indication of thi: way tl ie child is- meeting l i-tc in.gorenl'When the chilrl,s cooperntio[ ]ns been ob*rined, ihe mole formrrl

tesis arc given. The oBject of the standa|tl izeri test is to determiletrow ttre Ehild,s deYelopmenb compar.es rvith thrt of other chililrenof his rco. If he has^not come up to the stnncln|d, lrhrt are someo{ the fditors that mav possibl.y tf lbct his future develoPrnent? Onernust allow for the piemature child to catch up to his actual age;for the child whose^ph-ysical lctivit ies hrve beerr curtt i led. becauseof *onv i l l tesses; f& i1e c1i l t l * - i t1 I b i r t l i r r ju 'y ; r ' r1 for cSi l -dren witl other hanrlicaps. Hrrrrdetl 'ess rlso lrrrv be observed atthis time. At arr elrl.y ige the chilcl begins to shorv a prefercncefor the use of one hrnd. itrterference in the d-cvelopment-o.f _the i lseoi thr hands may rvork out disaclvantag_eo^usly to the child. The

]ittle cliild who has been forcibly changeil frorn the use of the pre-

f.tr.a left hand to that of the rig'ht is all too frequently recognizedbv other siqns of difficultv.

"tr urther Tnsight into tlie child,s mental cle_velopment is.hacl by .theuse of langulge tests. Thele is no phrse of developrnent ihat reqll lresniot. cr.if oi"obser vrtion _ and stucly. _ To distinguis-ir .betrveel. goqd,il-"our-td langrrage developrnerrt and mere -superfrcial verhrlisticfluencv is possjblionly to one irho hrs I knorvletlge of lrngurge tcstsnnd exnefrence with-children rrho slio'w *rriorrs phases of speeclaccelerdtion or letarcltt ion. It mrv be said that this phese of de-

reloprnent can be most mislerrl i i lg. The child wlio sperl<s a grertcieal'and. l_t_rn early lge is gener.ally regarded asintellectua{Iy supe-rior. bLrt this impr6ssron lnay or m&y rrot be correct. On the other

hanh, the child ivith poor enunciati6n and little facility in the uso

t-

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IIABI'I CLINICS F'OR CHILD GUIDANCE 11

of words is often consiclered retardecl. These deductions ma,v ormay not be true, depending upon the nature of the language de-veloDment.

T[e type of chilcl who has only a parrotlihe speech development isrvell knbivn to the clinical psychologist. He eiunciates clearly andhas several language patterns. 'lVhen

using these freely and spon-taneously, and in the nanner in rvhich he has learned them, he seemsquite like the average child. He fails, howeler, wheu he is asked touse these rvords in a new rvay or to show that he knows what theymean.

Daniel's history illustrates such a development. IIe articulates fairly welland uses rathcr long sentences. His comments are usually built around somepersonal incident or some object il the immediate situation. When Daniel isasked to indicate the meaning of some word he has used, he is unable to do so.All tilat a word seems to clo is to elicit a response that has been learned andassociated with it. He apparently has no grasp of its meaning. He also failswhen it is necessary to comprehend simple questions. He has learned torepeat words in a parrotlike way. but he can do little in using them intelli-gently. In truth, his acquisition and use of words are comparable to theIelrning of the defective, who gets the repetitive learning but can do little'oith his material irr new situations. Daniei's intelligcuce quotient falls intothe feeble-urinded grouping.

Another pliase of development often recognized in a young child isthat in ivhich his information is much in'-ach'alce of "his a'bititv toreason independently. This is often seen in an onlv child or"onewho has bedn uncler'the tutorshiD of an adult a sread de&I. Such achild may linorv colors ancl coins,^may have a nuriber concept beyondhis years, and may use pencil and paper with ease. In fact, he ismuch at horne rvith things that may be learned by individual help andattention. It is 'when Such a chiid is faced with a problem whlcttdraws upon his own initiative ancl ability to renson inclependentlythat he

^fails. His whole attitude is one of rvaitins to le shoivir

rai l rer thau of Drrzzl ins t l re problern orrt for himself . \Vhi le lhe abi l -i_Lv to learn rei.lity Jr6rn otl,ers is a measurement of irrtclligence, itdoes not constitute the sum total of intellisence. Neithel clois muchlearnins make one prrt icular lr intel l isent. f t is not so mrrclr thermounithrt the individual learns as his abilitv to use rvlrat he haslearned that is essential. It is in this respect tfiat t]re overambitiousparent is often deceived. The rnother, in lier zeal to hasten the mentaldevelopment of her child,_sets_ about'teaching him all he is capableaf acquiring, often to the disadvantage of the'child. When the iatterhas reaclred"'the satriration point, IrE gives the impression of beirrgoverstimulated and confnscd antl of possessinE kuowledce mrrch ifradvance of his years but having little meaning to hifr. He haslearned facts, but his intellectuai-immaturity does not allow him touse them well. This is the type of child rvho may have a very highintelligence quotient at arr eally age, but whose intelligence quotientdrops "perceptibly at some hteri ex"amination. This chYld *uy .*p"-rience difficLrlty in adjustment to his early school worli, the- reasonoftel being that, thlough having much direction and supervision bva second person, he has built up such dependence that he is inadti-q_uate rvh6n this support- is witiidran'n arid he is obliged to fit intothe methods of teaching by group instructron.

78985o_39-2

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t2 HABIT CLTNTCS FOR CTITLD GUID-{NCE

A similar mistake is often made with the dull, slow child andthe fecble-minded. Rcfusins to accept consciously the {uct oI rhechild's mental inadequacv. tlie parent ittempts to cbmpensate for hisdeficiency bv forcing the rote iearning. But the leariring is not as-similatecl, and thisaecomes verv evi-dent when the chii-cl is calledupon to apply it in some simple reasonins problem. Instead offiirdine it ?r^ptiv applied. one s6ts a resu"cftation of incidents andfacts.

-a talkinq aboft soirethin'c. as it wEre."without anv proper rela-

tion fo what the child is sayingf '

fn other words, he taiki ali arounda question without in the end-insrvering it. This type of child, too,is welt known to the clinical psvchol"ouist and of^ten has accom-panying behavior problems.

IYithin recent yelrs considerable studv has been macle of the so-called verbal. abitract. ideational tvpe bf child as compaled withthe practical, concrete'type. Wtiile iittle is known psrdhologicallyconc^erning tirese differeir6es, it is well recosnized thit" such

-a dif-

ference ex-ists. One child hdrs no difficulty in'mastering the symbolsrequired {or academic progress and hai no trouble"in rea"soningout a situation not in the Immediate present. In contrast to thi!child is the one for whom all forms oi svmbolic education are ac-quired rvith effort or are not acquired at itl. In the irnmecliate sit-uation and in working with concrete material he is intelligent, buthe fails miserably in-his attempts to meet academic requirements.fn other rvorcls, he has a type of inteligence which mav idjust wellin a progrrrn ihat calls for the pract"ical everyday auUei of life,but wili bl lelv nuch orrt of step ii a bookish, acaderiric environnrerri.,\gain, this type nin;'le recogniTed at.a very i:arly age.and profitabicad.vrce grr-en wrth leference to eclucational plans, if the pnrent nillaccept iT. Too often this is not 'w'hat happars. The plans and am-bitions of the parents for the chilct will n6t allorv this'. They tutor.they drill, tirey rrng, arrd they_ force. _and all their eflorts have only avery detrimerital eflect upon the child.

One.cnnnob-hope to porlrqV. all the types seen in a clinical service,and it is not the purpose of this writinq to do so. Rrther. the aim hrsbeen simply to indiiate the nature aiid variety of problems that aclinical ps1'chologisb may meet and to emphasize the iruportance ofadequate training.and expelience. This u'ork requires-the abilitynot bnly to adnrinister the tests but also to interpret the results anclto recoguize the various phases of development-lvith their possiblerelation to the problem foi which the child is seeking clinical^help.

THE SOCIAL WORKER

The social work in the habit clinic is complex and varied. All typesof problerns are referred from many difrerent sources. The visiii}snurse who firrds a physically well child refusing to eat; a family-n'ei1fare rvorker rvho seei a moiher so o.r-erwhelmeE with ine difficult lre-havior of one child that her agency's help is of little .l'alue to thefamily; the social worker frorn a child-irelfare agencv rvho seekshelp ior a child rvith the problenrs of defective speich br continucrlbed--wetting; parents worriild and lrarassed by the irdinarv, ever.ydayproblems of iife as they are related to the child-all tuln td thleclinic for assistarrce. Many of the childr,en come to the clirric directly

I

-a-a----"- --

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- EI

IIABIT CLINICS TOR QEILD GUIDANCE 13

frnm a nursery school or a kindergarten. In these groups the teachersoften note the"child who finds diffiiulty in making aljuslment to- otherchildren, who is obviously tlie victiri of unrvis-e tliining; and theywill euide the mother to tlre clinic' Probablv the most satisfactoryreferial is the one made directlv bv the mother rvho realizes thather child has a problem rvith rvliich"she needs help, for cooperationis then assured.

It is the social worker in her role as clinic manaser who makes theimnortant first contact with individuals or asencies wishine ciinichefp. She selects the cases which the clinic is be-st equipped to'handle,mai<es the appoitrtments for attendance, and wheii tlG mother andchild arrive sleers them through the routine clinical examinationsand intervieu's.

The social worker is a member of the team consistinE of psvchi-atrist, psychologist, and social rvorker, rvhich mahcs a thrlefold sludyof tlie child. She in'r'estiEates and studies the environment in n-hichhe js livirrg, inchrding the horne and the neighborhood. and especiallyl l rat nrost- inrportant ' fart of the chi ld 's en, 'Tronnrerrt , the aduits withn-hom he comes in contact. She learns from the parents. the teacher.and the nurse rvliat has lreen observed of the chi]d's neisonalitv. hisl 'eact ions to prrnislrrnent, l r is choice of plavmates, his af iect ions, nioods,impulses-ritatever rviil help to make rip a picture of the ctrita ashe realiv is. She is. *oteovdr. in a positi-on t6 obtain much yaluableinformation through visiting'and observing the chilcl informally irrthe nurserv. the nilrserv schi,ol. the school."the home. the settlementhouse, the fiayground, 6r the community center. For'in this way thechiid'may^be'ibserved at his play or 6ccupation, quite at ease" andunperturbed, free from the fear and anxiety that are frequentlyassociated with the more formal clinic contacts,

To this cross section the social nrorl<er adds a lonsitudinal view-she learns sonething about tlie family stock frorn which the childcomes, the conditioni under rvhich he"v.as born and reared. his de-velopment, the accidents and sicknesses he has had, and his reactionsto them-everl'thing that,will.help to explain the child to the psychi-al'|.rst wnen ne conres to ilre cirnle.

\\rhen the child has been studied at the clinic and a plan of treat-'ment has been made, the social rvorl<er assists iu car:rving it out.The direct treatment of the child is carried on bv the bsvchiatrist.I{ol-ever, the success of the program for the child bf haditlclinic aeerleDends largelv orr tlre cooDeratJon of the grol\'n-lrDS responsible folI r is t rr i r r ing. T]re fat her 's and the mother 's"att i t r rde' ton-al d mastur l la-tion, the. method of hanclling a temper tantrum, the teacirer's per-sistenc.e jn correcting a -spe3c-! defect, may all have to be changeh ifthe clrild is to be helped. It is often necessary for the social lv"orl<erto explain to parentl $gain, and again the ciinic finclings, to- shon.thenr. ihe important role each step plays in can,;'irrg orrtllre plan oflreatr]rent satrsfactorrl)-. tleassulance and eneorrrugerrrerrt are ofterrnecessary, sirrce the tggk,9f supplanting poor habiti n-ith goocl onesmay prove a long and tedious process.

Flequently thJplan for the -childts

treatment involves some servicswhich-the cl'inic is not prepared to sir.e. For this leason the socialworker must be familiar wilh all poslible resources in her communitvand must know the type of case tliat each organization can best serv6.

-E

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L4 HABIT CLINICS F'OR CIIILD GUID.{NCE

4 more complete phr,sical eramination rlar be nece,csArv. Deafrress,f o r exa tu l r l e , r r r l ; " . , i , , . e t . t r ' 1 , c r ' r r r r t l l l l ns o r g i \ e l r r , r 1 , l , ca lance o fgenelal retrldrtion ancl musl be rulecl out biiole an\'^t-)lan can behade by the clinic. Ennresis (incontinence of uririef cannot beconsidelecl n habit problem lrnless no physical basis for it can befouncl. Litensive neirlological studies uid"un intensive investigationof tlie endocliire glands may be essential. OnIy those most experiencedin these particulir fields oT medicine can be tlf real heln to ihe chilcl.

Camps or schools give a temporary change of envir6nment wiriciris very heJpful in determining the effect srrch a charrge nnlies inthe chi l t l 's^problenr . Elen, n ' i t l i a g l 'oup o. f ch i ldren"of the.pr ' * -school age, the only possible solutiou sometimes seems to be long-time piacemeut in a foster liome. In srich an event the cirilcl-pla,cingngenCy gives inlaluable assistance. If, as often happens, the lnotheiis so p leoccrrp iet l rv i th sonre worry, t inunci r l or ot l rer , t l ra t s l re f r r i lsto recognize the necessity of help for her child or if her own \rorryis adding to the child's clifficulties, the cooperation of r fnmily agencythat cariwork out a buclget ancl'give surpplernentary relief"or steerthe mother to a relief-giving organization is tlie fir'st step in treat-ment. The social work"er uirst Enorv the clinic o. agenci' tlur,t carrkrest help the child, considering his erge, his ploblem, ind ihe familynrlarlces.

Althoueh the most important part of herrvork is the service totlie cliild

"who comes to the clinic, the social v'orker in the habit clinic

has otirer chrties, arnolrg rrhich the supervision of stuclents rvho rnaycome to the clinic fol pllctical t laiuilg is iurportant. The stnclentsrvil l acqrnint thenrseli 'es rrith tlre clinic rnethods by the stutly ofrecords and through stafi confereirces at 'nhich the psvchirtlist, thopsycl ro logis t , rnd lhe socia l lo lker present thei r pui ts of t l re inves-iigation

'and trcatment. Study of ihe contacts oth.r ng"r-r.ies have

nia wittr new clinic cases giveJ the students tlie opportuiiity to le"rr'tof the communitv resources at first hand. Follo'rv-up visits tesr ourtheir abilitS' to make satisfactory iltervie'rvs and pe^rsonaL contacts.Finallv. a ie.v cases are turned bver to the stucleits. ahvavs undercarefui

'supervision

The material lvhich is gladunllv collected in the form of recorclsis par t icu lnr ly va i r rnble for rc-eal ih pulpose.s. rs i t t le l ls rv i th yorrngchilth'en u'hose lrloblerns nra.y bc projected into tlre frrtrrle and rvliu{rs r group lend tliemseh.es to follorv-ntt stuclies ancl research. 'I'he

collec-iing^ancl rnalyzing of snch data ai may be obtained slioulcl benseful iri shol'ing iarious trencls ancl in evaiuatinq results of treat-ment at the clinic when compared with carefulh controllecl un-treated problems of a similar irature.

The amount of educa,tional rvork which t]le habit-clinic socialrvorker can clo seerns to be limited only bv the time .which she caugive to it. That tire chilcl's early veari are important in his futureidjustment to life's problems is itiit not rviclely'appreciatecl. 'Iallis

to nrotherstc lnbs, to 'groul )s of leachers, anr l tb o ihcrs in terestet l inchild training, on the*imltortalce of tr.ei'ttal he:tlth ancl the value ofthe serv jces of a chi ld-guidanee c l in jc . especin l lv to preschool ch i l r l len.are time-consuming brit unquestiorrably anothei imfortant par.t of thctoD.

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rIABrr OLTNICS FOR CHILD GUTDANCE 15

With so broad a scope of activities it is most important that thesocial worker not onlv fulf i l l the usual lequiremenls of echrcrtion,training, and experienie but also have a sufficient reserve of stlengthand eri?icv to inlble lret to meet ltr inrerous and varied demrncls*ith .t itt-irndl resourcefulness, to be reacly to tackle a ne\\' situationrvith initi:r,tive, and to be abld to see the-old problems with a freshpoint of vierv.

TIABIT.CLINIC PROCEDURE

Parental education mav be said to be the backbone of habit-clinicploceclure, strpplomentecl b5' a direct ps1'chitt l ic allp-rorch to theinentll treattnbi the ciri ld in an attempf to understand his partictLlardi{licuities in making the uecessary acljustments to life. The sourcesof trabit-clinic caseJ ar.e r-aried.

- Social ageucies, nlrrserY schools,

kindergartens, priv-lte physicians,. hos.pitals, l lurses'.arrd ,parents allrefer cnses for stucty. As educatron In merltal h.\ 'glelle hfls becomemore gerlernl anrl ptrents ltave beconte more concernetl ovet' evl-dences"of maladiusiment or inadecluacy in tlieir children, and moreenliehtened conc"erning the envirofmerital factors afiecting conduottan Increasing numbei of cases have been referrecl by the parentsthemseh'es.

.'Whether the child is re{erred by a nurse, a teacher, a

social worker, or the parents, the procedure is the same.

A visiting nurse entering the home of N{rs. S found the mother very muchupset, nervous, and agitated on account of having been worried aU day byher little daughter Mary, aged 2 1'ears 2 months. Casual inquiry at this timerevealed the follon'ing facts: 'Ihe child rvas extremely disobedient, almostto the point of being negativistic. She absolutely refused to respond to adirect command and could be managecl only by constant coaxing. AlthoughXlary had been weitned months before, the mother had resorted to the use ofthe bottle in order to comfort her before her nap and before her bedtime, andas a help in getting sulJicient nourishment into the child to keep her fromIosing weight. At every meal the mother was put through the typical ordealof feeding the child herself, often being rewarded for her efforts by havingthe child spit the food out on the floor. It was also mertioned quite inci-dentaliy tllat the child wet the bed every night and had done so ever sincethe mother had resorted to bottle feeding.

With this information at hand, the nurse reported the situationto the superr.isor in charse of the settlement house x'here a clinic rvasbeing held. havinq first interestecl the mother in the habit clinic andrvhaf it js'tr.ying-to do for this tvpe of case. The sttpervisor thenre-ferred the"faririly to ihe social ivor]<er of the habit clinic, wh9within the next 2 "or 3 dat's made a careful social investigation ofthe home. The followingis a brief summary of her repoit:

SUMMARY OF SOCIAL WORKER'S REPORT

Case of MABY SilrrE

The family live in a very poor and crowded district. The street is narrow,unpaved, and cluttered with papers like an alley. There are three-story bricktenement houses on each side, and one has the feeling that it is a cougestedneighborhood, as the street is crowded with children, there is a great dealof noise, and many people are hanging out of the windows'

The patient's family, consisting of father anrl mother, l\{ary, and a littlegirl of 6 months, occupy a four-room tenement with bath, on the third floor'ior which they pay $20 a month. The house is very clean and is neatlyand prosperously furnistred. It has a liviug room, a dining room' a kitchen'

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16 I IABIT CLINICS F'OR L'EILD GUIDANCE

and a bedroom. All members of family sleep in one room. The patient hasa crib by herseif.

The mother is a slight, delicate young rvoman of 20, who enjoys housekeepiug and is very n'uch interested in her home. She went 2 years to highschool, then worked as a clerk before marriage, and has been married 3/2years. She has a bad temper and is easily excited. She told the worker thabwhen the patient does not mind her immediately she becomes impatient and"feels all stirred up inside."

The father is a short, well-built man of 24, wbo drives a garbage truckfor the city, earning $24 a week. He is in good health, is interested in hishome, and plays with his children. I{e and his wife differ in regard to dis-cipline, he often telling the child that she can do things which her motherhas forbiddcu.

The patient was born fuII term, instrumental; one eye was black and blue.Development *'as quicher than that of the average chiid. It'irst tooth: Fourmonths. Walking and talking: Under a year. The patient has had no diseasesor convulsions. The only evidence of illness is that 3 weeks ago she had afever of 10ll and lvas nauseated.

I1nbl1s.-Sleeps from 6:30 p. m. to 6 a. m. Is restless and oceasiotrally criesout for mother in her dreams, awakens, but goes back to sleep again. Nonight terrors. Has a 2-hour nap in daytime.

Feedirtll.-She is not finicky but has a capricious appetite. At different tim€srefuses different foods. Always has to be coaxed and occasionally spits outher food. Will not drink milk except from a bottle. Is always given one whenput to bed.

Ettrffesis.-Wets bed every night.Disposition,.-Affectionate; demonstrative; generous ; not jealous, pugnacious,

nor domineering; very stubborn and inclined to be negativistic. Alwa5's has tobe coaxcd to do tbings; is very disobedient.

Play l.ife.-Ilnjoys playing with other children but can amuse herself if leftalone. Likes dolis.

Sumnory.-There is no evidence of nervous or mental disease in the family.The chief problems are refusal of food, enuresis, and disobedicnce. 'Ihe rnotheris excitable and easily loses patience w'ith the child. The father seems sensible,but the parents disagree in regard to discipline.

The mother was asked to report v'ith the child at the clinic thefollolvins week. c"t which time-the child was immediately taken incharge b! the psychologist, whose report is here summari;ed.

SUMMARY OF PSYCHOLOGIST'S REPORT

Some 15 or 20 minutes before the psychological examination was begun,friendly relations rsere established. The chilcl, after an initial hesitancyand shyness, quickly became interested in playing and enjoyed especially thedrawings of a cat with long whiskers. As she is of that age where best exarni-nation results are obtained with the mother present, provided she uses discre-tion, the mother was given the usual instructions as to how she could helpin the examination. The mother was quite interested, and excellent cooperationwas secured. She srniled encouragement from time to time and did not letMary know \qhen a failure had occurred. She wisely refrained from distract-ing her by urging her to do better.

Mary showed but slight hesitancy about entering the examination room. Assoon as she saw the pictures and the colors her self-consciousness disappearecl.The tests given her were presented. as games and she quickly caught the playspirit and very willingly tried to do everything that was asked of her. Themother, too, was pleased and incidentally quite surprised that the youngsterdid things whiclr she had never tried before.

Mary is 2 years and 2 months old. She developed rather more quicirly thanthe average child. Her flrst two teeth came in at 4 months. She said suchthings as "mama" and "papa" at 6 rnonths and a lafge nunber of words plainlyat I months.

As far as formal tests are concerned, this chiltl made a very good showing.With one exception she did satisfactorily all tests that the average child of2 does. Pictures took her eye, and she interestedly pointed to objects in thepictures aDd nameal one or two in each. She quickly imitatecl such movements

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as raislng arms anal clapping hands and quickly carried out simple requestssuch as 'Bring me that baU," "Now throw it to me," and "Go over there andsit on that chair." Before eating a piece of candy, she removed the paperin which it had been 'wrapped. Her one failure in the 2-year test was thatof copying a circle rvith a peneil. As her mother has never allowed her to usea pencil Iest she mark up the house, this failure is insignificant. She passedfour of the 3-year tests. She l<new her full name and her sex and she took delightin pointing out her eyes, nose, mouth, and hair. She poiDted to shoes, stochings'and dress, and was faniiliar with the names of common objects, such as penny,a knife, a key, a watch, and a pencil. In all informational questions she didexceptionally rvell.

Summing up results, we find that Mary has a mental age of 2 years and6 months, as against an actual age of 2 years and 2 months, whichgives her an intelligence quotient of 116. Her developm€ntal history, her gen-eral alertness and interest in things about her, her quickness in learning, andher rating on formal tests show a child above the average in intellectualequipment.

INTERYIEW WITII PSYCHIATRIST

Shortly afterwards the mother was interviewed by the psychiatrist,and althirush the following conversation was not ta,ken verbetim, itrepresents ivhat was said as nearly as can be remembered from thendtes dictated a fe'w hours later:

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Docmn. I understand from Nliss W, who visited you the other day, that Maryis becoming quite a problem.

1\Irs. S. She is, indeed. I hardly hnow what to do with her. She refusesto eat an)'thing, anil she gets me so worked up and so tense inside that I goiDto hJ'sterics.

Dooron. Then perhaps you are not feeling yery well yourself.l\frs. S. I aln feeling all rigltt non', but at times I get nervous.Docron. Under what couditions are you most apt to get Ti'orked up, Mrs. S?n{rs. S. Usually when I hirle had argurnents $-ith my husband regarding

ffary-how to make her uritrd and x'hat I shotild do. When I am tr]'ing tomake her mind or tal<e her food, he butts in and says, "Let her alone. Don'tkeep bothering the child." And ou other occasiorrs when she is doing thingsthat lie doesn't like, he asks me why I don't make hel rnind.

Docron. One may assume from the report \\hich trIiss \\'brought to methat you and your husband get along very n'ell, that J'ou are both fond ofand very much interested in Mary, and that you want to do eyer]'thing possibleto have her overcome these undesirable habits.

X{rs. S. Yes, sir. lVlary's behavior is the only thing orer ryhich we have anyargnrnents at all, and n'e both want to do all we can to help her.

DocroR. You know, Mrs. S, that a child of }Iary's age, especially a child ofMary's intelligence, has a very much better understanding of the ordinarythings going on about the household than you gir.e her credit for. It is sur-prising horv early a child learns that there is some doubt in the minds of herparents about just what is right and what is wrong, and, quite naturally,when there is any doubt in the child's mind about what course he is to follow,he is very apt to take the easiest one. So it is extremely important that youand 1\Ir. S have a definite understanding about what you are to expect ofMary. You krrorv, too, that not infrequently parents are apt to discipline chil-dren in a rather erratic rvay. By that I mean that much depends upon howthe parent happens to be feeling at the time the child neecls discipline. If themother is in a cheerful state of mind and not tired out by the household duties,some breach of discipline may be looked upon as quite amusing, the parentsmay speak of it as "cute," and the mother may laugh at the child instead ofreprimanding her. On the other hand, if the same thing happens at the endof a hard day rvhen the mother is worried and annoyed and somewhat out oftemper herself, the child may be punished, sometimes severely and out of allproportion to what she deserves. Of course, you understand that I don'tmean that is the method used in your home, but it is a method used in mosthomes more or less. I just mention it so that you will understand better whatI mean by the importance of getting together with your husband and talkingthese matters oYer.

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Mrs. S. Yes; I know lots of mothers who rlo just that-laugh at the babyas "smart" one day and slap him for the same thing the next.

Docron. I would also call your attention at this time to something that youprobably know already, and tllat is, that it is yery bad to have the parentsquestion each other's rnethods of discipline before the child. It is much betterto have the mother or father carry out his or her own method, even if therrther parent is not in full agreernent'n'ith what is being said or done, and thendiscuss tlle whole thing in priTate after the child has gone to bed. It is onlyin this rvay that the child learns that the parents are united in their efforts tobring about the desired marlDers and habits. I think it is of the greatest im-portance that you talk these things over with your husband and have an agrec-ment that *'ill prevent any discussion of authority before the child.

l\[rs. S. Yes, sir; I see exactly what you mean.Docroa. Now we will discuss the feeding problem. I understand that Mary

has not as yet given up the bottle.Mrs. S. I had her weaned from the bottle, but she absolutely refuses to take

milk from the cup. It was only when I put a little water $'ith it that I couldget her to drink it. I took her to the doctor, and he said if sho \r'ouldn't taliemilk from the cup, to let her have it from the bottle, and that is lvhat I havebeen doing the last few months. She gets the bottle every morning at 10 o'clocliwhen she takes her nap and every night when she goes to bed.

Dosron. Of course, you appreciate the fact that l\{ary is old enough to give upthis bottle and that her clinging to these habits so strorlgly simply represents aclesire on her part to stick to those infantile methods which she should be grad-ualiy giving up. The feeding problem, and the bed-wetting as well, representhabits that are quite norrnal for infants but that she should have outgrownsome months ago, and it is going to be a great deal easier to break her of thesehabits at 2 years of age than it will be at 4 or 5. There is no better time tobegin than the present.

IIrs. S. I realize aU that and am willing to do n'hatever you say.Docron. TelI me a little about other difficulties with her feedinE.Mrs. S. She absolutely refuses to take any food unless I feed her.Docton. You mean that you hare to sit down beside her at each meal aud

actually take the food from her plate and put it into her rnouth?Mrs. S. Yes; and she even spits it out.Docmn. Then mealtime must be a very trying experience for you.IIrs. S. Yes; it is the worst time I have.Docaot. 'l'hen let me tell you what I have learned from my experience re-

garding children who cause so much difflculty by refusing food. In the firstplace, we must remenber that it is a very natural thing for all human beingsto crave attention, and this is particularly true of children. The refusal offood is frequently a method that children use to get the time and attention ofthe parents. At that time they become the center of attention, and it is a batUcof wits between the mother and child to see rrhich one will rr-in. The mothertrequently puts the food on the table rvith serious doubts aud misgivings in heron'n mind as to rvhether the child will eat it, and perhaps her first remark is,"You have got to eat this. You are not going to get up from the table untilyou do eat it. You didn't eat any breahfast and you cannot go out to playuntil you have eaten your lunch." This immecliately puts the chilcl in a ratherdefiant mood. Even if it had not occurred to the child to refuse his food, thisin itself acts as a challenge. It is just as though there were a litile play goingon, in which the child is taking the Ieading part-a situation in which boilrchildren and adults like to flnd themselves. lVe know that the child knows thlrtinvariably, if he does not eat his meals at the regular time, the anxiety of themother will make her only too willing to provide food between meal hours.So in this way the child is not only trble to defy the parent and attract attel-tion anal win his battle, but he is also able to get the amount of food which hissystem requires. It rnay be that he doesn't get the best type of food and thekind best suited to nourish him, but he gets the food which pleases him mosrrtnd satisfies his hunger, and that is about aII the child wants.

Mrs. S. But, Doctor, if I let her go without her meals she will set so thin.Docron. It will be haral at flrst, I know, but I would suggest that from now

on, or at least during the next week, you and your husband agree to the fol-loJving plan: Place on the table a smaller amount of food than you wouldnnturally n'ant the child to eat. This should inclucle milk, cereal, fruit, andwhatever else you may wish her to have, and absolutely nothing should be said

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regarding the food itself or the child's eating it. If the chiltl is eating withyou and your husband, pay no attention rvhatever to her eating. After youhave finished and sufficient time has been given the child to eat her food,remove the dishes and say nothing at all regarding the amount of food thechild has eaten. If l\Iary has not been in the habit of having milk betrveenmeals, under no circumstances give it to her.

llrs. S. She has been having the bottle at 10 o'clock, just before she takesher nap.

Dosros. Then, under those conditions, I shoutd give her an equal amount ofmilk in a cup. On the n'ay home, I should drop into the drug store and getsome straws and let her use those during the coming weeh. It will bea step a$'ay frorn the bottle and rvill interest her in taking the milk from thec l lp .

But to continuc regarding the more general statements as to her feedinghabits: Do not be concerned if she does not eat much for the flrst few days,It will take a day or so for her to learn from your apparent lack of interestirl her eating that no one is very much concerned whether she eats or not. Inother n'ords, try to get anay from romaDce at her feeding periods. Xlary willsoon find that she no longer occupies the center of the stage during the mealhour. I appreciate that you will be just as concerned, but the important thingis not to let llary knorv it. The task I have outlined is a difficult one, I know,but it is not nearly so difficult to rnanage now as it is going to be a year ortrvo from now; and although the resuits may be discouraging at first, you maybe assured that in the end it will work out not only to l\{ary's advantage but to)'our own.

lIrs. S. Wel], I'll try this week and see if I can stand it.Docron. I don't want you to look for improrement today or tomorrow or the

next day, but I x'ant you to thinl< ahead 3 or 4 months and then picture Maryeatiug in a pcrfcctly normal, healthy way 'witirout causillg you or the rest ofthe famiiy any disturbauce. The onlJ' way to do this successfully, that I knorvof, is to follow the pian that I har-e just outlinecl.

It is absolutely essentiai that lou and IIr. S work together on this matter,because if you do not cooperate the whole plan is doomed to failure, and thisfirst victorJ' for llary may rvork out to her disadvantage in later life. I amsnre you hrro'w rnany people your own age who are terribly finicky about whattirey eat, havirrg nII sorts of digestive upsets, refusing to accept any suggestionmade by others-the type of person who is generally disliked and hard to getalong with. It is just such people that children with all sorts of fiuicky habitsare quite likely to develop into.

n[rs. S. I certainiy wouldn't like nlary to grow up like an old woman wholives near us. She's just like that, and nobody can stand her.

DocroR. Do you think you will be able to carry out the plan I have outlined?I mean by that, do you feel that you wiII have the courage to let IIar5' gofor a few days n'ithout what you feel is a sufficient amount of food in orderto make her appreciate the fact that n'hether she eats or not is a thing wirichprimarily concerns herself, and that going lvithout food is not going to developa tremendous uliset in the home?

Mrs. S. I think I see what you mean, and I surely will make every effort tocarry out your instructions and get my husband to also.

Docror. Now, let us consider tlie problem of enuresis. I understand thatl\Iary wets the bed practically every night.

l\{rs. S. Yes, Doctor; every night. It has been much worse since she has beengetting the bottle just before she goes to sleep.

Docron. Now, since the time is getting short I want to outline a plan forthat with less explanation than for the feeding problem, as I think this isa much more meciranical thing and rvill respond to treatment more easily.

Mrs. S. I have whipped and whipped her, and as it does no good I havegiven it up as useless.

Docron. You were wise in giving up whipping her for this habit because sheis undoubtedly in no way to blame for it, and it is quite an injustice to whipchildren for things over rvhich they have no control.

!Irs. S. I agree with that.Docron. Norv, at n-hat time does Mary usually go to bed?Mrs. S. At 6: 30.Docron. And at what time does she have supper?i\trs. S. At 4.

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Docron. Then I would suggest that you follow out in detail this plan. LetMary have her supper at 4 o'clock, with such liquids as she is in the habit oftaking, bearing in mind that she is to take the milk from the cup and not thebottle. Between 4 and 6:30 she is to have no fluids whatever. Before goingto bed she is to be taken to the toilet, and you must see that she passes herurine. When she is put to bed make her understand that she is to be takenup later on in order to prerent her from wetting the bed. What time do yougo to bed yourself, IIrs. S?

Mrs. S. At 12 o'clock.Docron. Do you mean that you go to bed every night at 12 o'clock?Mrs. S. Yes.Docton. Isn't that rather late?NIrs. S. \YeI], after supper my husband listens to the radio until about

10:30. Then I make tea, and we have a little lunch, and by the time I get thedishes cleared away it is about 12.

Docron. Then I would suggest that you make a tour of inspection every hourin order to determine at just what time llary wets the bed, and that, at ],0o'clock, 3r/2 hours after she has gone to bed, you get her up, thoroughly awakenher, and take her to the toiiet. Ilake sure that stre realiz,es why she hasbeen wakened; that is, that it is in order to prevent her from wetting thebed. It is irnportant that you do not pick llary up in a semidrowsy stateand simply place her on the toilet; she must be awakened thoroughly andgiven to understand exactly why you have wakened her. l'hen you can prlt herback to bed and allow her to remain until you get up in the morDing, rvhich Ipresume is about 6 o'clock.

llrs. S. Yes, sir.Docron. I am sure that if you follow out the instructions I have outlined

regarding the feeding and bed-r'etting, you will be able to report considerableimprovement when you return next week.

l{rs. S. I hope so, for it makes me so much extra work to have her go onthis way.

Docron. Before you go, f want to remind you again of the most importautand fundamentai thing that I have said this morning, and that is that youantl your husband discuss this matter of discipline openly and frankly anddecide upon a plan that will insure cooperation. It seems ouly natural, in-asmuch as you see more of the child than your husband does, that the disci-pline should be in your hands and that he should support you and help youfollow out the plan that you agree upon. Under no condition allow llary tofeel that there is any disagreement between you trvo as to l'ihat is best for herto do. As soon as she finds out that the household is divideil against itselfthe battle, so far as you and your husband are concerned, is lost, and a greatinjustiee is done to l\{ary.

I see by the tests that have been worked out this morning that l\Iary is akeen, bright iittle girl of unusual intellectual equipment, which means thatshe will be all the more capable of taking advantage of any faiiures n'hich youanrl your husband mrke.

You may be assured we will do everything possible to help you duringthe next few weeks, and there is every reason to believe that by Christmastime n{ary's diffculties will be weII overcome. Can you arrange to come backa $'eek from today?

NIrs. S. Yes.Docron. Then that will be all this morning. But the problem of correcting

her undesirable habits n.ill have to be solvecl very largely by you rather thairby trIary. I should like to get just a bit acquainted with llary before you go.

The mother brought the child into the examining room, but noefiortlvas macle on-the first visit other than to rnalie friendlv con-tact with her. She appearecl to be a bright, keen little giri welldeveloped and fairlv well nourished. She seemed intelested in everv-thing

^in her enviionment. In running about she fell down aid

knoc-ked against a chair hard enough to hurt herself considerably.She immediately began to cry, but it n'as not difficult to attract herattention to something else, and the tears did not last long. Her at-titude in the clinic d.-uring'the short period of observatioin revealed

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I1ABIT OLINICS F'OR C}IILD GUIDANCE 2T

u,rtliing that hail not been brought out by the reports of the socialrl olker tr,nd the psychologist.

Hacl this chil^d "been i vear older. with her rather superior in-rtlligeuce, an attempt rvouid have been made to interest hei in keep-.ng"e record of lier success regarding both feeding habits and

"riuresis. She would have been siven a chart such as the accom-

lrxnying one, and every effort would have been made to arouse iterirrteiest"irr obtaining as manv stars as possible otr her chlrt. rshiclr.he l 'oulcl bring to"the clinic the follorving week. Not onl.y can thechart system be- made a matter of gleat interest to the child, but it,rlso seives as a dettilecl record of-what has been ilone durins the.' l inic irrtervals. Thrt is, instead of having the parents repolithatthe child has done pretty well or poorly relardirfg such pr6blems asfeeclirrg, enuresis, ind temper tantrurirs, i'e hnie a v6ry definiteournti i i t ive record of exactlv what success hrs been attained.^

The chart system has been criticized by some as savoring of bribery,but there is no reason why the child should be denied some visibleevidence of approbation of his efforts. Neither is there any reasonwhv such e{forts should not be rew-arded if conditions permit. Theinc6ntive for most efiorts, in either children or adultJ, usually re-solves itself into a striving for approbation or reward and it is ratherunreasonable to deny children the sarne approbation that most aduitsare seekrng.

The folliwing chart shows how the record is kept:

NAME: Sall11 Jones Ocr 5 to Oct. 12.

EVERY STAR I\II]ANS SUCCESS IN EATING }IY I\IEAI,S.

Monday Breakf ast Dinner SttPPer

Tuesday'W'ednesdayThursdayn'ridaySaturdaySunday

Ilorvever, it was not feasible to utilize the charts for }Ialy, as theylvere beyond the comprehension of a child 2 years old; but if theparents, who rvere keenly interested ancl rvho had at least averageinteltig6nce. cooperated. ihere was every l'eason to believe that tfiechild'iprobiem ivould nbt be palticularly difficult to solve.

An eifort has been made ifr the foregoing paragraphs to give ihereader a fairly good idea of exactly r'vhat takes place during thefirst visit in ihe" case of everv chiid cominE to

^the habit Jlimc.

Whether the problem is one -of

enuresis. f-eedinE, or masturba-tion, or wheth6r it is one of the more difriult persbirality defects-such as jealousy, shyness, cruelty, or abnormal fears-extreme tactand diplomacv ale needed. in order. on the one hand. not to ofiend thepnrenti, and,6n the other hand, to impress them widh the importance

"f the mental side of the child'i life.

'They invariably feel that they

have used all the patience and good judgment that might be expectcdof anv one handlinE the prob-lem '#itli which thev are confrbnted.Thus it is necessary"to gerieralize and speak in a riore abstract way

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on the first visit than is necess&ry after rvorking relations have beenesta.blished and the parents have developecl con-{iclence in the clinic.It is essential in coni'ersing n'ith parents to esplain the po^ints madeby examples that are rvell"rvithin- their comprthens-io.u.

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b6 exercised not to criticize harshly or uniustlY, and it tnttst alwaysbe borne in mind that the irrterest of physiciani is plimarily therapyand not science or morals.

COOPERATION \YITII OTHER COMMUNITY AGENCIES

It must be kept in mind that if children as a group are to benefitbv the available knorvledse reqardiug mental hellth,-every resourceoi the comrnunitv must

'be uiil ized

-to its fullest el.tent.- It is of

paramount imporiance that every organization interested in the wel-iare of children should make a barefYul survey of what other organ-izations with similar interests are doins and of rvhich activities [avebeen most successful. The value of thiresources which such agenciesha'r'e for supplementing the rvork carried on by a child-guidanceclinic cannot be overemphasized.

The available facilitiis which can operate independently or in co-operation with the clinic verrv according to the size of the communityaiicl the interest and progre'ss that haie been shorvn in the field otclr i ld guidance. In urban comnrunit ies there are usul l lv nrany or ' -cunizrTions n'hich are directlv or indilectlv concerned l' ith somerrspects of this problem. Somb social agenci'es providing selvice for,,lrildren or farnilies lle equipped to clo aSild-grridance rvot'k andothers have psvchiatric social-workels on the stafi able to give thetreatment indiiated by the study of the child made by a child-guidance clinic. Public agencies such as the schools or the juvenile6ourt also may be equipped to provide child-guidance service to someof the children neeciin^g^such s6rvice. In addition, there are usuallya greab variety of agEncies that can assist the ciinics. Anv rveli-orianized clinic shouft use all the facilities in the neighborhood thatar6 of value in the treatment of the problem and that would helpthe future development of the child.

In the treatment of preschool children health centers and nurseryschools and kinderqartins can render significant service to the chilci.These important cdnters of training should be recognized by child-guidance'clinics for their educatioial value in helping paients toilnderstand that a child's emotional life is as irnportant as his intel-lectual equipment and his physical endon'ment. These centers shouldalso assume'the responsibility of studying behavior problems in orderto treat the child iith ri'isdom at a timJwhen rvise treatment meansso much to all concerned.

The public-health nurse, for example, is in a most strategic posi-tion not only to recognize'undesirable habits and personrlit '-1' tiaits,but in many instanceJ to institute simple methods ivhich rvili correctthese tendencies before they become firmly fixed as a part of thechild's personalitv. Everv nurse should have some traininq in mentalhvgiene. This ii particuiarly true of those engaged in Eommunityh6a"lLh work. Ilany of the siinpler problems of eating, sleeping, an6.toilet habits are mattels of training which the nurse should manageefficiently.

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Teachers in nursery schools and kindergartens should look uponrlr,. ,letelopment of personality as an edu-cational problem. They,r,,,r. irle In a untflue iituation ind should renderuaiuable service torlrc l)arents and the public by detecting deviations from normal con-,irrct^.'rvhether it is id rate of achievement in schooL work or whetherit has to do with the child's abilitv to get along rvith his playmates.'l ' lrey usurllv eujoy a friendly and cooiierativelelationshiir rrith theI,irrduts of cniiaren under th"eir clrarg6 and are often in^a positionio kno.r intimntelv the home condiiions under n'hich the Ahild isbeing reared. Herlin lies the opportunity for much valuable work inrlre field of narent education.

Older children and some preschool children may need service fromotlrer tt'pes of organizationi. fmportant among ilrese are case-workrgenciei^which piovide service to children in iheir own homes andrJsist parents to understand their needs, such as familv agencies, chil-clren's'asencies. and visitine teachers iir the schools. " Some of

'these

aqencies"provide the financ]al assistance that is essential to the de-p6ndent iamilv. Others place the child in an environment bestiuited to his need. whether-this is a foster home. a special institutionor hospital, a nursery school, or a vacation camp. Ctinics and hos-pitals carrv out the examinations and treatments that are essentialio health ai rvell as the follow-up service for the child who is in needof medical care. Other agenCies giving servicc to children arethose providing organized ac-l.ivities for bdys and girls or opportnni-ties for recrea.tion such as Boy and Girl Scout or Campfire groups,Big Brother or Big Sister Assbciations, organizations foi' youig urencr voul)g rvonren. recreational certers. ors;-njzed plrvqrou"nds. Eettle-,neitts. a.-nd chur6hes. Some children miv neecl^th6"special serviceof the school for social counseling, schooi placement, br vocationalsuidance.-'

The work of a child-guidance clinic should be that of a communitvcenter. Only by intelllgent poolilg of all community service can tt"ebe sure that the child is receiving all the advantages which the com-munitv has to ofier.

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THE CHILD AND HIS PERSONALITY

Almost everv discussion of the child and his personality carriesrvith it a long"clissertation on heredity which is iikely to l-eave oneeither in a st ate of increased perplexity or rvith some very dogmaticitleas, depelclirrg on the authoi. Some frriters maintain a consiSteutlynoncornmittal attitucle, and others state their viervs for or agairrstthe importance of heiedity with great conviction. Thus, for ex-arnple,^John Stuart Mill inade th-e statement, "Of all the vulgarrnohes'of escaping from the consideration of thi: effects of social andmoral influences bn the human mind, the most vnlgar is that of at-tributinq diversities of conduct and character to inherent naturaldifferen&s" I whereas Frederick Adams stated just aq emphaticallytliat in iris opinion both "experimentally and statistically, t!ere is nota grain of proof that ordinar.y enviionment can nlter the srlierttmeintal nncl

-moral traits in any measurable degree from what tlrey

rvere predetermined to be throigh innate influe"nces."The^ consensus of opinion of irhysicians deaiing tritlr the practical

problems connected riith the su'bjrict of heredity is rr'ell expressed byI(irkpatrick in the foliorving paragraph:

n'rom the individual standpoint, heredity should neither be ignored as of noimportance nor yielded to as inevitably fixing one's destiny' Instinctive andhereditary tendencies are the roots from which the phJ'sical, mental, and morallife develops. Some individuals develop more readily and to a greater degreethan others. All are of the same human characteristics, but each may make themost of his environmeDt, Some canuot go as far as others in certain direc-tions nor as easily, but no one has exhausted his possibiiities of derelopmelrt.The practical problem is to expend our.efforts upon the useful characteristicswhich we possess in the greatest degrees.'

It seems onJ.y reasonable at this time rvhen so much disparity existsin the opiniois of various writers on hered_ity that .a_ con_servativenoint of^ vierv. such as that presented bv Kirkpatrick, should beientatively acc6ptecl. SLrch a hipotliesis mdkes it pbssible'to get au-ayfrom the iessirnistic attitude to wtrictr the fatalist il ings with undyingtenacitv.

^ Doinu this is not seekins a fool's paradis6 and becominf

oblivioirs to the"biological facts of"life. Wha^tever may be the rela--tion between the gerniplasm and the color of eyes or the size of foot,and whatever re6arch'may determine in regird to defective germplasm-horv it afiects the nimber, size, and distribution of brainiells,ividentlv resulting in variations in inherent mental equipment andsetting &efinite hfritations on brain development-no one, as 5'et, isreadfto say that per;onality and all its compouent parls are ttotmolcied and"colored by sociai heritage to a greit degree' After all,social maladjustmenti are more fr"equently- due to emot'io-rral in-stabilitv thari to intellectual defects.

-More is to be gained by con-

centrating upon the study of environment and its effects on the de-

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1 Kirkpatrick, Edwiu A,: n'undamentals of Cbild Study, p. 29. llacrrilian Co., NewYork, 191?.

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EABIT CLINICS F'OR CEIILD GUIDANCE 25

selopment of,personality than by accepting a hopeless, fatalisticilreorv or nerecutv.

In ihe attempl to understand the child it must not be forgottenthat iust as he has ears. er-es. a brain. and a heart. so he has ins'tinctsrnd emotions. He has, ior'example, an instinctive fear of fallingand is afraid of loud noises. He nds an inherent hunEer for selflexpression thlt !s constantlv infringing upon a code of laws andcustoms of which he has, as yet, no unJers-tanainq. \\.e rnust rememberthat the child has plans, hopes, and ambitionsf he has doubts, fears,and misgivings; he has iovs^and sorro\rs. some \-ery sljuht and fancijful. othelrs velv'deep and"real. This emotional life is"thwarted andgratified in milch the same way at the age of 3 that it is going tobe at 30.

With all these instinctive and emotional drives, which have muchin common with those of the adult, there is necessarily lacking thestabilizing factor of experience which can conre only with lears."Thechild is donfronted wiih manv new situations to" which" there is arlefiuitely unpleasant emotionai tone. For example, many of the pri-nrary experie-nces of children with animal. are i.ccompanied bv f^ear.Jealousy is often aroused when the child first appre:ciates that themother is giving some of her attention to other- members of thefamily. - Anger is aroused repeatedly until the child appreciates thereason for tfie acts which qiie rise io these emotions. and then sud-rlenlv^and unexpectedly.th6 e_motional reaction changes. The child,thelefole. nrust _be considered as an individual rvith- all the equip-mentlecessrry for register ing joy and Sofrowr pleasur.e arrd pain, butwith little- expe_rience-for propl,riv evaluating't}e details of

'the situ-

r tron so that the quant irv and qual i tv of the emotion wi l l be ade-,luately expressed-.

-Regrettable as it may be, adrrlts all too frequently

.timulate some of the child's most undesirable emotional reactions fortheir own amusement,. leaving permarrent scars on his personality.

Childhood is not only tlic <ipportuue time but the orrl.y'time to ii i-itiate a.progra-ry qf mental nealttr. Seecls of prrgnacity", sel{ishness,and..fe.elings of jnferiority are sown early. Th'ev-mav not bear frrrituntrl later-perhaps never; but if one expects to cler-elop ln ade_quate, well-rounded, self-sufficient personaiity. one mrist'plant theseeds for it during the child's earliest years and carefulli nurtutethem. The mentnl life of the child is chaj'acterized by his tendency toimitate, his suggestibilitv, his love of app'obation."and his mar"kedplasticity, These qualities, in association r:vith his Iack of experience,training,- and _edrrcation, render an interpretation of his mentaiactivity less difficult at this time than in laler r-ears. All these fac-!olq,Tay be,utilized to great advantage.in oui efforts to stimulate,rnhrbrt, or alter his reactions to the problems of evelydav life. rnthe eflort to understand human behavi,or th-e th-oughts and'ieelings ofthe child must be taken into account. His daydreims become mattersof importance. More intimate knowledge of 6is mental life is needed.It is lecessary to take time to find out why he is queer. quiet. or re-served.,.why h-e is rvorried or sad. The sitriation demands'the utmosrlnqenult:y and,patience ,in assisting.the child to solve his own prob-lems and at the sam_e time appreciation of the fact that it wouldbe of little value to solve them Tor him.

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26 EABIT CLINICS F'OR CHILD GUIDANCE

The infant at birth has no habits, ancl the habitual reactions whichhe acqui les in the p loce:S oI grorv ing up a le r lc l ,err , Ierr t r rpon h isexperibnce, training, and educl't ion. "He

seems, ^horr.r '.r,

t 'o havecertain inherent tendetcies rvhich manifest thernselves at al earlvage. Thus one child reaches out and embraces the rvorlcl in ilhappy manner and another rvithdrarvs and rejects all attention. Suchtendencies seem to be present at birth. Yet these so-called instincti'r'ereactions are all mocl^ified, either to the advantage or to the disad-vantase of the individual. throush the efiect of environment. Habitsrepres"ent the child's responses t-o the innumerable, orclinary, ever'),-aay-tite situations. Knorvledge of an individual's irabits ^i[es pos-sible a fairlv accurate quess as to what mav be expectecl of him iuordinary situations. Al Doctor Dervey haj pointecl out, habits arenot like a garment to be put on and taken ofi as the occasion cle-mands, or as it pleases us. They are very much a part of us I we arethe habit.

We begin to acquire habits at birth and contjnue to acquire them toa greate ior less degree, depending upon our p last ic i t l ' , i rn t i l the errdof life. The functions of eating, sleeping, ancl elimination becomehabitual. We develop habits of conduct torvard those in authoritv.In some situations 'r'r'd acouiesce: in others rve rebel. \\'e h'ave habilsof conduct rvhich include^morals and ma,nners. Our mental attituclestoward life are but habits of thought, and such traits as selfishness,shvness. crueltv. and fearfulness are merelv emotional resnonses thatha"ve become h"abitual through repetition. Lying, stealing, and a dis-regard for the rights of others are likewise responses to certain situ-ations, which through repetit ion become a part of the l ife pattern;in other words, they are habits.

ft therefore becomes obvious that habits considerecl in their bload-est sense are nothing more nor less than the indiviclual himself, hishappiness and efficiency being largely dependent upon the habitswhich he acqnires in the plocess of growing up.

Almost from the moment the child is born he is confronted lv'ithall the varied li{e situations evokinE rvhat rve think of as adult emo-tional responses. The cliilcl does not ach'ance \:ery firr in life beforehe knows lr'hat it is to be jealous, to be fearful, to be angry, to lor-e,to hnte, to feel inadequate, and to experience sorrow ancl disappoint-ment. He is continuallv subiected to environmental situations andpersonalities n'hich stimulate these variecl responses and lay thetoundation for mental attitudes which er-enturilv become habitual.

The child is recosnizecl as being amoral (rvithoit morals) at birth.IIis responses to liTe are those tiiat are ess'ential to the preserr-ationof self.^ IIe reaches out for that which brings him plcasiure, smilingupon those who cater to his appetites, provide him with food, drink,and creature comforts, and stimulate pleasant bodily sensations byfondling and kissing him;and he lejec^ts things and ieople notseri.-ing his immediate needs. IIis dernands for attention must be recog-niZed: his attempts to exhibit an influence over his environment mustnot be thwarted-or there rvill be evidence of resentment. He is. in-deed, a self-centered, egotistical individual rvho feels no responsibilitytorvaid life except tliaiof trying to satisfy his olrn needs. Att ttrat tr"eacquires in the n'ay of ideals, altruistic tendencies, cooperetion n'ithhis environment, ancl desire to please must come from his experiences

{

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IrABrr cl,rNrcs FoR crrrlD GUTDANCE 27

\vith life, and duling his early years these experiences are to a verylarge extent closely tied up with his parents.

I ' i is therefore i inportrni that parents appreciate the raw materialrvith which thev hafe to cleai. thit thev kno-w something about theseinherent strivings of chiidren, their 6motional stabilifu, and theirintellectual eouipment. As time soes on pareltts should be in-timately acquiir-tted with the pcrsoiiality make-up of the immatureindividiral whose future l ife is'so depend.ent upon their interesb andrvisdom. Thev cannot alTord through ignorance to tn'ist and distortthe personality mahe-up of the devd"lopiig child through a domineer-ing'intolerand" or hunii l iation, or by^lea'sing, ridiculing, and cheat-in[ him, and destloying his sense oi securit 'y. The ch"iid subjectedto"personalit ies that aie egotistical, domineering, ttttstrtble, quick-tenipered, and il l-mannered.Jras a right to become i6betlious. It mustbe k^ept i ir mind that the child is not satisfied rvith beirrg simply apassivie part of his environment. He is persistently reachi'ng oui inditruccli i ls to make the environment sati ify his emotional neEds. Thepare"n'is' dutv is to see that t l ie emotional needs of the child are satis-hed iri a .taj' that is compatible n-ith the requirements of society.

In any efiort to understand the behavior of children and to recog-nize the imnortance of the part environmental factors plav in thJirconcluct, it is essential to keef in mind the personality mikelup of theindiviclual child. No two children are subjected to the same environ-mental infhrences. The rnaterial situations may appear to be notvery clillelent. but the personalities of parents and others who areresponsible for the training of the child vary widely, and these per-son^alities are the most imiiortant aspect of ihe chiid's environment.'Io

a very large extent the liabits and the mental attitudes whichbecome incorporated into the chiid's personalitv mnke-up are de-pendent upoti the wisdom of the pateirts. 'Ihej' are the'ones whoinust prep^nre children to live-in a worlcl outside the home. Thevmust sie io it thet children u'e both ready and rsil l ins to make th"enecessary acljustments to life as it really exists. In this"outside rvorldthe environrnent will not be altered to suit the child, rs it flequentlvis in the home. Parents themselves must keep in mind. ancl muit heiiithe child to grasp the idea. that the individual and'not the worlilrnakes most of the compromises and concessions rvhen conflicts arisc.

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THE PARENT AND THE HOME

The home must be considered the workshop in rvhich the person-ality of the child is being developed; and the personalities-of theparents_will make up, to a. very laige extent. the-mental atmospherein which the child lias to live. I'his mental atmosphere may easilybecome contaminated and can be quite as dansero^us to the" mentallife of the child as scarlet fever or diphtheria looirlcl be to his physicalwell-being. Faulty habits are not ii-rfrequently due to the imiiationof bad ex-amples.

-Yet one is quite srfe in saying thrt the mere imi-

tation of the bad example is irot nearlv so danEerous ro the clrilcl'smental health as may bti the rvrv in rvhich the iridiscretion is treatedby the parent. In i,ny study of environment, therefore, it is abso-Iutely essential to have the ftillest cletails possible regarding thepersonalities of the individuals with rvhom- the child"comes- intointimate contact.

Parents who are largely resporrsible for the inadequate develop-ment of their children's"peisonaiities mav be divided into well-definddgrollps. There is first bt att the moth'er who, although rvorn anC*earled by her routine household cluties, tries to supplefrent the fam-ily income by putting irr seleral horrts a'day serving,irashing, bal<irrg.oi scnrbbing *hen si ie shorr l r l be in bed. She hns i i i t te en.rEv, ei ther

l

ilphysicnl ormeutr l , to g i r -e to an) 'considerat ion of the rvel fa ie of herchiidren. In striliinE"contrast io her is the work-avoidins. dutv-children. In striking contrast to her is the work-avoiding, duty-shirking, pleasnre-loving mother who feels thnt hel drrty is ended atthe birth of the chilcl and turns over hel responsibilities to a nurse-maid. Again, there is the mother rvith excellent intentions, rvhoser ! L r r t L w r r u r v t r D t I

unintelligent interest is apt to defeat its very plrrpose. Usually sheis oversolicitous and caters to everv rrhim and desire of the chilcl.is oversolicitous and caters to everv rrhim and desire of the child.Ail too frequentlv she is emotionallv unstable ancl the child soon findsout that she has no definite rules and regulations about discipline.What is condoned today is punished tomorrowl and in spite of hisability to make rapid adjustments, the child finds it difficult or im-possible to follorv a consistent line of conduct. More pathetic thaninv of these situations. ho'rvever. is that of the menta^llv ,Cefectivernotherwho does the relv best she can rvith her limitecl endorrrnentand vet ftrils and recoenizes her own failure.

So far onlv the mdther has been considerecl but it must not beforsotten th;t the fatherts influence also must bc considered. Hemaj spread pelce and lrarmony where chaos n'as rvorrt to prevail, orhe mav disnrnt ancl retrder chaotic that which was pe'aceful. Thestern, righteous, rigicl father rvho dlominates tlre household by fenr,is, from"a mental p-"oint of view, perhaps the most undesirable. Yetithere is no reason to envv thc child n'ho has r cruick-tempered. im-prr ls ive father a l r rays reahy r r i th a shrrp word an, l a b lo* ' . Luel<ris the chilcl n'ho does not have his discipline handed out in an erraticmanner by an emotionally nnstable fafher.

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EIABIT CLINICS X'OR CHILD GUIDANCE 29

Needless to sav. the foresoins tvDes fail to furnish the child withthe very companibnship n'"hich-hd'needs most. Cheerfulness, afiec-tion, and kindly considerationI frankness and honesty in ansrreringquesbions, so that speech and action mav be free ancl uninhibited byf'ear of piinislimenior silent contemptl"manners and speech that ar-enot {orbidding-all these tend to play a part t}rat caunot be over-estinrated jn the development of the child's personality.

To evaluate parental personalities requires more than a study ofthe personalitv^make-up'of isolated inclivicluals; it entails a study ofa complex reiatiqnship'between two human b6ings endeavoring tocarry 6ut a very difficrilt task, usually without traiiing or experrenceand sometimes without interest or desire. One need not be surpriseCthat two such inclividuals do not always create a quiet, peaceful,happv home in which the child rvill fintl erelvthinE necessarv for ahedlthy outlook upon life. Sometimes eveu" an Tntelligeni n'ell-eCucat"ed man and ioman n'ith common interests will noi make forefficiency rvhen operating together as parents.

Much sentiment has rightly been lavished on the home-the placewhere the disheartened aiicl the troubled find understandinE and-com-fort. the fortress where those in need may find sa{etv and securitvfrom a critical, demanding, competitive world. Unfbrtunately notall homes serve this ideal

-prrrpode. Al-l too -frequently the average

person-man, \\'onran, or clii ld-nrnkes less effort-to ke-ep up his mo-iale in tbe home than in the shop, office, school, and piace'of recr,e-ation. Too frequently the home b1'comes the reservoir into rvhich arepoured all the resentment, disappointment, grief, and frustration as-iociated rvith the unhappj exp6riences of ttr"e aay. A tired, harassedmother finds in the family circle the only audience that cannot runout on her rvhen she recites her trials and tribulations. A father atthe close of a trvinq business dav settles dorvn at home with no feel-ins but indifierence" as his contribution to the familv circle becausehJis preoccupied with expressing his grievances against those inau{lrority, his ilritation witfi his fei-lorv rvSrkers, his feblinq of failure,his anxiety about economic security. It is not surprising th:rt thechildren in such a home soon regrrrd it as the dumpine qrdirnd of allunhappy and unlrealthy adult ehrotions-a place used bv all its in-rnatei in their efforts to air the qrievances aEainst a woild that hascheated them of something yitalto their we-il-beins. Such a homefinds it difficult to compete with commercialize"d amusements-the dance hall. the nisht club. tnd motion-picture theaters.

Much good mav coilre of talkinq ooer pe"sonal dissatisfactions inan ord-er[t. intellettual t'ay. but a_rr"uninteiligeut outpouring of griev-arices,by ft group of unhallpy.individuals.seeking self-pity serrles noruseful pu.rpos_e.. ('lulctren rr-ho see in their parents unhappv, de-feated, critical-irrdividuals do not rrlnt to.be like them, nor aie theyinclined to find in their own home an ideal pattern for ihe future.

Unfot'tuttately there are paren{s s'ho have to live on such I loweeouomic level tlrat the pr6blem of brre subsistenee is confrontingtliem at all times. IVhen the clinic is faced rvith such a situalt iorr a rel ief agenc.y must lav t l re foundat ion for anv imDrove-ruent involving menfal hygienel T]iere are nlso pareuts *ho." int.l-lectual equipment is so Iow that it n'ould be beyond their compre-

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30 HABIT CLINICS F'OR CIIILD GUIDANCE

hension to carry out even a corrmoll-seuse proglan. For the problemchiid of such narents nlacemeut is absolutelr i:ssentiri. l{ordnumer-ous than any bf these'are, hon-ever, the paients 'whose orvn lives areso unstable emotionallv that little or nothius constructive can beclone for the child or frir the family until the plrents have recoveredfron their own mental di{ficulties. For this they need he1p, rvhichmav be provided either by referring them to some adult psychiatricclinic, oi, if tirne permits"and it seeils wise, by treating tihe parentsas well as the child at the habit clinic.

The child loohs to his parents for his sense o{ securitv. In his par-ents he meets authoritv

^for the first time and his love relationihip

with them is constantli beinq endangered. He has to recognize thalmany of his desires aie unaitainable-. In fact, it must seeir to himat times that many of the goals rvhich he is pursuing belong in therealm of tlie forbidden. Hd must learn to posipone the desiie of themornent for tha,t which his parents teach him is mole worth while inthe future. The habitual r6actions rvith rvhich the child meets thesesituatious depend uporr the wisdom rvith rvhich his palerrts meet them.Parents'who'are st i l l t ry ing to meet the problems^of adult l i fe r i ththe same emotional responses thev used as children r'vill obviouslv fail.'fhose rvho have had eiperiences deeply laden with emotion whibh areincompatible with their orvn ideals and supposed aclult maturity, aresuflelirg from a state of mind rvhich necessarily allects their conducttowarcl lheir children. \Yhen the chilcl's behavior sets off these po-tential emotional bombs. the tash of developing aclequate habits- ilthe child is indeed a probiem. The wise paient" rvill inake au efioltto unclersttrnd his orvn emotional iife as well as that of the chilcl.

The following case is a gootl e-rample of a mother who brought achild to the clinfc when the child sliould have brought the mother.

A *'oman about 40 years of age brought her little girl, f ysal's old, to the clinicfor examination, stating that she acted like a child 4 years old. The motherlvas unable to give any concrete examples of the child's immature acts. As faras could be discovered tlte child had Do bad habits. She slept fl"nd ate well andwas frank ancl honest. She rvould har.e lil<ed to be affectionate if her motherhad permitted her to be. She shorved no cruel tendeDcies, aDd about the worstthe mother could say was: "She takes up n'ith any citild she can fitrd, regardlessof creed, color, or nationality. I rvill not statid that." The mother stated thirtshe would not permit her child to associate rvith the Catholic chiidren in theueighborhood and that the Protestant children tvere not good enough.

The patient appeared to be a bright, keett, alert little girl, who answered allquestions quickly and accurately. She manifested an interest in the examina-tion and in her surroundings. She had an intelligence quotient of 98. As faras the history obtained from the mother and the examination of the child wereconcerned, there seemed to be little evidence to indicate that the child was eitherabnormal or unusual.

The mother was interviewed again, and it was ascertained that the childwas not wanted, that the mother and father had been quite happy until herbirth, ancl that she was looked upon as a stumbling-block to their happiiress antleconomic success. The father's attitude toward the child was one of indiffer-ence. He rarely gave her any attention. The mother statetl that she was notfond of her because the child was hateful ancl ahvays made the mother regretbeing kind to her. When the mother and father were together they both ignoreclthe child. and she was sent off bJ' herself and not permitted to play with otherchildren.

X'urther investigation of the case by the socinl-service department of the clinicrevealed the following facts: The mother was lookecl upon in neighborhood asbeing "different." Although she \a-as verJ' affectionate toward her husband' theneighbors stated that it was not unusual for her to teii the cbild that she hatedher. It was later ascertained that until a year before the patient was born

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IrABrr clrNrcs FoR OITILD GUIDANCII 31

the mother was looked upon as a very desirable neighbor. About that time shewent arvay to live with a man who had been a boarder in the house and re-turlecl to her husband oniy after the authorities made complailts. shortlyafter her return the patient was born. Since that time the whole situation hadchanged.

Ole of the most pernicious inflttences to which a child is subjected

is that o{ persisteirtly interfering members. of- the family- group.Glandparerrts ut" perliaps the wors"t offetlders in this respectr althoughother ielatit 'es muiy complicate the problem of bringing up childrenquite as much. if ihev are so inclined' This is palficularly trtte, ofdo,r"s". if theie indiiiduals are living in the Jame household, butnot infrequently their iuflttence is felt-even rshen they reside-a-t somedistauce.

'Too inuch streess cannot be laid on the rrec-essity of having

the l iglrt to discipline the child vested entirelv in the parents. Noth-inc tl6es more to^lessen paretttal authorit.y than to have some iine ofacTiotr rvhich the parent^ has decided to iarry out questioned in thepresence of the child.^

Another situation frequently arising with reference to the problemof discipline is that broright about by the divided household.l that.is,the inaliility of the parenls to agree dpon any plan of action for train-ins tlie child. each one forming as tire occasiott arises a spontaneous'iudement entirely on an emotioial basis. I{uch of the difficultv aris-irrg-t ..uo." of hivided opinion regarding some particular irct ofthE child might be avoided if par-ents tiremselves -could ge-t someclearer idea 6f the relative impbltance of so-called misconduct inchilciren. For example. rill too frequently the same punishment isrneted out for some cuite accidental offense, such as breakinq awinclorv rvith a baseball, as wonld be given for some obviously vol-untary, malicious act involving crueltv.

Foi the child who has the misfortune to have a physicallv handi-cal)l)ed parent----+specially a nrother-it is verv important, on the onena'ncl, that too mubh stre".gs shoultl not be laici uport her incaprci-t ies.and, on the other, that the child should appreciate at the earliestpos:ible ase the burden which the parent is cal'ryinE and the con-iidelation'to which she is entit led. One frequently sees problems ofdel inquency ar is inq under t l tese condi t ior rs because the parent hasbeen ihvs i ia l lv unable to "make t l re c l r i ldren mind." Much can bedone by appeaiing to the clri ld's spirit of fair play, especially when theobiect of h is svmnathv is ahvavs before h im.

All too ofti ln adulis are prbne to uti l ize what appears to be themost potent nreans of obtaii l ing obedience from th'e'child; namely,fear. As this is one of the most primitive and easily stimulatedemotions it is used more freely peihaps than any oth6r. "ff youdon't stop crying, I ' l l go back to the hospital again," is a threat of aconvalescent paient. i 'Don't touch the telephoni," a mother remarks."It

'rvill bite you." '(The policeman rvill get you if you are notgood." "The doctor will put the stick do'wn your throat if vouEon't answer his questions.l' Fortunatelv for the child's peace' ofmind he soon finds that such promises and threats are not to be takenseriolrsly, but unfortunately he is unable to distinguish between thepersons n.hom he can trust and believe and those rn'irose advice and.t'arnitrgs are simply idle prattle. Conserluentlv he is likelv to de-velop an absolu le d isregard rnc l d isres l leet for the opin ions of others,and later in his life he will be insensitive to praise or blame.

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Cheating the child by making promises which the parents knorvthey cannot keep or which they have no intention of carrying out isperhaps the origin of the absolnte disregard for truth and the ex-aggerated suspicion seen in manv children at an earlv aEe.' '?Ttre doctoi has a lot of nice things in his bag which'ire will giveyou if yon stop crying," one motherlvas overheird to say. She'iol-lowed tliis up with the statement that ((Llother is going to buy youheaps of pretty things as soon as the doctor is through," and madeother promises which obviously slie had no intention of caruying out.

The parents rvho take time"to understand their child, who'Lnowhis responses to praise, blame, r 'ewar<1s. and punishmenis. and whoare afrectionate ahd tolernnt ri ' ithorrt being unduly sentimental andspineless, are the ones who r'vill have the most to ofier their children.The child imitates the habits and attitudes of his parents. Theyare a constant source of suggestion to him at a period in life wheirhe is most plastic.

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HABIT PROBLEMS ASSOCIATED WITH EATING.SLEEPING, AND ELIMINATION

The physical well-being of the child is largely dependent on the*tliciency of three f undemental organic {unctions I namely, eating,sleeping, and elimination. These functions become controlled andregulated by habit, and therefore habits of eating, sleeping, and elim-ination are the first to receive attention. The mother of the ne'wborninfant is conf lonted with the dual responsibi l i tv of supplying propernoru'ishnrent and helping the infant fo develof desira6l,i ni'bits Tortaking this nourishment at such times and in such ways as will bestserve his physical needs. Almost at once she must also teach him tosleep at regular hours and without special attention I and, a little later,she tries to establish resular toilet habits. lVhen these habits areproperly established at a-reasonable time, the clii ld has been providedilith a iastins {ounclation for both mental and nhvsical heaith.

It is in connection with these simple phvsiolo'sical nrocesses. how-ever, that many of the ini t ia l mistakes' in chi ld"training are mrrcle.either because parents ignore iheir importance entirely or because theybecome unduly worriecl--and anxious bver the difficufties encountered.The consequences of ignoring an undesirable habit are not alwavs ap-parent. The immediite effe'Ct may be trivial compared with th6 ulti-rnate results. On the other hand, oversolicitucle on the part of parentsjntroduces into their relationshir; with the chilcl an indefinable some-thiug that the child assumes-to lie doubt, misgiving, or rveakness, andthat"prevents.him.from looking to them foi guir" lance, an essent ialtactor ln chl ld t ra lnrng.

The methods recornnrencled for establishing satisfactorv hnbits ininfancy are discussed elservhere.'? The discussion here is rather baseclon the fact that mistakes are made and undesirable habits formed.fnasmuch as these undesirable habits cause parents much concern andinterfere with normal ,personality development, the habit clinics canbe of va luable sery ice to the conrmrrn i tv .

EATING HABITS

No problem causes parents more concern than that of the child whohas cliff iculty in taking and digesting his food. The more commonfeeding problems are refusal oFfo-od, :u.ck ing of . foot l a f ter tak ing i tinto the rnouth, regurgitation, and vonrit ing. The fact that par.e"ntsdevelop a nrarked anxiety rv i th reference fo these d i f f icu l t ies 'makestlrenr oversolicitous, and this, in itself, is a most important factor inperpetur t ing t l re d i f f icu l ty . A par t of the body wlr ich is easi lv af -fected bv emotion is the gastrointestinal tract. Physioloqical researchhas established the fact that emotions of various sorts,iueh as fear,anger, rnd excitenient, directly influence the florv of digestive secre-tions. It is therefore not surprising to find that an "orplanism

sorsee Infant Care (Chi ldren's Bureau Publ icat ion No. B,1988), pp.4r1-r19.

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highlv der-eloped, yet so unstable, as that of the nervotls svstem of the

"hTlA"t""y u.iy Zr"q,"ty reveal the relation betu'een psycirogenic and

nhvsiolosica I processes.- it i. u"sually not difficult to pick out those children whose loss of

apnetite and inabilitv to digesd and assimilate food are due to psy-choqenic rather than" phvsi<jiogical cnu5es. Nevertheless, it is essen-tial"to have these cases'clearlv d-i lTerentiated by carefrrl phvsical exlnl-inations. I\Iany children who come to the cilnic becauie of diff icultvin feedins are not poorlv nourished, anernic individuals. On the con-trarv, thjir phVsical cohdition is frequentlv such that one sees l itt leeauie ' for ani ieW ul t i l the h is torv of - the case is presented- . ln sr rchca.es it is found that although ihe child's intake of food is fairlvsood. the food is of such a qtralitv and tlkcn under such emotionalstress that it fails to serve the child's needs. The mother states tltatthe child absolutelv refuses to take food unless she sits down by hisside and actuallv carries out all the necessary motor processes to getthe fooci from the plate to the child's mouth, and even then she maYhave to tease, coax, threaten, and sometimes punish the child in orderto make hini swailow tlie iood. After sat:isfying herself that theproper amount of food has been taken by the chiid, the mother is nat-urallv quite dismayed to have the food vonited before the child leavesthe t;bb. \\'hen bne consiclers the effects of emotion upon the processof digestion, it is not surprising to find that under emotional strainthe stbmach leieci s the food.

A somewhat" different problem is presented by the child who be-comes antagouistic towaid certain types_ of -food-as. for example,sollns. cereils. or vegelables of a special color. Srrch antagotttslnsperiisting ovei a lon"g period of t inie may have been aroused by in-iudicious-methods uti l lzed the first t ime the food ras presented toihe child. There is no doubt that parents sometimes dake a greatmistake in forcing a child to eat some new food which they considerr,bsolutely essential to his well-being, the parents themselves beingdominate'd bv the idea that unless'they aie successful at the firs'iattempt the battle is lost. Ilnder such conditions there is apt to bea veri unpleasant emotional scene rvhich rvill lineer iu the mind o{the child

-and be recalled the next time the food is presented. It,

therefore seems rvise to guard against making an event of introduc-ins a new article of dieiinto the child's rrenu. The food should ber-'rrcscnted without commeut and without any evidence of doubt intlie mind of the parent or nluse that it rvill be eaten But if, forscme re&son kno*n or unknorvn, it is not talien at that particularnreal. an unpleasant scene should be avoided and it should be pre-sented at a l-ater date witirout comment or show of indecision.

A certain amount of manual dexterity is required before childrenare able to feed ihemselves, and all too often parents firtd it easierto feed the child than to terch him to feed himself. Feeding is oneof the first complex acts which the child rs called.upon to-do forhimself. and it is not surprising that he accepts this new responsi-bil i tv n:ith a certain anrount of reluctance. Usuallv, however, suc-ccssbrinus with it a kind of satisfaction which stirnulaies the childto make iurther efforts torvard accomplishing the task.

It is of palrmount importance tb avoid disctrssirtg the child'sfeedinq habits in his preience. Such discussion tends to fix the

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EIABIT CLINICS E'OR CHILD GUIDANCE

erent in the mind of the child and make him cognizant of the factttst he is the center of attraction during the meafhour. Ilany chil-dren tintl that a negativistic altibude, ilot only toward feeding buttorrrrrrl sleeping. phying, and genelal obedience, is one way otrrrrucr irrq tlie aiierition wlhich thJv clesire.

Oncc ti're phvsiolosical causes oT loss of appetite and malnutritionbrve been etiminate-d. it invariablv works but well to serve thechild onlv a small quantitv of food.-first nraking strre that it is wellpreDared'and then allowin'g a suffici6nt period of-time in which to eabii siottlv. If i t is not eatdn. the food is removed at the end of thatrreliod without anv ceremonv. tLis procedure being repeated for ai 'r ies of meals. Uhder those conditi6ns much of the dlama in whicht[e chi]d delights is eliminated, aud much of the unpleasant emotionrlreaction prod-uced by creating'an antagonistic attitude in the young-ster is avoided.

Some of the cases illustrating the difficulties associated with feedingwill uive more detail regarding the importance of neither directingthe c"hild's attentiorr nof arousing his antagonistic rtt jtude towardhis {ood and the trecessity of allaving the

-doubts and fears in the

rrlincls of parents so that ihey may-at-least appear less concerned.

Allen was brought to the clinic at the age of 3 years with the followinghistory: Birth was difficult, necessitating the use of instruments; birth weight'10 pounds; breast-fed ; normal developmelt; no illnesses or diseases. At theage of 2 he was treatecl with radium for a persistent thymus; at the time ofthe clinic visit he had enlarged adenoids and tonsils.

According to the mother this child. never slept restfully- but tossed andtwisted about in his crib, often talking and crying orit, IIe was extremelyfinicky about food and had marked likes and dislikes. He dicl not care formilk ancl refused vegetables, but he would sometimes eat seYen apples a day.He was fond of meat, rvhich was given to him occasionally. IIe never rvantedthe food set before him at mealtime.

He rvas consiclered somewhat shy and diffident, especially with strangersanrl adults. He plated fairly well $'ith other children on the street-usuallywith girls about 2 or 3 years older, but also n'ith boys when he had theopportirnity. Ile was fond of throrting a baII and wanted to be doing justrvlia.t others were doing in games. IIe was very active. IIe rvas very fondof his mother and was often called "mother's boy." He was cbummy withhis father and most considerate toward his sister, 2 years younger than be.He 'was very selfish and most reluctant to divide tbings with others, al'lvayskeeping the "Iion's share" for himself. His mother stated that he was verystubborn and woulcl not do as he was told, being, in fact, more likely to dothe opposite. She punished him at times, but she believed that a more effectivemethod of discipline rvas the threat to leave him.

At the clinic the child was keen and responsive. EIe answered all questionsquickly and in detail, cooperated well, and was interested in the tests. Eleenjoyed being the center of attention anrl was Yery pleasant and liindly aboutit all. He paid much attention to lris mother and Iittle sister. His intelligencequotient rvas 130, and his mental capacity 1 year abead of his chronologicalage'

There seemed to be nothing unusual or significant in the home situation.Both parents n'ere fairly intelligent, very frienclly, and cooperative. Althoughthe father was an occasional drinker, he never came home drunk, nor was hea man of dissipated habits. llhe parents were working together for the goodof their children. The father's salary was adequate. The family occupied.a four-room apartment which was in good condition and well kept. Tbefurnishings were of the average type.

Bum.m.ary.-It appeared that this chilcl, 3 years 4 months of age, was ofrather superior intellectual endowment. His environment presented nothingoutstanding in the way of a social problem at the time of the exa.mination.The principal anxiety of the parents was the feeding problem, the child beingpoorly nourished and underweight, extremely finicky about food, showing

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strong likes and dislikes for various artieles of footl. The chiltl was stubbornand very negativistic. He rebelied against authority wheneYer he wasthwarted and whined a great deal.

The first and most important step ln tbe treatment of this casc appearedto be the regulation of the sleeping hours, it being perfeetly obvious that achild of 3 years should retire before 10 p. rn. The mother was instructedthat before'any improvement could be expected the child must be trained togo to bed at ? o'clolk and have at least 12 hours of sleep. She rtas .warnedof the initial difficulty in trying to put this new program into operation andwas given a careful explanation of horv much easier it would be to institutesuch a program at this time ttran 2 or 3 years later. IIer cooBeration wasthus assut'ed.

The next step necessitated a rather long, detailed explanation to the motherof the means and methods which children use at an early age to obtain theirown way. The futility of tr)'ing to get the child established on a proper dietn'hile giving him apples and caudy whenever he refused to take milk andvegetables rvas pointed out to her. She was also advised that iust so Iong asstubboruness ser|ed the child as a means of obtaining what he desired .just solong rvould he utilize that method; and that it rvas extremely impoltantfur him at this age to learn that whining and rebelling would not serYe as amethod of gainiug his orvn ends. A diet lvas carefully pl'escribed, and themother was instructed to place only moderate portions of food bcfore the childat eacll meai. She agreed that the food should be left before him for a periodsuflicientiy long to pelmit him to eat slowly, yet not long enough to permit hinto play w-ith it, and that it n'as then to be removed. She also promised thathe would recei\'e nothing betrveen meals except the extl'a milk rvhich rrasprescribed in the diet because of bis being underweight' The parents $ere inno lvay to concem themseh'es rvith what the child lvas eating. A carefulrecord of the success or failure of the treatnrent was to be kept on a chart.The entire plan rvas erplained to the child as sinply and conciseiy as possible.

The results ir this case alternated between success and failure for 5 months.Cooperation of the mother duriug the first part of the treatment was llot alLtiiat had been hoped, but eacir time she returrled to the clirtic, rcgardless of\yhether success or failure had been reported, renewed efforts were made to haveher carry out in detail the plan outliued.

At the end of 6 montbs the follorring report was made: "Tbe child is doingremarkably well; eats all vegetables including carrots, spinach, and stringbeans; still has a strong dislike for miik but takes one glass per day." Amonth later the report read: "Patient continues to take his food witl:out diffi-culty; has shown marhed physical improvement; takes great interest in pt'e-senting his chart, which shon's a perfect record for the last 2 weeks; is rnuchless negativistic; is no longer shy; and tahes great pride in telling the physiciarrof his improvement"'

With the establishment of proper sieeping hours and feeding habits, the childbecame more obedient and less selflsh and lost many minor neurotic manifesta-tions, such as nail biting, whining, and restlessness at night.

Com,ment.-This case is particulariy interesting because suceess in treatmentcame oniy after a period of 5 months, duritg rvhich time the outlook seemedrather discouraging. It emphasizes the importance of persistent and continuededucation of the parents in a certain group of cases where cooperation is notof the best and where suggestion is not accepted readily by the child. Theresults, horvever, justified the efforts.

Barbara, aged 6 years 9 months, was brought to the clinic by her motherbecause of persistent vomiting and enuresis.

The child's history was as follows: Normal birth, full term. Developmentretarded; walking delayed until child was over 2 years of age; spcech stillquite indistinct; teething delayed. Illness included pnetimotlia at 2 months,whooping cough at 2 years, influenza, and chickenpox. Child subiect tocoughs and colds.

The ehild slept and ate well and bad no history of any unalesirable habitswith tbe exeeption of enuresis both day and night and persistent vomiting aftermeals, a habit which began about 4 weeks before the first clinic contact.

The child was described as shy and unwilling to speak unless spoken to'even at school, She frequently hung her head wheu spoken to by her teacher

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HABIT CLINICS F'OR CHILD GUIDANCE 37

and refusecl to answer. She was extremely selflsh and was Jealous of the otherclrlldrel. At home she .was quarrelsome, but outside the home she got along*itirout difficulty. She seemed to have a normal interest io other members ofrht- family with the exception of the younger sister, Susan, torvard rvhom she\\ ils lery antagonistic.

,lt the cliniE she seemed to be a duII, aptrthetic child who h'ng her headr1xl refused to loolr at the examiner. She was laching irr self-corrfitielce andtlisnlrrvetl absolutely no interest in her surroundings. One felt at ouce thatth"i'e was a problem of nental cleficiency' This impression \Tas borne ottt bysLrbse0ueDt tests ancl psychometric examination, her intelligeuce quotient beingrj{. which secmed a fair indication of her mental equipment.

.Ihe hoDre environment was poor. The family Iived in a very narrow tene-rnent street. They hacl an apartmeut of three rooms wlrich were vely untidy,u'ith dirty clothing ]J'ing about or the floor. The hand to'rvels attd dish towelswere very rnuch soilcd. A pail irr one gorner of the kitchen was used as atoitnt. 'Iire mother and the youngest child, aged 2 years, shared a double bed'autl the father, the patient, and susan slept in anotlter double bed. They hadlir.ed in this place for 5 years. Altlrough conditions were extremely poor, theyh"d-.ho,un c^onsiderable improvement durilg the last few years. PreviouslytiiJ famity hacl lived in one room and was very much in debt. The father hadbee' driniiing; the mother had taken no interest whatever in the chilclren. Atthe time of the clinic visit the father had stopped drinking, the lother wasiaking more interest in the ehildren, and they 'rvere no longer in debt'

ThJ patient was brought to the clinic because of persistent _voYtiting, whichheeap ibolt 4 rveelis prior to the visit, and for enuresis, which hacl been almost

"oitinrroos siDce birth. No attempt had ever been made to establish a routine

that $'ould break up the latter habit.It was not diffiCglt to determine how the vomiting had its origitt. The

mother .was preglaDt and had been vomiting during t-he_ preceding months,irequenfly in- thc presence of the child. How much of the behavior of thechild was imitation and how much rvas stimulated by the physiological re-actiol of seeing another vomit was difficult to say. .Ilowever, as,soon as themother was instructecl about the neceSsity of seehing privacy during tiresevomiting periods, and after it was explained to the chilcl (although she wasmentaiiy clelicient) horv unnecessary it was to persist in this habit a-nd howfoolis[ it rvollcl be for her to continue to tahe food if she persistecl iu throrvingit up immediately, the problem seemed to be solved, for within 2 n'eeks thevomiting ceased comPletclY.

Further investigatlon shorved that Susan, 2 years youn€€r and , of higherintelligence, was also troubled with bed-lvetting at night. The routine corree-tive measures were at once instituted for both children. A chart system wasintroduced and rivalry was stimulated betweetr them. The results in bothcases were extremely satisfactory.

Another youngstei was subsequently added to the household, making fourchildren in all. when the oldest was iust over 7 the mother found it neces-sary to go out to rvork and took a job cleaning a theater at night. She leftthe- house at 10: 30 p. m. antl worked for 8 hours, sleeping most of the da5"She rvetl represents the type of mother rvho is worn and wearied by toil antlwho has little to contribute to the welfare of the home. She was, horverer,extremely grateful to have her burdens lightened as much as tbey were' Bothchildren

-continued to visit the clilic at frequent intervals, the mother feeling

urat they \Tere more easily clisciplined when they hacl to make a report to theclinic occasionally.

contmettt.---JIhe interesting point in this case is that it sho\ys how importantimitation is in the meltal der:elopment of children and aISo that feeble-miirdeclchildren do respond well to the simple training nethod.

Carrie came to the clinic at the sge of 5% years. Birth and developmentwere quite normal. There rvas nothing of significance in her history uor iDtlie phlsical examination made at the time of the flrst visit to the clinic.

'Ihe patient was brought to the clinic by her aunt, who stated that she rvouldnot eat unless fed, that she heid her food in her mouth, and that she persistedin regurgitating it. when left alone at her meals and told to e&t she invariablyhicl the lood and told fanciful tales about what had become of it. On oncoccasion when she \yas told to eat her breakfast, she hial the food 0n tha attic

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IIABIT CLINICS X'OR CIIILD GUIDANCF

stairs and said she had eaten it. When taken to her uncle's store and givencrackers she secreted them on her persoD and then threw them al\'l4y, some-times hiding them behind barrels in the store but alwa.ys insisting that she hadconsumed them. She was said to be able to plaj' all day rvithout food. Therewas, however, no difficulty in getting her to eat ice crearn aud cattdy.

The clrild's father anrl mother had both died during an influenza epidemic,when she was 2 )'ears of age. At that time the paticnt had been taken by theaunt and uncle, with rvhom she had continued to live. 'I'hese relatiles \yereapparently devoted to her and were as seriously interested in her welfare asin that of their orvn child. At the time of her parcnts' death she haal uotlearned to feed herself, and the struggle to teach her had persisted ever since.She had formed the habit of not eating uDless her aunt sat down and fedher, which meant cutting up tlre food and conveying the morsels from the phteto her mouth. Ilore recently the child had begun simply to hold tltc foodin her rnouth, refusing to swallow it. The aunt reported that breakfast wasa daily ordeal, as she felt that the child must be forced to eat before going toschool. She further statcd that Carrie had gone beyond all limits of the nor-rnal hunger period for the ordinary child. trlxcept for her capriciouslessregarding food, there seemed to be no undesirable habits. She slept rvell, u'irsordinaril)' obedient, had well-establishecl toilet habits, and seemed to have noparticular defects in her personality make-up.

At the clinic Carrie did not aplrear at all undernourisheil and seemed to behappJ' and cheelful. Her only cornment regarding not eating was as follorvs:"I dream of a beautiful faily in yellow who told me that I should not driniimilk." After having a careful physical examinirtion, ho$'e\-er, the chiltl diddrink a glass of miih and eat a half slice of stale bread rvithout any hesitatiorl.

The aunt rvas instructed not to be so solicitous orer the child's meals. Shewas told to prepare the food and place small quantities of it before the cltiltl,telling her that she lvould haYe 15 or 20 minutes to eat iler meal and that itrvould then be taken away and she n'ould have nothing else until the nextmeal. She was strongly urged to carry out these instructions faithfully untilshe came to the clinic the follorving rveek.

The problem lvas also discussed rvith the child, an effort being made toimpress her with the importance of takiug her food at regular intervais andalso of eating it rvithout assistance from her aunt. The following week theaunt reportecl to the clinic that the patient got along rrell for the lirst 4 dnyslfter their visit but that since then "has been calr"ving on pretty much the same\r'aJ' as she ahvays has." She found it more di{ficult to discipliire the patientthan her own child and clung tenaciously to the idea that she wailted to clofor the cliild rvhat the child's mother rvould have had her do. One could seethat she was activated by the idea that she rvished to avoid showing anypartiality toward her own child.

The famiiy lived in a comfortable, sunny apartment, which, horvel'er, \\,'askept in an extremely untidy state. \Vhen the socia.l n.orlier visited the home,the table was piled with dirty dishes and half-eaten food, and such food aseoukl be seen in various pans looked most unattractir-e and poorlJ' cooked.Tlre floor was uns$'ept, and there \yere large pails full of un'rvashed clothesstanding about. The aunt's clothing and persor were dirty, as were those ofthe children. At this time the aunt felt that she rvas at the end of her re-sorlrces *'ith regard to the patient aud said, "I wouldn't mind trying to feedher if she rvould only eat what I feed her." Yet sire seemeil glad to have thechild as a member of the family, in spite of her difficulties. She felt that thechild had been spoiled by her own parents, 'r,r'ho had lost an older child asthe result of an accident rvhen tbe patient was 1 year of age. 'I' l i is had un-doubtedly made the patient's mother very solicitous and anxious, and thechild had been permitted to have her own way. The aunt stated that she feltthe child's difficulties with eating were getting worse, rather than better.

It seemed impossible in this particuiar case to organize the chiid's routinesin,a satisfactory way in her ov'n environment, and an effort n'as therefore madeto rernole her from her surroundings until normal eating habits could be estab-tished. 1'his n'as accomplished by sending the patient to live rvith anotheraunt in one of the nearby suburbs when the aunt with whom she had livedwent to the hospital to be confined. While living in the new environment shedid extremely well and no eating problem was evident. Shortly after return-ing home, however, she resumed her olal habits. Attempts were made to persuadebotl the auut and tbe uncle to have the cbild go to the study home of a local

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chilal-rrelfare ageney for an extenclecl period, but their attachment to the girl

"na ,L.it inability tb appr.eciate the gralvity oi the situation made such attempts

lu t i le .IIABITS OF ELIMINATION

Ilie function of elimination frequently becomes .the center of

rrrr, lesirable b.h"oio", rangi*g j ' seiio*srress frorn simpie delay in

,,.toblirhing toilet habits t.-o sdrious neurotic mnnifestations.an$ fe1;i-..siotts. The most common problem concerned rvith elimination rs

.;;*.{ und u. this is the type ol behavior for rvhich habit training

rs narticularlv important airt l with rvhich it is very success{ul' the

.i istussion rvii l be'lalgelv l imitecl to this'E[uresis '''uy o.cui b"ottr day ar]d niglrt. It occttrs in both sexes

,rittt about thc'same {reqrreucf. It urfr ' begin in infrncy and" last

unti l the sixth or se1'enth year, or it may cease at .the elld or tne

li;. i v;"; ; i th rhe corrdit ion ietrrining at indefinite periods and las-ting

i; ' ;t ' i ;A; d;\= 6 a few months at-a time' Doct6rs Holt and How-juua itut., "P"robably the. most^impoltant cnttse is. l iabit ' resllt ing

from poor tlaining. Habit is often a potent {actor in contlnurn+tleincont-inence, ereu after the primary.caYle.l ias rttsaPpeared." " It 1s

*;in tni, 9r.6,,p of cases thrt the habit clinics are concerned.Before starli'g to treab e'uresis as an undesirable habit, it is, of

coln,Se, necesslr.;ito eliminate, So_far. as p_ossjble, evely or'gatllc callse

for the conrlit ioh. Conditjons aflecting the bladder: lcute jrtf lamnta-

tions. and calculi are the most comDron causes. An adherent pleplrce(plimosis). a narro\Y uretl iral meatus, or local irritations from rvorms

Jii t i . i ,,t.J in the r.ectum may be the cause. Enulesis m.a_y.be associ-ated with a highl; 'corrcentraied acicl urjtre rrhen the fluid irrtake has

teen it lsum"iert-r, 5r it ma1' be brorrglrt about bv incrersing the flrrid

intake, which naturally increlses tlre arirouttt o{ f lutd to be excreted.The more general cotti i t ious, alremia, nrlhrutl it ion, and an unstaLleluervous sy;!e,m (of rvhich entiresis is only a symptom), should receiveDroper corlsroeratlon.'

.dft"" all orsanic conditions have been excluded as calrses of the

enuresis there si ' i l l remains a large group of cases n'hich are dependentupon faulty habit fornration foit ireir ciuse atrd persistencc' Even in

tliose cases n'here definite phlsical c&uses have been forind and cured,the conditiolt nrlY pelsist flon habit'

There are certaiir general principles that may be applied in everycase of eluresis. Tl[ child should so far as possible-L)e follorving a

resime that is free from an.y excessive nrentrl strairt. He sltould havea iinrple. blarrd diet and clefinite Sours of sleep. Routitre me&suresshould b6 instituted to avoicl constipation and to stimulate free elim-ination through other sources than

^the kidneys. One of the first and

most imnortairt steps in the treatmetrt of enulcsis is to interest t lte

child in^makine ai efiort to oYercome the habit. This should bebrousht about b"v appeaiing to the chjld's love of approbatiou ratlrerthalr-rhlonsh puirisiui,ent oJ'lnmiliatiol. Tlie chart systerl l has beenutilized wilh Juccess in tliis counection. Not only does a chart serve

i t; k.9p ? definite^ record of_the child s acliievemeut during the interva-lI r w a E E y 4 " - _ : . ' :

- : ' ^ ' * . " ' : - ' - - -

I that h'e is away from the clilic, but in a way it serves as a motive foll -I . Holt, L. Emmett, M. D., and Jotn .Ilowland, U. D. : Th-g Disea-sgs- of Infancy anal

I cnaciir6o, b.-olT- tentn pditlon- D. Appleton & Co., New lorlr [1933].

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the efrort needed to overcome the habit. The child keeps his own chart,makes a mark for each day ald night of success, andover each marka star is placed. rn a ceitain gr;uo of cases. sussestiou. n-hen thechild is goirre to sleep at nighil has workecl ir.eill"The rirother sitsd.on1by. the bedside of the ciii lcl and just as he is about to fall asleepshe. has hirn repeat over and or-er again, ,6I rm nob going to wet th^ep.d." ' l ' lns suggestrve treatment is similar to hypnotisnl n-lrich lrasbeen used succei#ully in many adult cases and rvdich lends itself quiteeasilV to home treatment.

x6t in{reqrrently one finds that pareuts for one reason or anotherhave tal<en for grantetl that a particular chilcl rvill continue his habitof bed-l-etting. long after the time rvhen he should have been traineclto ttre ciry habit. one mother statecl that she herself had n'et the beduntil after she reached of age of pubertv and for this reaso' she hadignorerl the problern i-n he. i-year--old cliughter. Another rnother ex-plained that the clii ld had inherited weallkidne;'s from the fatrrer,sside of the, farnily, the patient's gr_andfathe" un,l"father hnving botlrbeen trorrblerl in this u'cy. A thiid mother reporterl that none'of herforrr chilclrelr \\ 'as ' 'dr.y'tbefore reaching the iue of 5 r.elrs and thatshe just assrrnrecl that ihe patient. rvlio iruil com-e to the clinic becauseof niglrt terrols, should nlso be n'ettil ig tjre bed at 4Lb \-ears of ase.such au att i tude in palerrrs i rwariably prevents ther i l t i .onr start i "ngoXrTJ intelligent plarr of trrining; inileed, they often seem to ge;a feehng of satisfaction when their-half-heaited itternpts at trarnrngfail.

It is not unusual to find children reverting to the habit of enuresisdespite_ arlequate trailing. A little girl, 4"years old, who becarneintensely jealorrs of the newborn bab-y, begair u.etting her bed andher clothes again aftel havinq oyercome this habit mo.-re tlralr a veill 'before. Another little- girl ivho rvas devoted to her nurse bdganwetting the becl rrhen the nurse left lier to crre for a youngel chTld,Peter, aged 6, fonncl that the beil-wetting of his voung-er si*er. agedI, ggt so nruch attention that he began the sam6 perTormance' af"terhaving beert pelfectly trailecl for 3rA vears.

. One- must keep in mind that th6ie rre many emotionrl and err-vironmeutal situltions which are related to enulesis. esneciallv inthose crses irr rvhich the child has been ,(drv" {or i loirs peiiod,Notwitlrstandiuq the fact thar pnnishment nnd humiliatioi a^re notusually successful as m.etliods of i.reatment, it is perfectly fair and justto. impose upon_the.child a certain amount of c-are and"responsibiiitywhich go rvith looking-after the soilecl Iinerr. SLrch tasl<s as puttingthe clothes to soak, aiiing the bed, and rvrshing off the lrrbbei.shee{should be handed out, nof as punisirment. but ra"ther as aids to correcta diflicult situation.

'It mavl howerer. brovide the essential motive

if the child is to take the prbblem serioul"ly enough to make it worthhis while to set over the h;bit.

It is also -wise

to point out to children the clisaclvantages asso-ciated with the habit of becl-wetting. It prevents overnishivisits tofriends ancl relatives and perhaps i'icling bn trains. It iJ frequentlyan obstacle to the child's irrivilege of h-avins overnislrt suesti or o"fgoing an'ay to camp. Tlrese clisadvantages-should'6e p"resented asreasons why every efforb should be made-to overcorne the habit anduot as threats against its continuance.

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EABIT CLINICS ['OR CI{ILD GUIDANCE

D:r,itl, first seen at the age of 5 years 2 months. Born at fuII term; birthftrjirt. 7 pounds; breast-fed; development norm&I.

lle n'rrs in the habit of going to bed at 6 p. rn.; slept aloue; was restless onlyr;c. rille occasious, n'hen he would talk during sleep. He was uot finicky aboutf.:,rl: liad a good appetite and no history of constipation or indigestiou.

ll:,. nother stated that trouble began rvhen he was 2 years of age. At that::::c be was very ill rvith pneumonia. Following this illness he began to soil!:::r:elf and wet his clothes and his bed. 'Ihis condition persisted for 2 years,b-:r for the last year and a half he had been troubled rvith enuresis only at:,:gLi. This occurred about 5 nights ottt of 7. 'Ihe mother stated that she!,ad spanked him, rubbed his nose in the urine, ald deprived him of things, ands: the time of her cliuic visit she was refusing to give him clean pajamas oYer.,-,:.g peliods of time, tryiug to impress him with the fact that he must learn not:o rvet his bed.

Ihe chikl was generous and friendly, Iiked other people, played with othertbildlen, and was rrot jealous. He was inclined to be obstinate and could noti<. dliren, but could be easily disciplined if coaxed. The child had no particularlerrs and enjoyed playing outdoors n'ith other children. On the other handl:i. spent much of his time playing dolls with his little sister.

lu his psychological examination he received an intelligence quotient of 92.IIt waS fairly cooperative but inclined to be boastful, constantly saying, "Ital do this," "I can draw that." He was particularly interested in drawing. Inf.rct, it was difficult to hold his attention because of his interest in making pic-rures, He was attending kindergarten and prefened going to school to stayingxt home.

-fhe home environment was quite satisfactory, the family occupying a smallhouse consisting of five rooms. The home rvas clean, tidy, and attractive; eachchild had a room to himseu. The mother was interested in her children audrunbitious for them, looking forward to getting a larger house and a yarcl forrl)em to play in, where they would be away from the dangers of automobiles,She was, however, of a neurotic make-up, having had two nervous break-downs.The father was in a successful business with his brother, earning an adequatesrrlar-v. The two children rvere both in good health and enjoyed eaeh other's,.(,nlpany. TIie mother was in fairly good health at the time of the visit to the, l i r i ic.

Summ,ar11.-Cbild, 5r/z years of age, with an average intellectual equipment,etrming from a good home, troubied with enuresis 5 nights out of 7, with nouther undesirable habits. The treatment, to date, had consisted of cruelhumiliation and se'r'ere punishment.

The fact that the patient had been treated at numerous clinics led the motherto believe that the case was hopeless. She maintained that she hacl carriedout all the directions given her by the physicians, but in spite of this the etluresiscolt inued.

The boy, as seen at the clinic, was attractive ancl bright, interested in histllvironment, and anxious to demonstrate his ability in printing and drawing.He discussed his problem openly and frankly, without any apparent embar-ra,rsrlent, and expressed willingness to cooperate. Physical examination andleboratory examination of urine rvere both negative.

The routine treatment for enuresis was outlined as follows: The patient'sdiet $'as to be simple, free from spices and sweets, with only a moderate amountuf meat; his evening meaL was to be served at 5 p. m., after which hc was tol.are lo fluids. He n'as to retire at 7 p. m. He rvas to be taken up, thoroughlyenal<ened, and sent to the toilet at 8: 30 and again at 10, and then permittedr'r sleep until rnorning, when he was to be awakenecl at 6 o'clocli. Stress was:nid on the fact that the child rnust be thoroughly alvakened and made to realize*'hy he was being aronsed. The mother rvas warned to be sure that the chiltlr c'ided when he was taken up. A chart was then brought out and given toil:i. lior. ancl the rnetliodl of keeping the record was carefully explained.

Tlic child responded to his part of the program with much enthusiasm, butthr nlother showed considerable skepticism about the routine outlined. Theyreturned to the clinic 1 rveek later, tnd at that time it was apparent that sheLnd not carried out the directions, in spite of her statements to the contrary.Ste had instituted her own treatment with kidney pills. She was, however,!'rrlrriled upon to continue the prescribed routine for a month and was requesteclto risit the clinic each week. The report of the next visit to the clinic read:'.She is much pleased with the change that has tahen place in the patient, feel-

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ing that the ehart brought it about, She is anxious that the younger chilcl,aged 27/2 years, be admitted to the clinic for tlie same trouble. She states thatshe did not contiuue to experiment with a patent medicine blrt decided to follorvthe advice given."

The next time she brought both children. She reported that the bed-wettinghad completely ceased and that she was greatly reliered.

Comntent.-The only comments that necd be macle 0n the above case are inreference to the tactfulness necessary in getting cooperation from the parentsand in making them feel that, although they have tried various remedies atdifferent times, they have perhaps neyer put irto operatior any plan that tookinto consideration all the aspects of the indivirlual case.

This case of enuresis was uncornplicated by arrl other nervous symptomsor undesirable habits, and it is n-orthy of note that the enthusiasm which thechilcl showed in keeping the chart was, iD itself, favorable from a prognosticnoint of vierv.

Another case of this type was that of Ellen, aged 3 years I months whenflrst seen at the ciinic. 'I'he pa.tient was born at full term; birth and develop-meDt were nolmal; she rvas breast-fetl to the age of 11 months.

The child's hours in bed rvere from 7: 30 p. m. to 6 a. m. Sometime preyiousto the clinic r-isit she began waiiing up during the night; she seemecl frightened,cried out, and talked about soldiers. She trad ahvays bcen flnicky about food.Slie wouid not trke milk until she started attendirlg nursery school, but shehad since developed a liking for milk and ate everything except meat. Shedid not eat betrreen meals.

The patient was very shy and said nothing iD the presence of strangers butclung to irer mother. She was very quiet, and her mother stated that shewas capable of entertaining herself. When younger', she had had a very badtemper and had frequently gone into tantrums. She was extremely jealous ofher younger brother. This jealousy rv:r_s c:lt'ried so far that wlren her inotherhad first begun to nurse him the patient had not lost an opportunity to slapor otherwise bother him. She did rlot care to play wirh other chitdren and$'as self-centered and retiring. She was obedient and rarely had to be dis-ciplined. Her play life was occupied largely lvith her dolls, occasionally withher brother, and rarely with other children.

The patient had an intelligence quotient of 84. She atteDded kirdergarten,where she was getting on fairly well.

The home consisted of a fir-e-roorn tenemeDt on the second floor of a three-story brick buildirig. Tbe family had lived there for 8 years. It was clean,and although irr poor condition, rvell furnished. The patient hatl a room toherself. She was more attached to her father than to her moilrer anil lackednormal interest in her brother.

The problem as described by the mother was enuresis, which occurred bothday and night. I'his condition hacl persisted since birth. X'or a long timethere had been difficulty in sleeping. l'he child was put to becl at ?: SO p. m.and usually s'ent to sleep within half an hour. She woke. up at 1 or 2 a. m.and then every houl thereafter until 6 o'clock, when she insisted on gettingup. This wakefulness, accompanied by crying, had become a very disturbingfactor in the household. X'ol the 3 preceding rveeks the child had developedan unusual fear of soldiers and upon waking cried out in fear, saying, ,,Don,tIet the soldiers get me !" The story was that she had been taken by lier motherto see some soldiers drilling. This had alanned her for some unknown reason,and since that time she had talked constantly about soldiers, saying that theywere going to take her away. When she awoke at night she cried out to hermother, "Close the door, the soldiers are coming !', She refused to go into anyroom alone since this event and rvanted her mother constanily by her sicle.She had become much afraid of the dark.

At her first visit to the clinic she was extremely shy and would have nothingto do with the examiner, speaking only to her mother in whispers. She re-sented any attempt of the doctor to become friendly, and because of thistimidity the first ciinic visit was unsatisfactory.

Routine measures for the enuresis were instituted, however, as described lnthe preceding case, except that the child was permitted to go to bed at the usualhour of 7: 30, was awakened at 10, and was permitted to sleep until morning.

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Tte nr,ther rras instructecl to take the child again to see the soldiers tlrillingl: . j : , , i , ,rv her to observe them as closely as her fear would permit. TheEr,ri:r rvas told to assure her ancl to instruct her about soldiers.

.\t rhe end of the month the mother reporteal that the child had sho.wn con-tilrr:il,le irnprovement and had not wet the bed for 2 weeks, had slept better,url n-rs rro ionger afraid of soldiers. The fact that the mother had taken her tor': ihr soldiers drill every day seemed to dissipate her fears. The child wasr..:,:'. frieldly toward the doctor but was stiU shy and bashful.

I:.lrrorernent continued during the summer months, aud in September the childeirrrd kindergarten. The teacher reported that she got along well, showedsorlrrl interest, and adapted herself to the school work. She enjoyed the asso-eiarion with other children, was quite unselfish, tvell-mannered, and obedient.TLr nrotl)er reported that the patient was getting along very well-that she dirtu"rr set the bed and that she had Do difficulty about her eating. She no longerertertained any fear that disturbed her either day or night.

Contnrcnt.-lt was interesting in this case to note the degree to which thiscL.ild n'as able to make satisfactory adjustment to both home and school condi-iir,rr,-. She became relatively independent of her mother and interested andrrffrctionate toward her little brother. She was sleeping well, her appetite wasgi-x'd, she had no difficulty with enuresis, norwas she any longer disturbed byferrrs and terrifying dreams.

,Uthough it was impossible in this particular case to determine the untler-lfi'g cause of the terrifying wakeful periods, it is of interest to note thatrDarry favorable changes took place subsequent to, if not simultaneously with,rhc treatment of the enuresis. This happens so frequenfly in the treatment ofrhis disorder that it leads one to believe that the feeling of inferiority andshame associated with enuresis in many cases colors the entire mental lifeuf the patient. It is of practical importance in the treatment of mentalproblems where enuresis happens to be one of the symptoms (inasmuch asenuresis is orie of the most trying probiems to the parent, although one of themost easily curable) to institute treatment for the enuresis at the earliestpossible date.

HABITS OF SLEEP

. Mos{ of the problems that arise in relation to sleep are broughtabout by poor training or lack of training on the nfrt of Darenrs.('hildren frequently get the idea that bedls a plac6 to be dvoided,becarrse it has been used as a rreans of punishrn-ent. When _\farv isnaughty, she is threatened with being s^ent to bed. Tommy. on theother hand, is told that i{ he is good he may stay up a half h"oirr later.Both attitucles implv tlrat bed is.-a place to be avoidLd.

A sleep routine should be established to which t)arents and childwill conform, for there is no demand made upon fhe trhvsical well-being-of the child in rvhich sleep and relief fro^m physi-cai fatigue donot play important parts. The tired child i.s uGudtty an. unirappychild. Tantrums, -enulesis, starnrnering, varlous mannerisms,

^airil

numerous other physical and emotion;l problems are freqrientlycrused by fatigue due to insrrfficient sleep.

The irnportalrce of sleep should be tlken for granted. neither fea-trrred nor ignored, and the parents'rttitude should be preciselv as itis to'n-ard the meal hours. The hour for retirins should not 6e oer-rnitted to be a time for "putring on a shorv" arid settinc attention.I'lre child will soon Iearn that after he has been adJquately preparedfor.bed, comfortably brrcked i.^, q"4 had his par.tirig ,,goo'rl nighb''srid., the c.eremony is or-er and & belated request for-a s'iory, a

-trip

to the brthroom, or ftnother drink of wtter is just a *ay ,if tryingto get attention or exert a little influence over the solicitous mo[herlYielding to such requests is the beginning of an inclulgence on the

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part of prrents thal may cause them much tronble later and createin the ctii l.t r feeling of "dependency that will prove a rerl handicap.

The overtired chii-d or tfie child-who is saicl to be srtfieling fromgrorving pains mav exhibit considerable restlessness-tossing, turn-ing, trvisting abouf, and complaining of not feeling rested the nextda:t. These-periodi of phvsi6al urrre-st need not catise prrents undue

"rlii.tu. Thiv are indi'cafions that there is need for more rest, less

violeni phvsic-nl exercise, atrd perhaps a \rarm relaxing bath beforeretiriug. Xiqht tellols,'so cailed, ire a mltter of cleeper concerllbecausdthey ire invarirblv related'to some clisturbrltce in the psychiclife of the"child. Thele-is no doubt that many fears are plantedrlurins the ear'lv life of the child, are awakened b.y subsequent ex-perien"ces. and eienturlly play au important part in producing nighti"""o"..

'Children shouid not be tfireatened rvith i'iolence bf one

kind or another for indiscretions, because the auticipation of punish-ment, like threats from other children, may lead t6 serions clisturb-ance of sleep.

Not iufredrrentlv intellisent prrents create sleeping difficulties forthe child blj rccitirg to lrfm, jirst before he retires,-stories lhat ltretirrsed u'itl i the myiteliotts and the ttnexpected' The.y often leavehirfrin susliense iu some very exciting ptrdof the story in order thatrL hrppv eineriertce mav be

-anticirrat"ed tlre following

-evening. It is

"lrtioud tha^t such a proceeclirrg is^ urrn'ise for the irnlginative child'

'I ' lre mentrl rctivitiei created"in this wt-y often preient the child{rorn going to sleep and frequently creafe both motor and metttalunrestl l,["any prog:raIns presented irver the-raclio- at-the preser]t timeare of tiris natu^re ind lav the foundltion for a btr,d night, 'which isfollowed by fntigue ancl'irrittbility the tre-rt clay. .Nlany childlerrlrnve strange. vag'tte, il l-defined rrolries and lnrieties over death,sickness. sclool. a-nd parental relationships. Strong emotional terr-sion is associati:d wifh these rvorries an-d tliey assirme undue pro-portions in the mind of the child after he has u'ithdmrvn from thedav's activities which ha'i'e been demanding his attention. Threatsof"punishrnent, fear of being deserted by prrents, or of being sub-jectecl_ to bullying and. teasiirg by othef clildren,, urd.many-otlter6vervdry enviionmental situations which threaten the child's securityare iubj-ects that are worthy of investigation v'hen one is endeavor-ing to solr-e a problem relatecl to sleep.

i"s the child advances to the age rihen he is able to read and com-prehend sensational nerrsptper heaclings relating to lurid tales ofinurder. suicide. robberv.-immorrlitv. and othei topics that excitecuriositv. a nelv'factor i!'introduced which often disfurbs his meutallife and iesults in sleepless nishts. Fortunatelv. much of the materialderived from radios, ne'tu.pafets, and other c6ntacts which the childmust make in his erlervdav 6xisience. does not resister on his mindbefore his fifth or sixth y"ear. All tirese nerv al'e"nues of enlighten-ment make a valuable contribution to mankind in general, but theyare a menace to a certain group of highly setniiive, imaginativ-echildren. It hardlv seems neiessirv to m'ention that fear stiirulatedby putting childreri in dark closets

-and down in the cellar, by threat-

eniiE thdn with unusual punishments. and by scaring'th-em withweird tales. is cruel and viiious and leaves sca-rs upon

-iheir mental

life that ar6 rarely completely healed and that may^lead to the most

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violent t}'pe of night terrors. some children are extremelv sensitiveand. symprthetic tb the rvorries and anxieties of parents, and drrri,gperiods of extreme eeononric depression. rvhen the secirritv of thEentire family is tlrrenterred, when- there is grave illness in tte honre,or rvhen unclue emotional tension exists be"trveen parents. a state ofmind is createcl in the cirild that frequently preveits normal sleep.

Besides creating l happy, carefreel unperturbed state of mind'forrhe child before retiring, it is also iurlrortnut to provicle proper sleen-ing a'rangemenis.. The bed i tsel f shbuld_be rrei t , c leaninncl or, ler iyi1 appe.a.ra.nce, rvith.clothing suitable to the season. In'other worcli,it should have an inviting appeurance. The room should be weliventilated but not ne_cessarll5r cbld or drafty. The shades shoulil bedrarvn so as to avoid bright earlv-morninE licht. Some of the minordetails srrch as the tvpe-of niglit clotheslpl-ncement of becl. ancl ar-langement of fur.nitLLie can bii lefr to the

'child when feasible. The

act of retiring-shou]c! !e taken for granted, featured neither as oneof the crosses that children have to belr nor as an uuusrral privilege,but as one of t l re evelts thnt take place in the rout ine of 'a i rappv9,,y. The mntter.of adeq,ate sleep is'a_ subject that ca'not be ign<ir'ecli t r at ty.c.orsiderat ion of the mental and phj 's icr l welfare of the"chi ld,e.specially drrlirrg the first fe'v years when habits ar,e being estab-Irshetl. Sleep is nature's 1'a-y of conserving the chilcl's energy-agains[the denrnnds made rrpon it by rupicl physilal and mental gTowitr.

John, a 2-year-old boy, was referred to the clinic because of irregular sleepinghabits, enuresis, soiling, irregular and finicky feeding habits, and disobecliencdHis birth _and development lvere normal, and his intellectual equipment n'asayerage, His parents were young and unintelligent. He had clevelopecl intoan undisciplined and untrainecl child. The mother had never made anyattempt to train the child to toilet habits, and the irregularity of his eatin!had been taken for granted. rn other word.s, the child ate when he felt hungr!rather than when food was served to the other members of the famiiy. Hismother could not remember that the chiid had ever slept \yell. she stateal thathe was put to bed at 7 o'clock but rarely r.vent to sleep before 2 or B in themorning. He insisted on getting out of bed anil going into the living roomto- join his parents. rn spite of their efforts, which werelncloubtedly feebte andmisdirected, he rvould stay up until 12 or 1 o'clock. He rarely slepl later than6:30 in the morning, at which tirne he rl.ould get up to haie br-eakfast rrithhis father. He then returned to bed and slent until 12.

The chi ld was irr i table_, demanti iug, and extrenrely dif f icult to get along with.rvhenever he was crossed or an effort was made to get his coopeiation iri doingsomething that did not please him, he would cry; and at the age of 2 he hadah'eady found that tears were apt to get him out of ma.ny rliffcutt situations.

The mother was a weak, negative sort of individual, entirely lacking inimagination, who took Iittle care of her own health or personai appearance,and who was a poor housekeeper and a bad manager. she rvas inconsistent inher discipline' so that in one mood she tried to control the child by cufiingand slapping him and in another mood she rvoukl indulge him in everything.When she slapped lrim, he slapped back; rvhen she was resentful, he, too, wasresentful. rn other n'ords the mother had settled don'u to a rather childish.infantile, emotional level, as was shown in her efforts to control the child withthreats of the doctor, the nurse, "the cop," and anything else that might forthe monent have affected the child's conduct. The problem was obviou-sly oneof parental education and of getting the child into a nursery school rvhere hecould live in a well-organized environment for at least part of the day,

Sarah was a tall, undernourished girl just under b years of age. She wasbrought to the clinic by her mother because of uight teirors whic[ hart existetlsiuce iufancy. n'or the 0rst 6 mouths she bail been diffcult to feed, became

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HABIT CLINICS F'OR CIIILD GUIDANCE

much undernourished, and had suffered from constipation; otherwise her de-velopment was normal. The feeding difficulty had, however, continued tomanifest itself in iudifference to food. She apparently enjoyed the attentionthat was associated with being fed by her mother, who indulged her in thisrespect.

This child, only 5 years of nge, was frequently allowed to stay up in thesummertime until 9:30, although she did go to bed somewhat earlier in thewinter. Retiring was usually accompanied by a good deal of talkiDg and laugh-ing with her brother, who slept in the same room. The mother stated, "Nearlyevery night Sarah has night terrors. After a half hour to an hour of sleepshe starts screaming and will yell out, 'I won't do it,' 'I don't like you,' or someother similar expression." 'I'he mother found it difficult to awaken her duringthese times. There was usuall)' a short crying spell, and then the child rvouldfinally settle dorvn and go to sleep. These episodes would be repeatcd sereraltimes tluring the night, but the cliild would have no recollection of terrifyingdreams nor could she remember much about what had happened during thenight. 'Ihese night terrors wcre invariably worse when she was sick, but themother had been unabie to associate them with any actual experiences.

'I'he mother described Sarah as "a high-strung, nervous child." At theclinic the psychological examination showed that she had a superior intelli-gence, rating 2 years al.ove her chronological age. Her cooperation was excel-lent and her general behavior indicated excellent training and manners. Thehome from which the child came was above the average economically andculturally, and the parents were rather superior intellectually-in fact, themother rrras "an amateur stltdent of psychology and child training." It ap-peared, however, that the parents' influence on their child had been counter-actccl by that of the grandmother, who was said to be psychotic and who in-sisted upon "smothering" the patient with her affections and attentions, rvhichthe patient resented. The relationship with her grandmother rvas of such anature that this ordinarily quiet, well-behaYed, sensitive child resented it andmade every effort to rcpel the grandmother's advances by assuming a dom-ineering attitude herself. The mother was advised to regulate thc patient'sroutine so that she would have adequate sleep, more rest, and regular meals;to eliminate so far as possible the contact between the patient and her graud-mother; to see that the child was kept interested and occupied; and to securethe cooperation of her maid in this plan. The child was placed il a kinder-garten in an effort to provitle a routine suited to her needs, and to bring herin contact $'ith inteiligeut and unemotional adults as well as a nornlal groupof children of her own age. The mother reported at the end of 2 months thatthe night terrors had disappeared.

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The ways in which the behavior of children brings them into con-flict rvith their constantly changing environment are lnany andvrr ied. Eqrrn l ly numcrous arrd vai ied-are the causes of th is bef iav ior , "l -or exanrple. . r ch i lc l may present a p ic tu le of rest lessness, destruc-tiveness,. pugnacit5'. and marked impLilsir-eness, with other evidencesthat he ' lack-s nonnal inh ib i t ions. Such bel rav io l rnav have i ts basisin certain orqanic defects either inherited or acouiied at an earlvage, mental deficiency being a classic example of'this group; or i lmay be a leact iorr to physical l imi ta i ions associated wi th d iabetes,in fant i le pala lys is . or 'ca ' r , l iac condi t ior rs . Not i r r f requent lv acuteinf la .mmatbry cbn, l i t ions of the bra in or i ts cover ings ' resui t ing i r rmeningitis and enceph-alit is- (commonly known as slee"ping sickne.ss)are followed by such djstulbances in the child's belrar-ior, i lue ro rm-pairment of the_normal processes leading to inhibition. Very often,hol 'ever , these d i f f ieu l t behavior problem's are not r lue to any of thecauses ment ioned, but are the resul t o f poor t ra in ing or lac l< of t ra in-ing. fn this case one sees an undiscirllined cliilcf ivho undoribtedlvhas the ability but has never learned tlie necessity o{ exerling w}ratrire commonly knorvn as will power and self-control.

Nor is the behavior of the child alwavs constant. X'or. a period,at least. olTensive attitudes may alternate with defensive, rha tnuichi ld nra.y put up a good f ight-against personal i r ics and s i tunt ionsthat are too st rong. There mrv be vagl le , in tangib ie s i t r r l t ions rvhichale overpo\ver i r rg to l r i r r r . Rebel l ion may bc of no avai l aqainst thesubtleties of a l,ersisterrtly oversolicitous parent. The Ahilcl \. i l lfinally succumb to defeat and accept a plan of life ill suited to hisneeds ancl necessitating much in the^ wav-of fantasv to mal<e it tolera-b le. l \ -hatappears to be s imply an und"esi rable hrb i t such as enrr res ismay have its roots deeply seated in jealousy. Crueltv mav be re-galded bv the parent as ; ' just- ordin_aiy meairness', when aciually itis an unconscious protest of the chi ld against h is orvn inadequacies.The sul len, r rnhlpp.v,chi ld . apparent ly lack ing in_af fect ion fdr arry-one, may be crviug aloud for someone who rvil l take time to find oirtrvhat his emotional needs really are and to see that some effort ismade to satisfy them.- The varied i:esponses wliig! human beings make to life do not lend

themse-lves rvell to any rigid classification. Because there is wide, l ivers i ty . in , the. constr tL l t jo la l make-up_of ind iv idrra ls , and becarrseilrese rndrvlduats are called. upon to adiust themselves to environ-rrrents that are varied and constantl.y changing, situat,ions are created* Irjch ,are necessrrri ly extreme]y variable-and complex. rt is withsr ear ornlcurr,y ancr always wlth more_ or less .du_lgpt that broad gen-c.rrl jzations are set forth _to be applied to the indii-idual case. Eiervchild must be considered as a iiving organism struggling to ^uL"e

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such ad'iustments to his environment as will permit him to surviveancl enjby natural grorvth and development and t.o accept and con-fornr tb ' the restr i i t ions which societv i rnposes upon Ir is behavior.Acquisition of the personality traits that lead to conformity is in-sistid rrpon b.y those rvho are'responsible for the orderly gloivth anddevelopment of the child. It is the {unction of chilrl training, so faras the'wisclorn and abilitv of parents permit, to see that the-chilct ismentallv and physicallv tiquipped to m-eet the world outside the horne.Societv deals harshlv with those who fail to recoqnize the necessityof su6ordirlating seif to the social group. UnTortnrtately. forc'erather tlran rrnderstanding is too frequently exertecl itr efforts tomake children conform. I{ear is often in the foresround of mostparental and social doctrines. The child is taught at rr,n earlv ageihat the rvav of the transsressor is hard. and veiit 't snile of ati tl i isplessure exirted from rvithout, the rroild is'full of unhappy, il-adequrte. poorlv adiusted individuals who have not prof i ted bv their 'earlv trairiins. " The question arises whether educrtidn should'not besubstituted fdr fear.

tr'rom the clinical point of view there are three clistinct groups ofproblems of this kifd: (1) There is the group represente? by thechild lvho because of certain limitations of intellect, physical defects,or emotional instability rviil be a problem regardless of his environ-rnent. (2) Tlrere is tire chilcl wlio, in the firocess of grorving up,goes thrbugh phases involvilg certrin charfoes in behlvionif ichdrtnse conce-r-n to his narents. llhese situationn ale not so nuch theproblems of the pnrticular child as problems of a particultrr stage6{ development, ild, if handled wisbly, they need lause but littieanxiety.

^(3) Tiiere is a tvpe of child behavibr that is only n symp-

tom of o rrioirl"m ennironnldnt. Manv of the cases referreci to ciiuiisfortunateiy belong to this last gloup. Constructive effort to ciransethe enviroirment'and cive the"chilil a better understanding of hisclifficulties is invaliabi! helpful in these cases. Examples- rvill beinclucled in the follorving cliscussion.

ANGER AND TEMPER TANTRUITS

In consiclering such aspects of conduct as tenper tantrums it isnecessirrv to apJreciate ffil lv the different plarres irpon n'hich mornlconcluct"is el,rctecl irr relatibn to the ase of the initiviclual rnd thestage of social development.a Those who deal n'ith childretl ilreconiernecl very largely with conduct crrried out on a low moralplane." I)uring the early yeals of life no moral judgments are folmed anrlthe chilcl" cloes not tLink of himself in relitioi to others. Ttie childis fundamentally selfish and consequently interprets everything ilterms of self, his own acts as rvell as those of others beirrg evaluatedbv the unonnt of pleasure or pain they bring to him. FIe mustlerm bv expelience that a certain line of conduct is a paying propo-sition, so to^ speak, rnd. that another line of concluct ii notf ancl'by"prving" one^impiies a gain to the chilcl in pleasule trncl comforl.ti ' ittr frroper training aid in the ploper errlirournent the averrrgechilcl soon learns thaY concltct cartieclbrrt in consitlelation of thole

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with whom he comes in contact in his everyday experien-ees bringsliim more Pletsure tncl less pain tharr he rroirld othei'rvise have. Hecloes nol t'ake lone to learn'that certain experiences are associatetlitiiih .i.fitrite nairF-for example. toucltitrg the hot stove-and ordi-rrrrily he cnn'lerm in the saine'ttay thef little or nothing i: to be

.-*i"uia by t{rat is commonly ctlled a temper tantrum. Such atantrum nas oeen oescrihed bv a parent as f6llows: "The child lies,iorttr on the floor, yells, kicki his-heels, and throws his arms aboutu'ith the intentioir"of inflicting bodily harm on those who comenear him."

Tlre tantrutn is. of course. purelv instinctive and must be met onits first flppearance in slch a. ivay a-s to impress on the child not onlyitiai trortii itg will be grirred buf that sucli-action.is positiv^ely pain-ful in its risults-painful in the sense of brin-ging a definite lossor of being similnrio the experience of-putting his hand on.the hotitou.. Thls crtrde and rntire^or less undesirable method of directingand inhibiting conduct.-d-uring^the early years of life should te dis-car(lerl ̂. sooTr ls possible in"favor o{-afpealing_ to the child's loveoi i,nrrr.ob"tion. u'hich riranifests itself early. Here the attempt is4irectbd torvnrd influencing the child's conduct by appealing to hisclesire for rrt'aise, on tite ofe ltancl, and his dcsire to avoid blame-, onthe other..

^ \Yitti chilclren who have reached this stage of develop-

ment it has been possible to utiiize in the clinics.a chnrt-system togive the child larigible evidence of the rpprobation of the doctor,ihe palents, ancl others tvhose p.r-a!se he most clesires.

T6mper tantrums, as was said before., are usually physical, mani-festatio'ns of the emotion of anger, which,may be stimulated wheuanv of the Yaried instinctiYe reactions are thwarted. lt ts importantto

''know this I'hen attempting to understand the tantrurns of the

chiid, because it is necessily To determine the cause of the angeJrrvhich nranv Darel)ts saY thei' are unable to account for. It is onlyafter the c]ti^ld. titrongh trainirlg and. experiencg has developedvarious means of nreet-ing and overcoming his difficulties, that theemotiolr of anger ceases t-o be one of the most darrgerous stumblingblocks. The i"nstinct of pugnacity, of which anger is the associatedemotiou, is esseDtial in the-deYelopment of ntost successful individ-uals. If is the drivi'g force to which much of the success in humanaffairs is d.ue, and it s*hould be controlled rather than stifled, if it isto work to th6 advantage of the inclividual'

In everv case that involves outbursts of temper it is absolutelyessential tb study the enYironment iu which the _child is being reared.in order to know under what conditions, in rshat places, and rvithrvhom these tantrums are most cornmon' It is of equal importanceto mahe a careful personality study of the child in order to under-stantl as fullv as pbssible thi conflicts that he has and the purposethat these embtion^al upsets serve. It is futile to treat each outbreakbv nunishinq the child or bv permitting him to gain some undesir-

"irle end. E"ither rnethod is-doomed to failure. Suclt corrduct nrust

be interpretecl in terms of the child's experience, if his personalityis to be

^molded so that he rvill be capable of making a satisfactory

social adjusttnent in later life.Harriet nas first seen in the clinic at the age of 2 years 5 months. Ilhe

birth had been normal The patient was breast-fed until 23 months of age.

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The mother statecl that it was Yery difficult to lvean the patient; she eriedso much and 'went into such teDper tantlums that the lliother nursed heruntil 3 mortlrs before her next cilild was born. Teething, $'alking, and talliingall tleveloped nolmally. She had had Done of the clrildren's diseases and hadhad no injuries or operatiOns.

Stre refused to go to bed uDless accompanied by either her father or hermother. She retired at 8 or 9 p. rn. and slept until 8 or 9 a. m. Trvo or threetimes during the night she would wake up and scream, Her mother said'"She is probaUly having tenper tantruns in her sleep and is dreaming that shecannot hale rvhat she wants." There was no feediug difficulty-she ate eyery-thing that was given to her-but there were some indiscretions in dlet, suchas tea for lunch. Enuresis occurred occasionall)'. The child had been knownto masturbate. IJer mother said that the child liad a "terrific" temp€r; thatshe would 1ie on the floor and kick and scream on the slightest provocation'When she did not get what she wanted to eat or was crossed at play shedeveloped one of these tantrums. Sometimes they occurred when themother had no idea what the exciting cause nlight be. They occurrecl fre-queDtly when she was playing with other children. tsollowing one of thesetantrums the cbild had had "pecuiiar attacks," getting blue in the face, tlremouth remaining partially open, the body becoming stiffened. These spellsiasted about 10 minutes. During the 2 'rveehs preceding the clinic visit shehad had seven such attacks.

The policy pursued by the family at that time \\'as one of acquiescence. Thepatient rvas said to be generous "tvhen she wants to be"; was jealous; didrlot want others to have things she could not have; did not get along rvithother childlen because she was pugnacious and fought them; was "alwaysvery bossy and donineering and tllwa)'s makes other children playing lvith herdo what she wants even if they are trvice her size." She was afraid of thedark, lvould not go to bed $-itltout a ligltt; rvas afraid of animals, especiallycats and dogs. At times she had shorvn marked affection for her father.IIer father took no part in disciplining her, and her mother had found thatcorporill punisirxrent rvas of ]ittle avail.

The father $.as Itaiian and the Drother was Irish-American. The mothersxid that the fatlier considered lrer an idiot and had been brutal to her.She did not knorv horv uiuch he earned. He was very close with his moneyand gave a dollar a day on rvhich to run the house. He spent little time athome. The nother felt inteilectually superior to the father and rvas al$'aysconscious of the racial differeuce. She said that the father hated their olderdaughter, Mar5., but was devoted to Haniet, whom he fondled and petted.IIe rvas also quite iDdifferent to the babl,. l'hey iived on a short, paved streetin a three-story brick tenement house. They had a two-room apartment onthe first floor. Father, mother, and Harriet slept in a double bed, and trIaryslept on the davenport. The mother had furnished the rooms with her ownmoney, and they n'ere fairly comfortable and well kept.

Prior to thcir marliage the father and mother had lived in Boston as manand wife. At the same time, he was keeping company with another woman.Even at that period he rr.as extremely cruel and abusive to the mother antlwas very irritable. He would throw cups at her when things he desiredwere missing at the table. He was arrested in 1918 and was sentenced tojail for 3 months. After his release quarrels were frequent, and in self-defense the mother had scalded and bitten him. Although he was still veryrough, showed temper, anal drank a great deal, he had not used physical vio.lence of late. The mother knew that he was not true to her and questionedhis relations with the patient. l'here was a story of his having infected theolder daughter with gonorrhea when she was 4 years old. His sexual demanclswere excessive anrl he masturbated frequently.

At the clinic the patient appearetl to be a quiet, demure, neatly dressed littlegirl, who sat quietly by her mother until she left to enter the examiningroom. The chikl then went into a violent tantrum, Iying on the floor, kickingher heels, and yeliing at the top of her voice. This behavior continued duringthe half-hour interval while the nother was talking to the physician, but itwas not followed by one of her spells. The mother verilied the history asgiven by the social worker and said that the child had been "cranky since theCay she was born, always crying and whining." She said, "I could not do athing with her-she has never slept soundly. I always have to lie down withher and sing her to sleep," Sometimes the patient stayed up until 10 p, m.

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irnd she never had a nap. When the patient got jealous of other chiltlrenshe trierl to inflict pain upon them. Whenever her mother paid special atten-tion to other children in the neighborhood or to the patient's sister, she wenti.nto a violent temper, bit her sister, pulled her clothes, and tried to bite hermother. Her mother repeated that she was afraid the patient had learnedto masturbate from her father.

Treatment.-The problems of enuresis and of establishing routine hours ofsleep n-ere attacked first. The mother was instructecl to see that the childwas put to bed at 6 o'clock and that she remained in bed at Ieast 12 hours.She was wirrned against all the difficulties that would arise in startins outon this program, but she was told that they would be only temporary antlslight compared with the trouble that would occur if the cliild was not taughtto appreciate that tempers could not be used successfully to get her own \r.ay.'l 'he routine methoal as described for entrresis was to be followed, and a chartwas gilen to the mother for the purpose of keeping a record rather than tointerest the child.

At the end of 2 weeks the mother returned to the clinic, stating that shehad instituted the 12-hour sleeping regime but found it impossible to carryout the measures suggested for breaking the habit of enuresis.

The situation was particularly difficult because the child cried violenily,the tenant downstairs threatened to hare the family put out, and other neigh-bors became irrittrted. l'he father told the mother that she had no brains-rvhat could she expect of the child? He said that he thought coming to theclinic was a waste of time. Under such conditions it was too much to exoectthe cooperation necessary for improvement. Jealousy and pugnacity contin-ued, and the patient, on one occasion after her last visit, had had i violenttemper tantrum on the street. The mother stated that to her knowleclge thechild had not mastnrbated since the last visit, and she was encouraged by theimprovement which follorved the routine hours of sleep.

Comment.-Ihis case illustrates one of the diffieulties of institutins trear-ment that may cause more or less temporary annoyance. not onl5 to the familybut to the neighbors. It is not to be expected that a rnother n'ill get l1D rwoor thrce t imes a night to awrken a chi ld. i f she knows thr t such a disturb-anee of the child'-s -sleep will be folloned by a violent temper tantrum and byt.hreats and insults from her husband and the neighbors.

It is hoped that the time is not far distant when faciiities will be afforcledfor taliing such ehildren out of the home and training them, temporarily atleast, under more favorable conclitions.

Isabel, aged 2 years 8 months; birth and development history nega-tive. She had ah.ays enjoyed good health ; slept well; had well-estabtisnetltoilet habits; had a poor appetite and was very flnicky about food. Her motheralways had to supervi-se her feeclitrg, and she refused to eat cereal, eggs, oroatmeal, but was very fond of meat.

The child spent much time sucking her fingers, especially n'hen moody. Shewas active and interested in outdoor actiYities. she enjoyed being with othcrchildren in spite of the fact that it was difficult for her to get along with them.only on unusual occasions did she have an opportunity to play with chilclrenother than her younger sister. When the opportunity arose to play with othr:rchildren during vacation periods in the summer months, she met every un-pleasant situation by deteloping a violent temper tantrum. She was rlomineer-ing and always wanted to be the boss. She was consideretl a fighter and wasrough and pugnacious toward smaller children. She rvhinecl constantly, andit was frequently difficult to rletermine just what she wanted. She would lieon the floor and kick and yell, and was extremely irritable and impatient.After getting the object for which she had tenacionsly fought, she would throwit away immediately. She was very destructive. Her fear of the dark developedafter the following incident. While her father was playing with her she ianinto a dark closet, and her father stood outside the door makinE a noise likea cat. She seemed to enjoy it at the time and askecl him to continue. Sincethis incident, however, she had refused to go to bed unless the door was leftopen. In spite of her apparent lack of affection, she made heavy demands uponher mother's time and wanted to be constantly by her side. She rarely showedany affection for either parent and utilized kisses only to get out of some situa-tion that was apt to be followed by punishment. She was rough with animals

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but not eruel. She was ordinarily kind anrl generous towarcl the baby in thehousehold but at times was rough and pushed and slapped her. Her motheradmitted that she did not give much time or affection to the child and said,"I am not naturally alfectionate, and my husband is more interested in thechildren." The mother was of average intelligence and appeared interesteal,but one felt that this interest was rather superficial and that one of herfundamental characteristics was to take the path of Ieast resistance. Iror ex-ample, she met the finger-sucking problem by giving the child a botile.

Comntent.-The outstanding features in the foregoing case rvere the unaf-fectionate attitude of the mother toward the child and the indifference the childshorved for the parents. The child's negativistic attitude ton'ard iife stood outvery prominently. She rvas ahvays on the opposite side. In other $'ol'ds, shebelonged to a group of children who, between the ages of 3 and 5, develop whatmay be termed "contrasuggestibility."

This condition in chiiclren usually lasts but a short time and passes withoutleaving any undesirable cffects upon the personality. On the other ]rand, theleare many indiTiduals in adult life who are chronically negativistic, who areimmediately prompted by any suggestion from an outside source to take theopposite side of the question presented. Ilany of these individuals developunusual ways. Their habits of living, of drcss, and of eating are all such &sopenly to defy custom and tradition. In children this negativistic attitude to-rvard sleep and general conduct is often di{Iicult to explain, but frequently itrepresents an effort to attract attention and to keep themselves in the lime-light ancl hear them-selves discussed. Invariably these negativistic children arepointed out by the parents as "simply impossible youngsters."

It seems wise, when this negati\-istic attitude is first recognized, to minirnizeit so far as possible, to see that the child gains nothing by such reactions butrather t t they work out to his loss. Above all, the apparent peculiarity of thechild shourd never be discussed in his plesence. This is one of the situatious inwhich the child must be led and not pushed.

This case blings out the importance of allowing chilclren to associate withothers of their orvn age. One of the most funda.mental ar.icl important instinc-tive forces is that which is commonly termed the herd instinct. Very eariy inIife the child is capable of benefiting greatly by association wth other children.He thus has an opportunity of seeing his own acts mirrored in the reactionsof those of his orvn age and is able to get a better understanding and developa more sympathetic attitude toward others by virtue of tliis uuderstalding.It is, therefore, not surprising to filld that the child who has been confined toliis o$-n household 9 or 10 months in the year, making contacts ouly wiiltthose in the family, experiences great difficulty in untlerstanding and gettingalong with others n'hen the opportunity arises. In these days, n'hen the hazartlof automobile accidents in crowded, congested districts canuot be ignored butmust be considered by erery interested parent, the nursery aud tlie nurseryschool afford the desirable oppoltunities for youngsters to get together. In theperformance of their simple tasks, in their play life, and iu the educationaltraining received, they n-il} learu much concerning the probiems of everydaylife as they are related to the group rather than to the iudividual.

Although not yet 3 years of age, this child l.as rapidly developing into a cold,calculating, unaffeetionate individual who utilized pretense of affectiotl towarclothers only to gain her own ends. This attitude. of course, oniy reflected thatof the parents toward the child, and it is not surprising that she utilized suchasocial reactions as temper tantrums and negetivism to keep from beilg oblit-erated from the family horizon.

The treatment in this case clealt primarily with the mother. She manifestedmore interest than the foregoing histofy rvould indicate that she rvas capableof; and as she was of an intelligence above the average, the situation seemetlquite hopeful. The treatnrent of such a case must continue over a pet'iod ofseveral months. Iluch can be expectecl lvhen this child enters the nurscry schoolin the fall and makes daily contaets rvith other children. lluch has alreadybeen accomplished by presenting to the mother the program to be followed,and by changing her attitude torvard the patient as mueh as possible.

AnEer is the chilclts emotional response to a situation in whichhis demands are not satisfied and he is beinE thwarted in his efiorts toattain some particular end. It is an expres;ion of resentment towardbarriers anilrestraints set up by his environment. It is evidence of

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dissatis{aetion and mav be of value in leadins to sreater efiort toattain the goal, if it dr5es not confuse and dorn"iirate"him. Anger isnot an ernolion to be eradicated bv drastic methods but one which thechild should learn to control. Any normal child or adult wilt beconfronted rvith manv situations in-life in which anv other ernotionthan anger rvoulcl be"entirely inappropriate. Indigiration is a con-troiled firm of anser and hds beeir^thd drivins forie behind many amovement that hast-benefited mankind.

The child must learn, as he develops, that uncontrolled anger isinvariably a handicap in that it results in confusion of thousht andaction, thus defeating the ends for which he is striving. RiEid dis-cipline which depends upon force and fear for its success mav pre-vent for the modent any^ expression of anger on tlie part of th"e sub-dued child. but externai influences are of"little use

^in teachins the

child contrbl of a normal and often useful emotion.It is the expression of anger resultinq from the constant conflict

bctween the cfrild and his erivironment "which

should cause concern.This is an indication that for one reason or another the emotionalneecls of the child are not finding adequate outlets and that he is notcallable of making the conrplornises rvhich are esserttial under suchcondi t ions. Such-a c l r i ld i -s unhappv, cr i t ica l , and into lerant , andhis pugnacious iendencies get him inilcr'all l<indi oI social diff ici lt ies.

T}eIe is no better wav-of teaching a child self-control than byexample. Parents rvho aie habituallfquick-tempeled, who lose con-trol oT thernselves on the slightest pr6vocation arid are always shout-inq at their childrel]. are Sbuioudlv settirrg a bad exarnpl"e. Evenif t l ie child. throuch fear. is submissive inttl 'e honre. he is l ikelv toconrpensate ' for h i i pent- i rp lesentment in l r is contaets wi t l r o therchildren, especially t^hose rihom he can dorninate through fear andbullying.

Jobn,2t/2 years old, was sent to the cliDic from the nursery school with thefollorving statement: "He has a bad temper, is ahvays fighting, strikes and slapsother children without provocation, and ahvays rvants rvhat his brother has andfights for it."

In the attempt to determine the cause of this exag€;erated pugnacity, rathercontradictory statements were encounterecl regarding the patient's older brother,Henry, aged 4. The hoDe life of the two youligsters was said to be vely

'un-

happy and chaotic. The mother and father rvere always fighting, and both weresaid to be impulsive and quick-tempered. The father hacl been arrestecl forassault and battery, and on her first visit to the clinic the mother bore evideneesof his cruelty in tbe shape of scars.

It appeared that John had airvays been "mother's boy" and his older brother,Henry, hacl been the father's favorite. It'rom the nursery school it rvas learnedthat the olcler brother was very sensitive and extremely quiet, that he was abso-lutely obedient antl more polite than other children. At times he rvas troubledwith enuresis and stammering. The mother's story, hon'ever, was quite differ-ent. She elairned tbat Henry was bossy and domineering, always wanted hisown way, lvas jealous of the youlger brother, had a riolent temper, and some-tirnes bit other children when he was angry. She further stated that he had anintense fear of her, that when she "exploded in anger" or threatened to punishhim "his legs actually shook."

When the mother's attention rvas ilrarvn to the discrepancy in the descriptionsof Henry's persoliality she said that the picture rvhich she had given the pre-vious rveek "$'as only true rvhen he rvas having ill turns" and that usually hewas extremely timi('l and nerer asserted his own rights, that John rvould "lrnockhim dos'n and rvaik aII over him and llenry never made any resistance 'what-er-er." I-Ie rvas extremely affectionate and liked to be petted aucl he was afraidof the dark, where he "saw things and people."

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In the examining room the chiltl seemed very quiet. He had a marked flushand breatlied through his mouth because of a profuse discharge of nucus fromboth nostrils. The cervical glands were enlargeti, especially on the ieft side;and the adenoids anil tonsils rvere enlarged. 'Ilie lad rvas underdeveloped andpoorly nourished. I{e rvas iurmediately refened to the medical clinic, and themother rvas retluested to return to tire habit clinic at the end of 10 days.

Careful social investigation revealed the following facts: The father andmother were "ahvays scrapping," and on several occasions the father hadbeen arrested for assault and battery. They were liviDg x'ith the maternalgranchnother because the father did not support or provide for the mother.'I'he grandmother reportctl that there were trvo distilict factions in the lrouse-hold. The younger child, pugnacious John, n'as lined up with the motheragainst tire father and timid Henry. Because of the father's work duringthe day aud his pursuit of pleasure at night he spent iittle time at home.Consequently Ilenry rvas left alone pretty much to fight his orvn battles. Tbemother hacl at all times been the protector of John, who htd learnetl fromexperience that he coukl tease ancl torment his older brother rvithout fear ofretaliation when his mother was about. Henry undoubtedly had learned thatit was the better part of ralor to submit to tormenting by his brother ratherthan to raise his mother's wrath. So clay by day the younger lad had becomemore domineering and pugnacious while the older boy had become rnore sub-dued and submissive, only occasionally turning upon his brother and bitingaDd scratching in a crucle, instinctive way at such tirnes. This was not merespeculation but was borne out by the fact that John had improred rapidly sinceerrteriug the school, x'here he had less opportunity of mauifesting his arrogant,domineering ways rvitirout punishment. IIenry, on the other hand, had re-

tained his shy and diffident manner.Comm,ent.-The t$'o important points brought out in this case are: (1)

The effect of environmerrt on the development of personality and (2) theimportance of certain types of s5'mptonls in makiug a prognosis. A question

thtt is constanily brought up is: If environment is such a treme1dous factorin the development of pcrsonaiity, why is it that two individuals coming fromthe same eniironment should be so diametrically opposite in character a1ddisposition? This case seems to bring out the fact that it is not the physical

enYironment that counts but the meutal atmosphere of the envirOnment. Herewere two boys who were born of the same father and mother and reared inthe same horne, but for rvhorn the meltal atmosphere of the home !r'as entirelydifferent. one }ived an absolutely sireltered life, basking irr the affection of anoversolicitous mother, and the other was living a life of torture, being subiectedto the torments of the youngcr brothcr and to the persistent reproaches of themother. It is not difficuit to uDdelstand why these two children should havedeveloped entirely different personalities, one characterized by a domineelingpugnaiity and the othcr by submission and a feeling of inferiority'---

fVitfr iefercnce to the second point, the prognosis is always discourngingwhen the individual,s personality defect has caused his retreat from contactwith humanity. Such a personality defect deprives the individual of the oppor-tunity to develop new interests outside himself. It takes away the necessityof his maiiing an effort at social adjustment and gives him time in whichto build, in fancy, life as he would have it. The individual who remainsactive, keeplng in contact with the herd, has erer beforo him the opportunityof learning life's lessons by experience and by the necessity of atljusting him-

self to the demancls of societY.

Katherine was a Negro girl who was brought to the clinic at the age of 2years 9 months. Birth arrd developmental history were quite normal. - she hacl

aln'ays had good health except for measles and bronchitis when she was 2years old.

Her habits regartling food had given considerable trouble' Until the be-ginning of the second )'ear she always had to be coaxed; hfld to be forced to

eat at-tim,es; was very flnicliy about carrots, spinach, and other vegetables.

X{other "persuaded" her by "shorving her the strap." She ate plentifully of

what she wanted. Iler toilet habits had been established. The patient was

very kindly disposed toward everJbody and got acquainted easily with- stran-geri, bottr

-childien and adults. She shad shown a tendency to be cruel. She

iouid punch the other children and at the clinic she would frequently knock

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tliem down When they crossed her path. She hact a very quick, violent temperzuld got angry when thwarted. She was extremely jealous of her youngersister because her father would tetl her he loved the baby better. Whenscolded or humiliatcd she put her fingers in her mouilr to keep from crying, andbefore going to slecp she always indulged in a period of thumb sucking. The

' mothcr had kept the child in the house most of the time on account of hermarked pugnacity and the difficulty that she caused with the neighborhoodchildren.

At the clinic she was extremely active and mischievous, teasing her motherby pulling at her dress and then running away, pulling dorvn the curtain, anddoing nurnerous other things for which the mother was constantly reprimand-ing her. She was openly rebellious toward any cliscipline and ctefled thenlother when any effort was made to thwart her. Instead of crying or whiningfor what she wanted, she pushed and fought lier way until she Sot it. Whenattempts were made by the mother to punish her she ran a$,ay, doclgingand ducking into the eorners and under the table, and when finally capturecland punished by the mother, she showed no resentment whatever.'After she-was completely exhausted she went to the corner, sat down, and began suckingher right thumb and twisting her curly black hair between the fingers of heileft hand, apparently perfectly happy and contented.

The psychologist stated that it was impossible to get any measurement ofthe child's intellectual equipment, as she was too active and unruly. she con-senteal to looli at one of the pictures presented to her, but her inlerest lastedonlJ' a moment. She appeared to be a bright, hyperactir.e chikl who demandedher own rvay at all times, expressed her ideas clearly in sentences, and playedwith the p€ncil and paper. She was interested in everything that was- goingon; showed marked curiosity and, when opposed, did not hesitate to scritcb.b i te . and k ick .

The patient's father was a hard-working man earning an adequate salary andenjoying good health. The mother was also in good health and had a fairintellectual etluipment, har-ing gone through the seventh grade in school.Since coming to this country from the west Indies she had eon]e to trade schooland learned dressmaking. She had worked as a housemaid and in a laundry.she was much interested in her children but was not particularly cooperatiieso far as the clinic was concerned.

Summ,arg.-We were_ dealing -with a child, not yet B years of age, havinga normal mentality and coming from a home that presented no outstinding de--fects of physical surroundings or social relationships. The most prominentcharacteristics in the men-tal life_ of the youngster \r'ere her curi-osity ancltendency to investigate,,and.a_marked hyperactivity and resflessness displayedboth at home and at the clinic. Much of ilre pugnacity which had been

-at-

tributed to the child seemed to be due to her desire for action rather thanto any desire to cause pain to others. under existing conditions the motherhad felt obliged to limit the fleld of activities to tlieir fotrr-room aparrmenr,which was quite inadequate to meet the demands of the child. rt seemed thaimuch of her mischievousness and naughtiness, so-called, could be attributed toher desire for play life and drat it was not associated \,vith any unpleasantemotional reaction. To dc{y and be rebellious was her method oi stimulatingher mother to activity. rrer motive was to be chased and to be gi''en th6opportunity of romping and running. one might well expect that ivhen theehild enters a nursery school in the fall and is given an opportunity to expressherself-- in group games and rhythmic dances accompanied uy music most ofher difficulties will be adjusted.

rt is always important to study carefully the motives for acts rather thanthe acts themselves.

DESTRUCTIVENESS

Much of the activity of the preschool child that is termed destruc-tiveness is brought, about by.the attempt to satisfy c.riosity. Thechllc\ tearns by, handtrng,.pultlng, pushilg, twisting, throwing, tak_mg.mrngs apart, and exertlng hrs own influence on his surroun-dings.lrmrtect, as rt.nray be. l)unn-g this process of investigation at a tiirelr"nen the chlld's motor coorclrnatron is not well established, it is notsurprising that he frequently miscalculates not only his'strength

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but also the value of some of the material things with which he comesin contact. The wise parent and the intellisent child soon work outsome plan which reduc^es darnage to a minimim. Needless to say, thisnlan

'must be started earlv itrd discipline must be enforced. It

inust be remembered, howei'er, that the child does not discriminatebetween what is vaiuable and rvhat is not. For that reason thechild should not be surrounded with breakable things that are ex-Densir-e to replace. but should be taught to regald ri i th ploper re-ioect the maierial ' thinss rrit lr rvhich- he conres in cortlnct. Therec'annot be one standard"for the nursery and another for the livingr.oom. If the child is taueht to be caiefui of the linoleurn on thekitchen floor he 'rvill have iespect {or the parlor lug. If he puts a'value on his heavy china mu! he will be-likely to haldie delicatechina in the sarne rvaY.

\\rhenever possible, the child should have some private place forhinrself. wlretirer jt is a room of his own or merely I cort)el ' set lsidefor his'use. This should be a place in which he crn ramble aboutr'vithout undue restrictions and *ithout fear of doing something tliatwill brinE him into conflict with the adult members of the household.'-fhe cont"inu-ous nagging.and scolding to,which matry,actire yourrg-sters are subjected-ire the cause of much emotiorral tenston on tlrepart of the ciiild and continued irritation ou the part of the parent.The constant fear that something is going to hCppen if Tom andnlary.do uot stop rvhatever they a"re do"ing,*cleltes-a bad rtnrospherein rvhich to lear a child.

Destructiveness l))ly be a n'ay of gettirrg attention, t lre result ofjea lousy, a lnethod of get t ing"revei lge, o i a nreans 'of set t l ing airruclce.' Under srrch cot-trdit iolns the

-cli i ld is rlot corrscious of the

i l rot i ie back of the conduct ; and only r f ter c t refu l s tudy of l l re c l r i ldand his environrnent, including the'pelsonalities and expenences heencounters, is it possible to be [elpfui in solving the problem.

Lydia was a very attractive little girl, 1-0 years of age, whose medical his-tory presentecl nothing worthy of note. She was in the fourth grade in schooland getting on $'ell.

She was brought to the clinic by her father, who stated that she n'as "r'i-ciously destructive" and "willfully stubborn." He gave the follorving detailsconcerning recent happenings.

All during the winter she had persisted in going down into the cellar andturning on tlre cold rvater, permitting it to run into the steam boiler. Ifor thisshe was severely scolded, threatened, and spauked, aud flnally her bare handswere piaced in the hot furuace so that they n'ere badly blistered and hadto be bandaged for ser.eral days. tr'ifteen minutes after the removal of tliebaudages the act for which she had been punished was repeated.

X'our days previous to visiting the clinic she scratched the piano rvith a pin.This episode was followed the next day by the mutilation of the top of thedining-room table with the cover of a tin can. For these two offenses thefather scratched her arm and the palm of her right haud n-ith a pin, leavingugly-Iooking wounds which were much in eviclence when the child was seenat the clinic.

Recently her father had missed several phonograph records and upon beingappealed to the patient admitted taking them to school but alial not retunlthem, although her father requested her to do so. She said she had giventhe records to her teacher, but the father went to the school and sarv both theteacher and the principal and found that the child hatl lied. She admittedthis later. She was severely switched about the legs on the way bome fromschool, but she maintained a sullen silence until the next day, when she toidthe housekeeper that she had put the records down through the cracks in theveranda. A carpenter was called and several boards were removed, but no

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records were found. A few days later, of her own aeeord, she producetl therecords, which had been hidden a\\'ay in her room,

She wrote on the wallpaper, hammered the walls, and destroyed furniture.She was the oldest of five children whose mother had diecl 3 years before

the ciinic visit, Her father stated, "I have had 20 housekeepers since then."The one in charge then was 63 years old; she was kindly and affectionatetoward the patient, and the chilal was fond of her. The father was a stern,reserved, quick-tempered man who was trying hard to keep his family to-gether, and in spite of his apparent brutality he wanted to do what was right.

At school the patient was considered bright, well-behaved, and tmthful. Athome she was untruthful, disobedient, destructive, selfish, jealous of materialthings, unaffectionate, stubborn, and resentful. EIer father said, ,,She is $,illinsto undergo any pain to aggravate me,"

At the clinic Lydia appeared to be a happy, cheerful litfle girl, who franklyadmitted her jealousy of her younger sister. She gleefully told about schooi-day experiences but suddenly became sad and tearful at the mention of hermother. She had apparently assumed the responsibility for ,,all the rest of thchids," as she called them. She was interested in her schoolmates. She wantedpretty clothes and liked her teachers, the househeeper, and her father. Sheshowed no resentment at the severe punishment she had receiTed and offereclno excuses or explanations for her misconduct. She seemed to be vcry friendlyand approachable. One felt that a sympathetic relationship had been estab-lished which would do much to get things going right.

The father was given to understand that punishment rvas useless, a factthat he had appreciated for some time. He was asked to get oD a morecompanionable basis with the children, and one Saturday he demonstrated hisgood intentions by bringing three of the children to the clinic en route to thernovies. The father's report at this second visit was encouraging. Lyclia hadbeen "getting along flne" for a week, none of the destructive-tendencies beinein evidence' She had seemed happier and more cheerful, had talked mor6freely, and had been much overjoyed at the prospect of going to the movies.

After the picture show the child returned home. Er-erything seemed to beprogressing n.ell when sudd_enly, for no apparent reason, she gatherecl llll sev-eral phonograph recorcls and destroyed them. There seemed to be no part-icularemotion attached to this ep_iso-de, it being apparenily the result of an impulsiveidea. - She- *'as not punished on this oceasion, and everything went alongsmoothly for 48 hours, her father being still hopeful that anothe-r weeh miehtpass rvithout further manifestation of her destructive tendencies. one eYenfnghe brought horne a new pair of white shoes for her, a present for rvhich shehad shon'n a strong desire for some tirne. She was happy over the gift, butwithin an hour after her father's return she cut the upholsterl' ori one ofthe best chairs in the lir-ing room wiilr a pair of scissor-s. This information'ryas reported to the clinic by the father over the telephone. He admitted thathe had reached the limit of hitq patience and said that some plarr must bemade to tahe the chiid from the home.- Arrangements were made rvith a child-study home in Boston to take this childfor an indefinite period; but although the father had demanded that such aplan be made, he Iet the matter drop at that point.

Nothing else was heard about the case until 6 rveeks later, s'hen the Societyfor the Prevention of cruelty to children was notified that the neighbors hadbeen much disturbed the prerious night by screams coming from tfre home ofthe patilnt. upon investigation ilrev found that the fathei had been whippingone_of th-e yorlnger boys severely. They threatened to break in, anrl the fatheiexplained that the boy had been damagirg the furniture in much the sameway as Lydia had done. The father admitted that he had a violent l"rop""and sometimes lost control of it. rt was generally agreed by those interestedthat the children ought to be placed out, but the'father would not consent.

rrorveyer, a pla-n, was -agreed upon and carried out whereby ilre- -children

would be sent to Maine for the summer monilrs. such a plan was, of course.only temporary.

comment.-This chilcl was not under the personal observation of the authorlong enough to enable ni- t9 formnlate any definite ideas of the underlyingcause of the child's destructiveness. There n'ere, horveler, several peitinentIact-ols in the history that gave an inkting of the line of treatment tfrat mustbe followed. The first and most important was the child's devotion io hermother, her inability to assimilate into her own life the situation caused by the

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mother's death, and her bitterness and resentment on being cleprivetl of her

mother.*i"o-'a'r"p"rncial examination of the facts presented it was found that all the

destructive tendencies of this patient were directed toward the house in which

rf." iio"a and the furniture in- it. At school, when visiting, or under any cir-CumstanceS or Conditions not fountl in her OWn home, she never marrifested anyof these destructive tendencies. It seemed that it was the association withh". o*o home that brought out all her vicious tenclencies. one also foundt.onitn" trl.torv that for.'*ar.y yeats prior to the death of the mother the sole

interest of both parents hacl b-een to save eDough money to builtl-a house that

would be more oi less of a show place in their community, a small .nattractive,iiiug"-i- the suburbs of Boston. Both parents haal workeal without daily

"e""e?6utr or vacations and noA even gone wlthout the necessities of life, until

;h;a;i;th o] the mother, in order that another rlollar might be qut_away. rt;;;;tilt-rft"" Ur" O"attr of the mother, however, that the father fi_nally^erectediil" g16,"000 house, which stood as a moDument to his arnbition and thrift. But

;;;.h"; one couid only feel that to the patient, consciously or perhaps uncon-

*"io".f', it was but a memorial to the toil and sacrifice of the mother for

io-11o* *iJfroO always shown a very strong attachment. This may be considered*"r"iy -p.""iaiive, tonsidering th6 little opportunity the writer_ had to observe

inis-po"t^i."rur case, but it was not unreasonable to expect to find an explana-

tion -for

these apparently voluntary vicious_ acts of destructiveness in some

i".ir_.""t.d ;entai conflict nith which the child was blindly struggling.

l\{artin, aged 4 years 8 months; birth trld development normal. Ile was

";;;;;-, fris motfrir for 3 months. From that time on Ire presented a- difficult

ffi;t"c;-bi"*.- fVfreo his nother's milk gare out, he refused to take the_ bottle-uiJnu-a^u gr"at deal of ngtritional disturbance during, hi"s flrst 2 years. Te had

bu"r, a resiless sleeper until recently, but lately he hacl been going to becl at

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t". a"A sleeping well until morning. Occasionally he had terrifying dreams'

O,i.riii 1i:iit.n" f,e- fiaA typicat nighr !er1ors. There were ver5' apt to follow

iome "Oefinite incident, suih as being frightened as he had recenUy been by one

oi-Jiro nei'hfors, tvho told him of the bogeyman. He ate well. There was no

history of enuresis or masturbation.'"T*;; ca;;;I- neatin ot tne patient had no-t been particutarly satisfactory.

Besides having severe nutrition-al tlisturbance during the first 2,vears of his life,

h e h a d h a d s e r e r a l c o n Y u l s i o n s ' t h e f i r s t o c c u r r i n g a t t h e . t h i r t e e l t h m o n t hu"A oifr"ts at intervals of about 6 months. The last one, which hatl occurred

*ir1" -n"

was at the hospital, was reported as being definitely epileptoid in

character and Iasted 30 minutes."''ff* "p-"tl"trt iounct it clifficult to get along with other chiltlren. He was

"nOoiv'p"g"ocio".; he got into r-n-any fights.and was constantl)' teasing those

*ilL *ir'".i he car11" in clntact. He ieemetl to enjoy playing -rvith animals' but

"*-*1v u"o"o bi using various methods of tormenting them. Ho- r,ras_extremely

;f;;6;".;- His mothei stated that when he was totd to ato a thing he alwavs

ail"iriiftrr"-"ppoiit". stte feit that she cou]d not trust him a minute. rf she

*a.."i" tne beitioom while he was in the kitchen he would turn on the water

i;;; o" -tti"

gus. 11e had knocked the parlor Iamp off the table, antl had

.[i*" o[fr". d6str'ctive tenclencies. If taken into a store he wo.ld pick up

;ttr;;";;;""oiJtrtu"t, p"t]r.anss-ra.bging u"-1P!1" andbiting into it' Recentlv'

nhile at a rest camp, n'e ctimuea into an automobile and started it. on two

;;;;; ;d.i"* tre tiao started automobiles on the street. x'or these reasons

;;; ;.ti". lived in fear of what was going to haDDen next'When rebuked tie retatiatea-frv

".i"E obs'cene and profane language. ,Recently,

'"h;;'1ii;-sfiday_schoot teacirei, thirlking he was too young to read, dirl not

iii:""ni'ii i..S"iriav-ictrool papei, he -stamped his feet, kicked her,-and. callecl

i". " "".iv "u-"'

mis fritit frad been growing sleldi,Iy wors-e fo-r the last

ib* ;&thi. Efforts at home to discip-line the, child had been fruitless' The

iijirr.1".iii.o,-"rr"is iust one of them-kids that is just smartv' It's lis dispo-

sition to be that way, and he can't hetp !L" slre further commentecl that in

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he usually said lhings with a twinkle in his eve' and

everybody liked him."'ii; -ilfi al*ays been extremely active anal destructive; lost no opoortunity

to s"t i;ib a ngirt; .""rrr"d iacking in any appreciation of the rights of others;

;ii; ';;i"; -u-"v'of

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appropriated what he desired. At the nursery school he was considered adifficult child to te[cl], seemed uutrble to follow directions, and had no senseof rhythm or order. He dicl very poor work and would not obey-was con-sidered a general nuisance. Of late he had been calling his teacher bad nameswhenever she asked him to do anything.

The family occupied a four-room apartment situated on a busy thorough-fare. Tlie house was well furnished and homelike, well ventilated and neailykept. Family relationships 'were unusually pleasant. Both the father andthe mother were much interested in the children and were easer to cooDeratein any n'ay possible. The riiscipline had bcen left very largely to the mlother,who looked upon the patient's behavior as something inevitable and thoughtthat it was too much to expect r.esults from the clinic.

sunt'ntur11.-The patient. uetrrly 5 years of age, had beerr having colvulsionsat rather infrequent intervals for 4 years. rt was eviclent from his seneralreactions to the problems of everyday life and his behavior in school that hewas not endorved rvifir a normal intellectual equipment or that if he had suchan endorvmerrt at birth, its development had been retardetl by the convulsions.rn spite of the fact that the home situatioD was at least averase and theparents ryere cooperatiye. it was perhaps useless to hope that satisfactoryresults would be obtained so long as treatment rvas carried on in the home,where the mother rvas irrclined to talie the stnncl that "rvhat is to be will be."There was ever)- reason to believe that this chilcl would be much beneiited byinstitutional_life during the developmental period. for not only was the young-ster's mental deYelopment somewhat retarded but the whole situation was com-plicated bI- the convulsive phenomena and the emotional instability. under theseconditions a very special environment, such as can be obtairied only in ihe bestinstitutions, rvas needed so that the limited abilities of the chitd could bedeveloped to their fullest extent.

DELINQI 'ENCY

The self-r 'egarding sellt iment of most irrdividrrals is to a very larseextent ' lePen^derrt upgn lhe opiniorr thrrr o{ lrer'people have of their.It is o'lr- :rfter cn indiviclual has achie.i,ecl su-ccesi and esttrblishedhimsel{ f irmly in scie.ce. business. or a-profession that he has suffi-cient co^fidence in his own achier-ementi to ignnr.e the opinions ofo lhers 1o any marked degree.

,. Dnring the early vears of a child,s life. when imitation and sugges-tron play.a^leading pa't. i t is particularly irnportant that he shriurdnot rbsorb fronr those about him ideas in-regai'd to his own ,-tualit ieswhich might react d isadvantageorrs lv on h is 'corrct r rc l . T l re c l r l ld whois corr t inual ly led to bel ieve that h i i word c iunr( ) t be depended uponor that lre has no regard for otlrer.-people,s prol)er.ty and other peo-ple's rrghts. is quite apt-to accept this_srrggestion i ls representing-thetnrtlr ancl to rnake no effort to a'oid doirif u'hat he {eels is expectedof hirrr. On the c,ther hand, srrggestiorrs tl in{ he lras eertain cariabil i-ties and that a certain moral standard is expectgd of him niay domuch to stimulate his efrorts in the direction of a line of coriduct'which will furnish in itself the satisfaction to assure its continuance.It is too much to expect that the child who is being rearecl in an en-v i ronment u-here tnr th-and honesrv r .e l re ld L ig l r th ' * . i l l r levelop ofhis owtr accold standurds acceptalrle to societ] '.

' No'orre expresses irnv

particular amazement over the f:rct that a" child br.ouurit rur in aGerman familv learus to speak Germa' or that the Frencli childlearns to,speak French, but'we. sometime fail 6 app;".iui"Jttu ru".that conduct as n'ell as speech is to a ver.v large eitent an imitativephenomenon.

. , o ' l? mothe. brorre l r t l re 'ch i ld to the c l i r ic . s tat i r rg qui te f ranklythat the cluld. aged 3)'eals, rrsed the sirnre swear words lhat her huj-

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60 HABIT CLINIOS X'OR CHILD GTTIDANCE

band used and that he manifested the same arrosant. defiant atti-tude toward her that he saw in his father. There is nothins obscurobetween cause and effect in this particular case. Anothei womanbrought in her youngster, quite perturbed because the child hadbought candy with a nickel whicli had been given her for carfareto visit the denlist. Only a week before, however, this same motherhad told the child that she was soinE on an automobile ride and thenhad taken her to the dentist. One finds that a child is quite capableat a ve^ry early age of differentiating fact from fancy and that oneof the first imporian_t needs in the deriel.opment of hon"esty and integ-{ty is conduct on the part of those with whom the child comes Indailv contact which he can safelv imitate.

Hbn'ever, the problem is not 6y any means one of suggestion andiTitation entire$, and frequently o""y complicated sit'uitions arisewhich do not peiririt such a simpie int-erpretition. A little sirl wassent to the cllnic bv the court- because'of stealing. Inves"tigationshowed that the molive in this particular

"us* *us-irrtense iellousy

of her chum, whose family could a{ford to give her mani of thilittle niceties which young- sirls crave but rv[ich the patient couldnot have. This feeling oT iealousy had persisted ovei a period ofyears, and it was not until she was qivei charge of the eioakroomat sch-ool. a _privilege_assigned to her bicause of h"er apparent honesty,that the jealbus-y made itself manifest in stealins.

Delinquent beliavior-that is. the type of actfvitv which is eventu-allv going to bring the child inio confli'ct with socielv-should receivethe same ionsiderition and thorough investigatirrn ai any other symp-tom of maladjustment. The onlfapproach"to the r:ro6lem tha[ w'illbear fruitful iesults is interpretaiiori bt the child,s ,iifficultv in termsof his past experience, lris present -environmental situatiori, the per-sonalities surrounding him, and his own intellectual. physical, indemotional make-up.

All children wfio steal cannot be treated in the same wav. Thechild who goes into the department store and steals somethinq whichhe desires although he has in his pocket a sufficient suonlv of monevto attain ths thing desired in a sicially accepred rtav^ii [uite a dif-ferent problem frorn the child who steils money to bir caridv for clis-tribution _among his contemporaries in the hirpe thit he .ivill thusbe allowed to participate in their activities.

Stealing in young-children often has its origin in what Dr. Healvterms "grudge formationt'u and in sex conflicti. Such cases call fo"rmost careful, intensive st!4y, frequently over long periods of time.Jh3l retuire patience and liindness ou ihe part oi the parents, andbefore .they- are satisfactorily adjusted they may tax the skili andrngenultY or the sDecralrst._.fnS pioblem.of'lving-also Tust-be regarded from various angles.Th_e lying associated with stealing is invariably of a protective natureand is quite different in its psvchological jrnplications from theproblem of the child who lies in-an effort*to bolster up his self-esteern.

Truancy may result from varied motives. some cloielv tied up rviththe personality make-up of the child and'others entir"elv clepfndentupon environmental situations. It is not a sufficient der:iatio'n from

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rlormal conduct to be considered too serious in itself. ft is onlv whenruancy represents an effort to escape from an undesirable eiviron-ment that it should cause concern, and then the environment ratherthan the symptom requires treatment. It is the spirit of "wander-lusttt in m6st'vounEsters that prompts them to inv'estiqate whateveris strange and newl To most' voungsters this means fiothing morethan investigating a new alleyi making friends around the iorner,or going to"the piark; rvith tlie more ienturesome it leads at timedto t]r9 motion-picture shows or wherever there seems to be anythingexciting going on. Unfortunatelv most of these earlv truarits ar"epunished"after the first ofiense, dnd the punishment in no wav in-hibits their desire for future adventure'or satisfies the curibsitystimulated by their fir'st experience. It is only when the moment toreturn home is at hand that thev reeall the last exnerience. Thisvery often prompts them to remain away from home on account offear. One youngster with the habit of remaiaing out at nieht withthe ot_her boys, who would leave him one by one.*said he wai alwaysafraid to reiurn home "to face the musicl" His mother said th,'athe had been beaten very hard but that it did no good. Beatings donot solve these problems.

The discovery of the child's motive-that is, what he hopes toaccomplish bv his misconduct--is a prerequisite for anv inteilisentplan o-f treatment. The importance o] thii is brought orit in the-fol-lowing cases:

Nora, aged 10i birth and developmental history quite normal. She was thethird of five ehildren. She was brought to the clinic by her mother becauseshe told "siuy lies" without any reason, stayed out at night without perrnission,and stole small amounts of money, The chilcl had had measles and n'hoopingcough, but none of the other children's diseases; had no history of injuriesor operations; slept and ate well, occasionally talking in her sleep but not soas to be understood. She wet the bed at infrequent intervals. The mothersaid that the child was selfish and always wanted her own way. She was notaffectionate and showed no attachment for her father or mother. She wasextremely jealous of her younger sister, wanted everything the sister had,and resented the mother's showing any attention to the sister. She was con-stantly quarreling with other members of the family, and was ,,irritable andsnappish." The mother stated that she did the puriishing with a strap, as thefather seldom disciplined tlie child. The patient was apparenfly afraid of herfather but not of her mother. The mother said that the chilcl got along well iuschool and got good marks, but subsequent investigation did not bear thls out.

The following comments on the other ehildren in this family rvere of inter-est: George, aged 15, was said to be disagreeable, troublesome, and a trialto his mother. When 8, he was arrested for breaking into the girls' highschool with two other boys and destroying microscope lenses. He was put onprobation, and his conduct since had been unsatisfaetory. X'our years iater'he was again arrested for breaking into ancl entering a grocery stole. but the icase was dismissed. Ile r-as always Tany at school, which he left at the aseof 14, having repeatedly played truant. After leaving school he workecl as anrurrand boy for 6 weeks at a stationery store and made $? a week. He waslooking for work at the time of the clinie visit antl spent most of his tirne onthe street. E[e was scornful and defiant towartl his father, and refused ro goto church. Joseph, aged 10, -was still attending school. fte had always be6n,well behaved until 2 years before, and after that he had become irritabl'e when'crossed. He was arrested with two other boys for taking a doctor's kit froman automobile and was put on probation. The two younger children pre_sented nothing abnormal in their physieal or mental make-up worthy of n-ote.They had no conduct disorders.

At the clinic the patient appeared to be quiet and subdued. she was ratherwell dereloped and well nourished and was fairly attractire. She manifestedlittie interest in her surroundings. lYhen questioned regarding her delin.

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I{ABI'I CLINICS ITOR CHILD GI- IDAN(]E

(lltcllcies she answcfed qriickll' but iippalently without frauliless. .iudgirrg frolrtlte data plcviou-sl5. obtaiued. Shc accouuted for the tirut' sperrt lrr-ay fronrhome as l)oing spout rvith her gill friencls and \vitl) the other childrerr on tlit,street. She saitl she nerer asked permissiou to go out because her mothcl ulways refused it. \\'hen she $'as out. slie snid, she was afraicl to go home.She appreciated thtr seriousuess of her preserlt situation and her attitude towardher clilficulties seemcd quitc rrorrrrzrl. She adrnitted quite frankly that she didnot like irouservork, but said she rvas rvillirrg to do it since she must. She waslookiug forrvard to learning cooliing in school the uext year'. She adnittedtakirig mottey that she fouDd about the lrouse. statiDg tlrrt tlle irrnounts l'rrie(lfrom 10 to 45 cents and that she ahvays denied having takelr the money be-causc she rvished to avoid the puriishrneDt that :rhva.ls follcrwed. She saitl sircenjoyed most liciug on the street or \\'ith her friends and lilied to be:tir-a5frorn horne. Shc rcad little ard did not care for the movies.

l'he follorving briefly summilrizes the home situation. The mother airpe:tletlto be a hald-rvorking lr/oman 'who bore the marks of hel toil and hardships. Shehad nevel had good healtli and was obyiously discouraged over the (liscordamong the mcmllers of the family anrl the poorness of the tenenent il stichtltey had to live. She had always had considerable worry and anxiety or.er thethree older children. Her husband kept her constantly upset becarse of hismar l ied i r r i tabi l i ty :u id f i ts of teuiper, u 'h ich disturbed the f r rmi l l -most r l f thetime. He rvrs appilrently disgusted \yith the lack of success they iiad had inraising the family, rntl there \yere many scenes bet\\'een liim and the oldestbol, 'I 'he husband's reactions *'ere aln'a}'s u'orse rrhen lle hlrd lreen tirinking.The patient seemed to be his favorite child aud had considerable influence overhinr rvher hc $'as having one of his "spells." l'he rnotlrer tried to adjust t{ithis chaotic situatiorr, but the alcolloiisul of her husband and the constanttlurrreling of the children made h(il'\ 'er'J- unhappl . l ' l le home situation rvirsquite intolerable. The fanil;' ocr:ulried a fi\'e-room flat in a poor neighborhoodon ir noisy, cro$'ded stfeet. 'Ihe tenement \yas damp and cold, and in spiteof thc mother's efforts to impro'r'e it it was not attractive.

lluliDg thc first clinic Yisit little was accomplished except to get the llistorJ'and an inten'ierv $'itli the child. The mother \yas requested to returrr to tltenerit clinic. but it w'as several rveeks before she al)peared again. The report\\'as very discouraging. The child coutinued to disregard her parents' wishes,pa.ring no rttention whateyer to her mother. She als'ays avoidecl telling hermother u'here she 'wa-q going and rvhere she had been, even if her conduct harlbeen such as to justify praise. Her school work'was not satisfrctory, and itwas expected that she 'would have to repeat her grade or else take summer-school work.

On the second visit sufficient time \\,as taken to discuss the problelr in sornedetail with both the mother and the child. It appeared that thc mother's re-strictions on the girl had been rather severe. Het an:ietl' o\'er the prtient'srvhereabouts and her distrust of her ability to take care of herself made thernother feel that the oniy safe place for her n'as in the house. The family budgetwas -such that the mother felt unable to gir-e the -voungster an)' allowance arldshe invariably refused her s'hen she asked for uoney. The mother was frrnkin admitting that on occrtsions her irritability torvard the other mernbers of thehousehold rvas spent on Nora, and that she rarely, if ever, hatl an5. time todevote to her except for mlltters of discipline. AD effort was made to presentto Nora some of the difiiculties of the mother's position and the importance ofher assuming certain lesponsibilities in helping out in the householcl nnd causingthe nlother' fls iittle anxiety as po,csible. It ,sas agreed bet$'een thern that thepatient should have an allo\\'ance of 10 cents a \\'ee.k and that she lvould ask hel'mother's permission before she rvenl out to visit other girls or to play in thestreet.

The mother did not return until about a month later, not$'ithstanding the factthat she had been urged to make \1'eekly visits to the clinic. She srrid that tliepatient rvas doing better, and that she \\'as rlot running away as she forurerl5.had. but that sh€ 'was still very ur,reliable :rbout keepilg her promises, irritablewitli the otlrer children, doing poorlS' in school, anrl of little assistance in thehousehold. The mother said it s'as difficult for her to get to the tiinic morethan once a month because her household duties marle heavy demands uporrher time. l'he rvhole situirtion \\-as gone over lrgrin in detail, anrl an effort tvasmade to have both the motlter and the patient make some concessions.

The follorving month the mother returned to the clinic. Although she 'was

very reluctant about admitting an improvement, she said that Nora "did not

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HABIT CLINICS ITOR CHILD GUIDANCA 63run awa}' nny more, and she did not tell silly lies" so often. she reported thatNora rvzrs still very quarrelsome and hard to get along with. Hei sctroot rvorkwas poor ilnd her deportment mark lorv. At this visil, the patient got a litilefriendly and confidential for the first time. She said that al^thoueh she dicl notIil<e her teacher and hated ths thought of going to school durinf ilre sumrrer,' she was ver)'rnrious to stay in the sixth grade so that she cooiil be \yith herbrother. The child rva-s apparenily in a very urrhappy frame of mind, resent.ingauthority and feeling that she was not having the opportunity that other childr€,nhad. Her attitude seemed to be that she had to takt whate.l'-er she got out of lifein spite of what othcrs thought. The mother seemecl to feel absoluTeiy hopeless.she had lost hel conrage to go on, rvas unable to s€e aD-ything bright irr thefuture of the patient, and clid not hesitate to tet the patient kuorv hlorv dlscouyagecland unhappy she \\,as about the ouilr,rok.

1'he patient did not leturn to the clinic for several noDths, aDd then shecame alone. She stated that she was getting along well in school, that thingsu'ere improving at honle, rrnd that she $'as getting more confidence in hernrother. But the mother's.repo1t, as gathered bv the social rvorkei, was thatof a harsh, pessimistic critic rvho saw nothing but the unfavorable iide of thesituation. she had just recei\.ed a school report which indicated Nora's ab-solute failure. rrer deportment, writing, and geograph)- rvere poor, ancl theniother laid great stress on these failures. Nora said, by way of^apoiogy, thathesides these poor marks slie hacl recei'ed four marks inoicaiing eiceptionauygood rvork-a fact that the moiller adnrittecl. when the pati;nt $,as aslie(lin her mother's presence if-she_rvas helping in tle househoto, the mother spoi<eup, sa]'ing, "Believe me, she rlon't do much. She lies anci steals monet. rrlon't dare talie lier in anyone's house for fear she might take somethiing.;;The mother still refused to give the chilcl money for ao5i purpose, in spite'ofthe- promise she had made at the clinic. The p:trtient saio irrai she never hada chance to go to the movies. that she got cand.v fron other children but neverhad any of her orvn-"only u'h2t I take. The girls I play rvith sometimes havecandl' and sometimes giTe it to ne." she thought

-thtt a litile girl of her.

age should have 10 or 15 cents a week.Th. child rvas given :r rong talr< on the value of honesty. praying the game

fair, and helping hel' mother. The rnother rvas intervierved- ai le;gth aboutthe absolute necessity of charrging her attiturle towarcl the chitd. The im-portance of making the child believe that something was expecterl of her wascalled to tire mother's atten,tion. rt was pointed out that nothing could heaccomplished if she persisted in impressing the chiltl with her deiinqueneies,especiallj' if this \vas done in front of othe| people. The fact that she haatunsuccessfully follor.ved her own meflrotls rvith the olcler children was pointedout to her with extreme frankness, and an effort rvas rnade to shorv h6r thatnothing eould be lost if she followed the plan ouilined by the clinic.

Notr'ithstanding the fact that the situation seemed eitremely hopeless ifthe child $'as to remain in that environment, it seemed worth iyhile to con_tinue the efforts in this ease. Something about the patient-her honesty andfrankness at the clinic as conpa.ed rvith her reported actions at home andher insight nnd appreciation of the irnportance of or.ercoming her delinquen-cies-gar'e encouragement in spite of the rvretched environrntntal condilionsin which she ryas living and the poor eooperation of the mother.

The latest reports from the school had been eneouraging. The patient lvasin the seveuth grade, got aiong much better than the year be'fore, got amark of "one" in effort and "t$'o" in conduct, and had not been sent to theoffice for tlis<,iplinar}' rea.sons during the entire year. The patient was frankand free in he-r tallis with the doctor and had lost mnch of the stubbornnesswhich characterized her first visit to the clinic. Her mother had put heion an allo\vance of 10 cents a \eel< and h:rcl leceDtly gir.en her B0 cents to goto a festival. There n'as no trouhle at home ahout tal{ing money, and thepatient seemed to be _making a fairly good adjustment. sie had'passed allher examinations in school anil 'was looking for a sunrner job instead-of havingto make up school rvork.

Altiough this improvement had been in evidence for a period of only BTonths and might not continue without oceasional relapses, the case \ras par-ticularlv intere-sting as an indication of what coultl be. done in spite_ ofwretched enrironmeltal conditions and lack of cooperation. Besid-es therather infrequent visits to the clinic cluring which the problem had been dis-eussed with both pare.nts and patient, suecessful effortir had heen made to get

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64 I{ABII' CLINICS F'OR CHILD GUIDANCFJ

the girl interested in a girls' club and in taking books from the library, bothof which activities gave her much-needed interests other than stleet life.

Olive, aged 6 years 4 months, third of four ehildren-the other childrenbeing 8 years, 7 years, and 11 months old, respeetively; birth and developmentnormal except that talking was delayed until she was 26 months of age andthat she had always lisped. Exeept for an orthopedic operation on account ofa shoulder deformity, the child had always enjoyed good health. Prior to thisoperation she was very restless at night and frequently walked in her sleep.but since the operation her sleep had been restful and quiet. She hatl a goodappetite and was not finicky. She was said to be domineering and quarrel-some and preferred to be alone, although she was not shy. She was ertremelyaffectionate and sensitive and was inclined to be Jealous when she saw othersbeing petted. She got along well at home-at least her mother said the childwas easy to manage. She enjoyed her play life and spent much time by her-self. Her mother deniecl that the chiltl had any propensity for stealing (inspite of a history to that effect obtained from outside sources) but admittedhaving lost money which she hatl left about the house. She said she coultlnot slrspect the children as she had always trusted them. The child was in thefirst grade. In spite of her history and the poor impression she made duringthe first contact because of her unattractive manner and unkempt appearance.she gxaded normal on the psychometric test.

The parents v'ere separated, but the father oecasionally came to the houseto see the children. The mother seemed quite devoted to the children, andalthough the Iiving quarters rvere poor-they consisted of a four-room apart-ment on the third floor of an extremely clilapidatecl building-and the homewas untidy and cluttered, she attempted to do more than give them purelycustodial care. She made an effort to amuse them, occasionally taking themto the motion pictures and for walks.

Olive was referred to the elinic by a settlement worker because of her per-sistent stealing and the eonditions under which the thefts were carried out.n'rom the settlement she had taken two hats and an umbrella. She was fre'quentll found going through the childrel's elothes, rifling their pockets. Sheadmitted these thefts only under eonditions in which it was apparent thatshe must be caught. Elven when called to aecount for having stolen an artiele'she rrould make attempts to take things from the person reprimanding her'It tlitl not matter whether the articles were of particular value or whether theywoulal naturally interest a child of her age. From the school she had takenbeads. a rubber ball, a teacher's key, fruit, and numerous other articles'

'When

confronteal by one in authority with the eharge of thieving' she invariablydenied the thefts but always eonfessed later. There seemed to be no outstand-ing problems except the stealing antl lying.'fire

trome situation was one of filth and immorality. The father had aPnarently sDent much of his time with other women prior to leaving home. Heitaimed that the mother was irresponsible in the eare of the children and thehousehold, that she used vile language, that she never had the meals ready,and that the house was always dirty. She, on the other hand' accused him ofhaving a violent temper, saying that he frequently went into a rage and thatthere

"was nothing too mean or vile for him to say. It appeared from the history

that both of them had associations of the lowest type.- Obviousty little or nothing could be expected by the clinie in the way of co-

oneration Ly the parents. The only hope of helping the child lay in those*th trhom ihe came in contact outside the home. The assistance of her teaeherwas solicited, and her cooperation did much toward any improvement that wasmade. The teacher stated that the patient was a dear little girl; she seemed tobe much attached to her. The chiltl got along well with the other ehildren inschool. but it was very difficult to make her concentrate. she tlitt not seemto have any interest in school, was poor in all her subjects, and probably wouldnot be promotecl. At school her speeeh defect was a great handicap. she wasconsidered very ehildish for her age.

At the clinic she entered the examining room in :l shy and difficlent mannefbut ttid not appear frightenecl or resentful. At ffrst she merely smiled at theeiaminer's queitions. Soon. however. she beeame more responsive and, witha marketl deiect in her speech, began to repeat letters and numbers for the doetor.

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She volunteered a little information about her home life-the faet that shehad two brothers, that her father took her to the movies, and that she went tothe beach and to school. On the first visit she was very reticent about dis-cussing delinquencies, and the subject was soon changed to a more pleasantone. She said she liked to play ball and skip ropre but did not like dolls becausethey break; she liked the dances at the movies and said she could dance; shetold of seeing Charlie Chaplin, told the doctor \'!'hat she had had for differentmeals during the last 24 hours, named a number of common objects in theroom, and gradually became more interested in her surroundings.

A week later the patient returned to the clinic. She was much more friendlybut still a little shy. She made an effort to carry on a few speech exercises,imitating the doctor. When asked with rvhom she playcd she said, "No one."When asked why, she said, "Nobody likes me." Then she discussed the subjectmore spontaneously, saying that she didn't see why they didn't like her-noone liked her except her father and mother and the baby. Girls didn't likeher; they knocked her down. She insisted that she was the only one the otherchildren did not like. She said she didn't like anybody but her family. Thereseemed to be real'emotion attached to the idea thal nobody likecl her. Shetried to hold back the tears, but it was difficult. She talked more franklyabout her thefts and tried to justify herself by the fact that she did notlike those from whom she took things.

At this time she was given a long talk, in which she took considerable interest,about how she might make people like her, about playing fair and square,and about how she would feel if other people took her things. She was toldthat a careful record was to be kept of the days on which she did not takethings and that she was to bring the recorcl to the doctor the follorving week.The teacher was seen, and arrangements were made to keep a cbart on whicha star would indicate each day that the patient's conduct had been satisfac-tory. This was carefully explained to the patient. She started ofr in a happierframe of mind than she had thus far exhibited.

Just a week later the following report was received from the school: ,,Olivehas been getting on much better during the last week. It was not until yes-terday morning that she was found peeping into the school desks in a ra[hersuspicious way. There is no record of her baving taken anything that ctittnot belong to her at school all week." At the clinic, however. she found twopennies in the toilet, which she returned with some reluctance. She seemedquite happy while at the clinic and said she enjoyed making the visits.

The following week the report was excellent. The patient was much pleasedat the interest the teacher had taken in her and was apparently making apersistent effort to get the coveted stars to bring to the elinic. At the setfle-ment house which she visited frequently, however, she was found several timesin the act of taking things that dicl not belong to her. IIer reaction on beingquestioned about taking these things seemed one of remorse-she eried andseomod very much upset.

There was something very inaccessible about this child. She chattered awayancl answered questions very readily, but it was difficult to get close to heiinnermost life. The last report received from the school was eicellent. ,,Olivehas not taken anything for a long time." She came into the clinic cheerful.happy, and eleanly dressed. She hatl genuine pride in the faet that she hadsuch a good report, and again it was felt that in spite of wretched environmentalconditions much had been aceomplished toward helping this chilcl to overcometwo very asocial reactions and to get mueh more happiness out of life.

Paul. a lad 13 years of age, was brought to the clinic by his stepmother, anunusually bright, intellectual woman, extremely fond of and interested in herstepson. For the last 5 years he had been developing certain delinquenciesthat had caused the farnily much concern. He began by taking money fromthe family and doing such things as mailing letters without putting onpostage and short-changing when sent on errands. He would tell lies to setout of difficult situations. He would not, however, persist in the lies but woulttconfess what he had done and then break down and cry.

About 3 weeks before coming to the clinic his stepmother lost $b. Aboutthe same time the patient came home and said that he had got a job ln astore. fle gaye the name of the store, the man he worked for, and the streets

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66 IIABIT OLINICS F'OR CHILD GUIDANL]]'

where he had to delir.er goods. He elabornted to the extent of telling whatthe storekeeper and the customer said to hirn. He said that he $-irs treatedwell and rvas gi\'en crackers at the store. At the end of the week he broughthome $5 and turned it oYer to his mother. Investigation revealetl the fact thatthe lad was not employed and that the money was the same that he haclstolen. Immediately after ttris episode, he made further attempts to take rnoney;that is, he was found searching in plilces whete money was usually kept.

This lad was in the eighth grade irnd was getting on well in school' Thepsychometric test showed that he had normal llental eqnipment. trIe hadnever n'orked. The father $'as generous to the children; he gave them adime on Saturday with which to buy cand.v. Paul rvas interested in playingfootball and baseball and in skating and sledding, and got along weII withother boys. He said everyone was kind to him. I{e admitted that he criealcasily but knew no reason for doing so. He appeared to be an unusuallycheerful, active boy n'ho, in the examining room, was frank and honest. Hemade no effort to attribute his deiirrquencies to others' He said he selclom wentto movies and never n'ent with a gang.

A study of this case showed that the motive was the d'esire of the boy toemulate his father and play the part of a grown-up in heiping to provide forLhe family. It was n'hat I{irkpatrick has called "passive enjoyment ratherthan active effort," bnt the rnotile was obviously not a malicious one, andiltelligent cooperation on the part of the parents made it quite easy to straightenout this lad's point of vierv. The social-service department of the clinic n'asvery active in this case. The lad's interests were broadened, and arrangementswere made for him to spend the coning summer on a farm. The last notesstated that he had been completely freed from his former delinquencies, thathe had been getting on well il school, and that the family had been relieved ofthe worry and anxiety that were naturally associatetl with liis former difficulties.

Quentin, aged 11 years, was brought to the clinic of t e psychopathic hospitalby his mother upon the recommendation of the principal of his sclool. IIewas under the jurisdiction of the court for entering a hotel by one of tho sidewindows and taking $10 from a desk. He denied the theft when discoveredhitling in a closet, but finally gave the nlone-y up_when th_e _policeman arrived.Ee had stolen many car tickets from the family. There had been a long historyof delinquencies.

The patient was a keen, bright lad, with normal intellectual equipment. Ifediscussed his trouble frankly and was anxious to overcome his "bad habits."EIe was kind, affectionate, generous, made friends easily, was interested in allsorts of games and sports, mixed rpell with other children, ancl never heldgrudges. He lacked interest in his studies and up to the time of coming tothe ctinic had never responded to discipline. He had been scolded, deprivedof privileges, and whipped, without results' He had no fear of policemen norof going to court.

Cnrousn the social-service department of the clinic this lad joined a boys'club, and supervision was carried on from the out-patient cligic. Results wereextremely gratifying, and the last report of the lad was, "Getting on well."

It is of interest to note that although the parents attributed the lad's delin-quencies to an accident which happened about 2 years before, the boy's state-ment was, "My mother says I do these things because I hurt my head and getcrazy, but it is because I want sleds and things. My brother useal to do allthese things. Now he is big and he gets me to do them." Frequently parentstry to attribute the delinquencies of their children to some sickness or accident,and sometimes the children themselves are prone to accept the suggestion asan excuse for doing those things which they enjoy.

Gordon, the older of two children, was referretl by his mother to the clinicat the age of 4 ]'ears and 9 months for disobedience, masturbation, and quarrel-ing. I{e was also deseribed as stubborn and very destructive.

Birth was br Cesarean section. Developmental history was normal exceptthat the patient had been given a bottle until he was 2 years of age, havingrefused to drink rnilk from a cup. At 4 years he had had whooping cough,

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TIABIT CLINICS X'OR CHILD GUIDANCE 67followed by influenza, pneumonia, and an abscessetl ear. He had been circum-cised. Tonsils and adenoids were removed wlien he was 2 years of age. FIiseating habits were always a problem. He refused to eat unless feal, tofd astory, or offered a reward. He had enuresis until he was 4. Occasionally hebit liis nails. He had masturbatetl since infancy, apparenily without realizingit. _ The patient presented the picture of an undisciplined child, very stubbornand negativistic. He r,vas prone to show off, and was very destluctive of furni-ture ancl toys. rre would throw objects about without any consideration ofthe possibility of injuring another child.

The horne situation was physically good, bD,t was undesirable from the pointof vien' of nieeting the patient's personality needs. Maternal relatives in thehome domiDated the situation, and the mother's attachment and dependence onthem shorved her orvn emotional immaturity. The psychological 6xaminationrevealed the patienr to be of normal intelligence. The case was carried in theclinic,for 7 months, but service was interrupted by the mother's inability toattend becanse of illness. l'he mother lost interest and the case was closedwhile the boy was still uuimproved. The psychiatrist considered the mother'sown adjustrnent verJ' poor. IIe observetl that she seemed unable to profit byadvice regarding a better technique for handling the patient's problems.

Two years later the mother referred the patient to the clinic. The same prob-lem appeared as before, with the additional problems of lying and stealing.The previous problerns were all intensified. Gordon had no itlea of obedience-and presented marrl' tJ'pes of habit difficulties. He was extremely jealous ofhis younger sister; he had begun to have nocturnal enuresis; he had developedthe habit of bitiug his finger and toe naiis; and he chex'ed his pajamas, blousecollars, and so forth. He took money whereler he could get it and useal it forthe purchase of guns. His mother threrv arvay the guns, because of her fearthat the patient would grow up like rrAbe" trt-, a man rvho had been involveclin a bank-robbery case and who was weII known to the patient's family.

Gordon was very inattentiye and a daydreamer; in fact his rnother had attimes feared he rvas deaf. His lack of concentration made his teacher in thesecond grtrde consider him the "worst child in the class." His first-gradeteacher, having had a rnuch smaller class, had had no difficulty s'ith him.l{uch of his behavior was thought to be a demand for attention.

A new psychological exarnination gaye the patient a ratirg of good, averageiutelligence. A hearing test showed a loss of hearing in both ears, but thiswas not considered sufficient to account for his lack of resoonse.

rlorne conditions had been somervhat irnproved. as rela-tiyes no longer livedwith the family; but the mother was stiti very dependent on the ielatives.She also rebuffed the patient and fa'rorecl his sister. she had not x-anted aboy. The father $'orlied long hour.s, saw the children seldom, and thoughtthat the problern was the mother.

The problem of stealing r'as treated by arranging for an allowance to theboy from the-parents to take the place of former gifts from the grandfather.A-ttempts to give the mother a more ob.iectire point of view and a knor.vledgeof mental-hygiene principles rvere not very successful because of her ownemotional immaturity. In spite of this, howe\.er. the patient's behavior showedsome improvement. Arralgernents rvere made for "tttitrde therapy', for themother. rt n'as also recommended that the father attempt to give^ihe patientmore of his time.

^ Mildred was 6 years and 8 months of age when first seen at the habit clinie.She had been referred by a school teachel bccause of lying, stealing, ti.uancy,and sweiring. She also had temner tantrums.

Mildrecl rvas born of :rn illegiiimate urrio'. and nothi'g $,as known of herparents. she had beeu adopted shortly aftcr birth b.v Irish parents of a lowintellectual, economic, and social ler.el. At the time of the clinic visit theadoptiYe nother was over 60 years old and the father abo[t .1.1. The reasoD forthe adoption was the mother's desire to compensate for her inability to havechildren of her own, since she N'as past the child-bearing age at ttri lime ofher marriage. Resirles the patient aird the adoptive pare"nts,"a naier"at auntwas in the home.

^.The pa-tient's early development was normal and she was in good health.she had had no diseases, operations, or accidents. she had gootl e"ating habits

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68 HAtsI'] OLINICS F'OR C}IILD GL-IDA\CE

but was a restless sleeper. she hatt the habit of hicting in _beii such stolenarticles as scissors. naiis, and pencils. She had been mastruiiiting since shewas 2 years old.

This'child lied about everything. she hacl stolen eandy from the fir'_e-.a_nd-ten-ce"t .ioi", anc1 she freque'tiy took tnings from about the house and hid them.She had siarted to sweir at;bout the time that she n'as referred to the clinic.

EIer temper tantrums dated back to the age of 1?--Pont\s' .'Ihey rvereresorted to- when she coulcl not haYe her own way. When hnYing such atantrum, she would scream, kick, pick up anything handy, and threaten hermother with it.

she usually played with younger children, and whenever she become angrywith them siri froritO hit the;n with tne first weapon she could find. On severaloccasions she had hit a neighbor's child on the head with a hammer.

She was hyperactive, stubborn, witlful, and quite unaffectionate' She com-pletely OominiteO her pareuts, who no longer made any effort to disciplileher.

It seemed unlikely that the patient would improve in this enYironment, asshe had complete control of the situation and her parents were _too il.effectualand ignorant to profit much from attempts at leeducation. Mildred was ac-cordingly placed for observation in the study home of a child-placiDg- agencywith the possibility of long-time placement in d foster home. The clinic, how-ever, was- unable io convince the parents of the advisability of such a place-ment, atrd the patient retumed home.

IntensiYe therapy was then carried on by the social-service department. n'orseveral weeks tlie patient showed improved behavior and the mother ap-peared to make an earnest elfort to help carry out the clinic's recommenda-tions. lfhe maternal aunt refused to cooperate, however, and the home situa-tion became worse when tbe patient realizeC that she was the cause of frictionbetween her mother and her aunt. The case was closed after 7 months, as itseemed useless for the clinic to try further treatment until the home situationshould be improved by the aunt's departure from the household or by a changein her attitude.

Truancv. which is a common problem among urban children, maybe motival6d either bv the desire to escape from an unhappy situationor bv curiositv abou[ the unknown and longing for something new..ts #ith mucli undesirable behavior, however, once a pattern is es-tablished it seems to become self-perpetuating; and although theoriginal motive.may be forgotten, the habit has become so strong thatno new motrve rs necessary.

Sam was a colored boy, 6 years and 10 months of age when first seen at theclinic. There was nothing unusual in his birth or developmental history.

The patient went to bed, when he was at home, at about I o'clock and sleptuntil 8. Often he did not come home until after midnight. IIe sometimeshad nocturnal enuresis. His appetite was excellent and he woulcl eat anything.He was quarrelsome, hyperactive, and stubborn. EIe could not be trustedand he tried to be very independent. IIe ran away whenever he had a chanceand often did not come back until late at night. EIis family picked him upin nolice stations and on the streets. According to hls mother he hacl "busi-nesi ability." He sold newspapers, ran errands, and shined shoes. IIe eithergave the mone)' to his mother or bought fooal with it. The qatient was euriousand lilced to look at books, but he had a reading disability' IIe was veryimaginative and invented stories. Once he made up a story from the illustra-tions in a book he was supposedly reading aloud.

This patient had an intelligenee quotient of 99.The fhmily occupied a six-room apartment on the first floor of a tenement

house. Tlie-apartment had a bathroom and three bedrooms. l'he furnishingswere adequate. Sam slept in a room with two brothers, sharing a bect withone of them.

The problem as presented by the father and mother was that of truancyand clifrcult behavior. Sam had been a truant off and on ever sinee he hadleft kindergarten. He would wander away with the other neighborhood chil-dren. The family moved away from the neighborhood and the first Sunclayin their new home Sam wandered back to the old district. He rnight go asfar as 5 miles in his wanderings, sometimes riding on the back of a streetcar.

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A week before his flrst visit to the clinie he had left home about 2 n. m. andbad been founcl by the police at 3 a. m. after an &hour search. He pictied upa dim,e to a dollar a day from his various activities, such as dancing, singing,or getting ptrpers and selling them. He would often bring home rolls n'hichire had bought. At other times he would bring home money, IIe was in andout of restaurants, eating until he no longer had an appetite for meals at home.Sometimes larger children took his money from him.

The patient, when interviewed about his truancy, stated, "I sell papers; Iwork in a barn; I mind the horses and keep people from taking them away;I n'ork in a show-pick up papers so I can get in for nothing. Sometimes Iciean automobiles; for a doUar I do the wheels and the windows and cleanthe seats and everything."

It was suggested that the patient be placed out in the country in order torfetermine the importance of environment in his conduct. EIe was placecl in asuburb by a child-placing agency and he got along very well. His problemshave been minimized and there is no evidence of truancy at present.

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69

RETREAT AS A METHOD OF MEETING FAILURE

Unlike children rvho develop a resentful, rebellious attiturle towardrestraint are those who respolnd bv retreat. These children do notbattle in an endeavor to breik don:n the barriers but are inclined toretreat in the face of obstacles, to become submissive rather thaurebellious. The mental charact6ristic known as plasticity seems toplay an unduly important part in their tnake-up., Thel' ofier noiesistance to factori in the environment which plny trpon them'These children as a rule are timid, shy, and cautious. They findlittle satisfaction in the acti'i'ities of their more venturesome com-panions. Thus. u'hile one child is t ltr i l led by the experience of play-ins truant from home or school. arrother finds his satis{rrction inthE overprotective atmosphere provided bv an oversolicitous mother.One lad^finds l ife crorvded rvith so man-v irrtelestirrg :rnd excitirrgepisodes that he snends but l i t t le t ime th i i rk ing what- i t is a l l ubot t t .'fb arrother child iife is dull. barren. and boreiome. IIe runs awtrr.from it. and. onlv in hisdavdhamins does he get etrouslt satisfactioirto iustifv his existence. These childrerr are"self-cenlered. crit ical,jeaious; ihev have limited interests and few friencls. They get butiittle satistiction from the ordinary, everyday acti'r'ities of life.Thev turn t l re i r headl ig l r ts i r r upon themselves rather than out upor lthe u'orld. They are i-nclined fo be extlemely dependettt on one 'rtwo people but- are quite withdrarvu from- the rvorld at large'Many of these children in early life are looked upon as being- re-sour6eful, capable of entertaining thernselves and- providing Theirown amuiem6nts. This in itself ls of value if it is not just part ofthe activity of an asocial child.

These cliildren invariably sulfer from a sense of inferioritv. Theydo not eniov anv feelins of security about l i fe. and in compalingthemselves ivithbther cfi i ldrel thev are vasuelv cottscious oI theiown inadequacies so that they seek tb avoid c"omfetition rvhen failureseems inevitable. 'Ihe importance of preventing the child from de-veloll irrg what is commonly krtorvn as an inferiority complex is ap-pareirt io all who are conCerned about his happiness and effieierrcS'.The child is so deperrdent upon the opinions of others, t 'speciallvthose from whom he seeks a-pplobatioi, that adults carinof be toocareful about helping hirn to

^build up' his self-esteem. A father

who tlrouglrtlessl.y'tr i6s to stimtrlate his-boy to greater ellort by con-stant tcirsing may be quile l lnD\r'are that t l l is humiliates the child anddoes someth'ing io his-pride that rvill not easily be eradicated.

\\rhen the stundards set for the child. *'hether in conduct or inscliool rvork, are so high that failure is the rule rather than the excep-t ior r . the chi ld is los i r rg t l re ot te great mot ivat ing force t<- ' fur t l rercffolt-success. Childreu rvho arelnfavorably compared .n'it lr othersin the home or neighborhood develop a serrse of inferiority very ensilr ' .especia l ly rvhen the cotn l rat ' ison is unfa i r because of t l re i l i r rhelerr tdeiiciencies in mental equipment or physical strength. Hrrbits likeenuresis ancl masturbation, when mana,ged unrviselv by thc parents,

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difierent. leadinliabilities instea

of,course, mental and-physical handicaps necessarilv inrrrose cer-tarn trmrtatlols upo_n a child, but even when these are b"esdnt euervcrorr snourcr be mnde to see that the child has an oppofturritv to de1velop.to the. fullest extent of his capacity. fru .t,i ldlfr"lr "orlr.io,r,of doing this rvill not feel inferiorl

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^,Yj::,j i,:,lhjl{.no matter what the reason,_ develops this feelingil,l:j::,""11* .T-1li-,lhioss,p*.y happen. As has beeir shown, somecllllQl'err botster up therr_self-esteem by aggressive measures such assfearlng, tluanc)-.. an_d clefianee toward arrthoritv. others assumel:..1::lj"tr;q .at15,rrde of atrvays being righ_t *tiite e"er1:nody-;l;;ls \rrolrg. rtllt i l le.group we are concerried with at the m,mentsuccumb to urerr'leelrngs and take the,passive course n.hir:ir appearsto them to be easier.

" shyness is a_mod6

"f 6"t

""i"" tt ui'.."o". u. uretreat for individrrals of all a_ges, but the emoiion;i -;;;";;;;e lead-ing to this behavio_r, is often o5scu"". I" th""i;li;i"nt'io.o'rr-,"""..

was associated with.stammering and both "onaiii;;.-;;;;,1

;;ril-a definite causal relation to ai unhappy h;m;-;il"#;";" whichthe child had been unabre to make "^Jr"tirr,r"t""v'ra;*iirr"Yrt.

, Adele, a Negro girl, 4 years and 9 months old, was referred to the clinicbecause of shyness.Birth and develonment were normal. she -haa_ had chickenpox, 'reilsles,wh.ognins co.gh, mirmps, and sore trrrrcats.-"ger habii* ;;;;-;i*:iri"r..

. Adeie wa.s a shv, quiet, unassertive child *no aia-"oi-;pp";; to'fie'ilt""esteoin her environment. She askg_4 fen, questions, neing'co-n'tt"t- tli "ii

t u"r. uoOrratch .wha.t- I'as going"^on.,,WI"l speaking, ler voice ,ou.

".u""niy-above arvhisper.. Although quite able to ruki care-of h;";;; *"irtJ,,ri"'"*as neververy acti'e or noisy and spoke o'ry rvhen neeessary. uet s-nyn"". ilao beenapparent at so early an.age rhrrr her.mother thought ir-mris- i ' t r-Ji*"ueen in_herited. At times the clircl stt'rmmered co"iioe.arrry] ;";;"di;; to"iie'motrre.,although the schoor and ilre criuie san'no indication. oi,-tii.l

"ii tio,l"r_garten the pati_ent did go-od work, but she talked litile;"0

"&".'*aoi'u,t.,,urr"",to the other childre' of her o'r'' accord. asiau r.om r.t"d;;gil; -she

hadritile -or no- corrtacts, for the rnotire,r treated her as a ,,hothouse florver,, arrdconsidered her too delicatc to plal- 'utdoor,s e-rcept in 'er.y pleasa't weather.whcn tested at the cli,ic the'chikl showed no"mnt -iit"iiis"".,;;

her in_telligeuce quotient was -10i. . As usual, sfre was shy and frasf,tif."" '

There was considerabre frictiou at home. The faurer was cr'er and abusiveto his wife and was interested in othe.vo-er,. rr" par.i^"o'titll_ntion tothe children. The mother had no sociat outiets.. There rvere, moreover, re-risious differences betwee'- the .larents. -{ii- this re;ilte;i-il liuir-"v rritt""quarrels in the presence of the children.- carefur st'dy of this case showed that after oue of the pirrents, quarrels thechild's stam'reri'g increased no_ticeably arrd h"" *ittdi;;;i' b"ililo _uruapparent. The mother wa-s urged to alow the child to p-r#'o"tjo"oiJiitf.,oottoo mr'ch snpe.r'ision from herself and to encourqge the child's sociar conracts.Arrangements were macle to have tne motrrer-ana"trr"

"nrii"i;-;t";Al .nrop.The harm of overprotection and flre res'lis--of, -u"itur aiii";ii;;; ls trreyrelated to the chilt|s nrobrem were disc'ssea. p1n *"th""-ili;A^iJ""Jopn"ot"with the crinic as far as she couto, ana tn" .uila a"r"i"lfi'*;;i#"ilrr,t*rr.".

rn the follo'i'i'g case shyness 'rvas associated with general timidity.Paurine was referred to^the clinic at the age of b years and g months beca'seof her extrcme shl'ness. she was atso aescrfLed' as oversensitive and timirl zrntrgiven to cryirrg easi ly.This child's bi.th had- bee_n diffcult (breech pres.entation) but her develop-ment was normal. she hacl be-en i' good health until rer iourif, v.u. uiro tn"r,within 1 vear she haa measres, wiooping cough, and too"toio"iiir.

*sn"

""-covered from all these infeetions. sne iryor[ arcn duppoits 6";;;;;;i ait teet,

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72 IIABIT CT]INICS FOR CHII,D GUIDANCE

but suffered from no other defects. Her eati[g, sleeping. and toilet habits$'ere rlormal.

IIer mother described her as being very shy and as haviug a tendency to beunduly anxious and worried or.er minor nratters. when she was with otherpeople she was likely to hang her head and seem embarrassed, especially inlarge groups and in school.

fhese traits were demonstrated at the clinic. In the cliuic playroom the chitdstayed close to her mother and was very reluctant to ioin the other children.Stre was overconscientious about the order of the toys, chairs, alld otherequipment in the room.-T[e

parents 'were intelligent and the home atmosphere was harmonious inspite of flnancial strain. There were two other children, who seemed entilelyn^ormal. A sister of the patient had died during the preceding winter anclthis experience had a serious effect on her. she was sensitive to her mother'sgrief over this loss and would try to comfort her. At the same time she wasdpparently having reactions of her own to this experience as well as to thefrimily flnancial difficulties. IIer mother observed that she seemed to be"walking in a trance."

In the psychological examination this child proved to be of good intelligeuce'having an intelligence quotient of 113.

In t*he absence of either physical or mental handicap, treatment was directedtoward increased socialization of the child and a change in the family methodsof discipline. The mother cooperated well with the clinic. She not onlyallowed the chilct to play more freely with other children, but she restrainedherself in the use of peremptory commands and in her constant emphasis oncleanliness and manners. In the more reiaxed atmosphere the child soon lostsome of her tenseness and no longer found it necessary to hidle behind a wallof shyness.

The death of some member of the family is often the source ofbehavior difficultv in a child-not that death in ilself is a cause ofbehavior problems but that members of the family are often unwisein their eiplanation of it or in the display of their own emotions andattitudes.

The following case is interesting in its presentation of an unusuallyeornDlex metho? used bv a 4-ve*ar-old child to esc&pe the mentalansiish associf,ted with ihe de-ath of his grandmothel. It also in-,lic.-ates that even at this early age the chilil meets his problem quite,lifferently in relation to different individuals. The symptoms intlris case were such as to calrse real anxiety, for the child's regressionfrom reality into a world of fantasy_seemed complete at times.Ilowever, responses of this typ_e to difrcult life situations are notnarticulailv rincommon in children. Although every efrort shouldLe made t6 so orsanize the child's mental outlook on life that hem&y become more objective and deal more efficiently with reality, theimplications of such symptoms during the preschool years are quitedifierent and of less siqnificance in relation to actual mental diseasethan rvould be the caseln a preadolescent child.

A mother brought a lad of 4 years to the clinic because of persistent mas-turbation and stubbornness. An analysis of the case revealed a complicatedsituation. The family history disciosed tuberculosis on both sides of thefamily. The general background was poor and unstable. The maternal rela-tives arrd the patient's immediate family were dependent upon public aid.

The home atmosphere was far from serene. The fatlrer was in poor healthand took only a passive part in family life. The mother rvas erratic audir)consistent in her discipline and showed definite favoritism toward the boy'syounger sister and an antagonistic attitude towarcl the boy. The home wassharccl by an arrnt and arr uncle, the latter adding to the difficulties by callingthe boy a "sissy" arld constantly teasing him in this way.

Further study of the case showed that the boy had been much attaciledto his gra.udmother, rvith whom he had spent much time. At the time of herdeath lie had stayed with the family upstairs and had cried bitterly for her,

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E[:\BIT CI,INICS F'OR CHILD GUIDANCE 73saying, "!ry grandma! gone." rre was told by his mother that grandma hadgone to New York. Two months later, however. he told hit;o;h;; that hisgrandmother was dead, lhat she "went down a big t ote.;' g"

"o"ti"""o to talkincessantly of his grandmother. wnenever Le iaa u p"""ir

-n"- *oirro writeletters to her, often sayitrg llut ne neara lis 'igrandma ciili"s nim';;-ana wnenpunished, he would say, 'il'u go to. grandmu.,'- u" called foi ner iri iis sreep.rris mother at times found.h-im gazi{g;i his grandmother's picture and holdingimaginar-v con'ersations witrr hJr. rinen nisinother interrriptea nim ie wourabe very angry with her, saying he hatett rr"". te]lirrg her to get out and stayout, and efen trying to sfr ike her.

The mother craimed _that his attitude had changecl eompletely sinee thegrandmother'-q death. ,whereas,_formerly, she had hacr no faurt to find wlthhim, he now cried for the least litile tniig, iraa become Uofa, anO iJs unUnAanrl disagreeable to her.

_-I.1T_^tlf -lccount given by the mother one felt that the child presented cer-rarn sy-mptoms quite malignant from a mental point of ii"w a"a-1uai he wasin need of careful sturly and supervision.------'The boy was normal .physicitty tuC nao many personarity defects in hismake-'p. rre n-as verv ibatous oi tri. tittiJ Jirtei arra ;"_]fi.h' *i;h ;;r, prob_ably because his mother openly favoreo n"r.- FIe held ; bfit;;;-;";agonistiefeeling toward his mother and-said thai hJhated her. She interpreted e\,erl-thils -h." did as being "fresh and rora; ano eipressed herself as too disgustedwith him ever to bothe_r- to praise him. His .ncte's teasing made him feelinferior. and hc rcsented beine called ,.sissy-., ne p.eterret^t? O-rrO'*ian aorr*and games about the house. and i t was "not

surprising to f ind that he hcda.lYlys beex kept close.to hi^s family a;d;; not ailowed to play with otherehildren. rre n'as afrairl of the rlaii ;"d ;"t"d "ou;

i; ttre iiis'#.idi piseonswere biting him. EIis mother admitted ttrai stre rrao ac iireJ?rig"hinr,"o ni-in order to make him ob_ey. tle wet tris "lofrr"s

ana iao ;;;p";i;."";;*..rn the treatment of this case there we."-set'e.ar factors to be dea* with.The most important wa,s lhe mother, ;ho-ir;d;o be reed'eated in her attitudeto\yard the rratient and in lrer methods of aisciptine. c;;"ad;"'-haa to bemade to rearize his responsibilitie. u"a trr" iiiila rr^a to be ed'cated to meethis problems in a more satisfaetory ;;;;.-"The treatment consisted -ot lreiluenf-ii.it. to,the elinie and long tarkswith the doctor. The, mother's ziilif,ia"

^ *us ehanged: masturbation wasstopped bv means of diversion and the substitution ?-'"tii""

"iiii"ilsts: tnechild was desensitized.to the oart< trrro'gir-eoucation-arrd^-irr"oiish-iri* roo"of approbntion; enuresis was stopped bi-ft instit'tion of routine measures:the boy rvas allowed to. play outhon"J"*iln other children; and he was nolonger tea-sed or calred "sissy." with6 a-tew-monttrs tne euiti mad" o p""_fectly satisfactory adj'stment to his n"me-a"o to his play aetivities. subse_q'ent investigation showed that he continued-io *urie o-",i"isl;.t;iiost*eot

com'nxent'-The foreeoiTF case is not particularry differe't from other easescited, except for the reaetion of the patieni^ii trr" death of his grancrmother.with his plavmates he met the situ^ation i""u rgiir.r'-ilriiiri.i"iij'"i'"y. Eren'ould talk abo't making trips _with them to N.; T;;-il t.i-.""" irl, i.'irrlo*^otrrer.npparenfly refusing to think_of her as being gone in the sense that she wourdnc\.er return, and undoubtedly tesgsning tn'e"sting bid;a.ii;;'^irr"''.iitoutiona-q a child might be exneeted to do. wilh his -"Trr"i"n"-rfr;""";il ficea theq'estion openlv and frankry, and tris ";i;;;;*;

toward her indieates ilrat hefelt her to be responsibre in. some_ *-"v to"ii" srandrnother,s death. rre statedthat the grandmother wa.s "in a hole"in ilrelriuno.,, rrri""-*u"."ir"is c^dneeptionof death. the child ha.\'ing none of tne, coficeptions of the hereafter whichthose of his age usuallv enlertain ana rvrricrr-iriip tlemlo'taco^.iiir^ r"o".o*rorsitnations during their earty years. Wh;;^;i;;e, howe'er. he rvithdrew morecompletely from the rearities s.rrouncling tne siiuation, ano ca""ieo orr]ingina"yconversatio's. rf the-se .symptoms had 6een presenteo rn a ctriici-iti^o"'i's y"o"*clder, thev wo,Id rrave app-eared to ue ratner fennite_psyctrotic symptoms, trut inchildren it is extre'rerv oifficult to separate til"-p;;d;;ir-;;",i"yir""J"ilJ'l"o ""_

filled n'ishes from symittoms that hav6 grave" sigrrificance.There is no cause for ^alarm if children have plavmates of an

iT1flj"u",v chnmeter cr if rhev t'"ri'."i,*ilii;;,.';iii-,'iir'Jir aortor other tols. l{ot irrfi,eqrrently their "*n

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TIABI'I' (]LINIL]S F:OR CHILD GUIDANCE

Dorar ih 'so that thev are det l i r rg appn|etr t l . ) 'n- i th t r ro or t l t t 'ee d is t inctindiviclu,rls nt the srrme time. askiltg irrrrl ansrvering questions, prais-ins one rnd punislring the other. It is these morCimaginrtive chil-.hEn rvho ro"i. up the"clreamers of later l i fe, some-of thFm achievingsuccess becruse of these drennts, other fall ing by the waysidc. unableto coDe rvith their nlore mflterit l istic brothers.

Tlieie is cause for cottcern enl',r 'rvhetr these definite retreats areusecl bv l lre chilt l to rneet some defirrite pr.-,blem rrhich iras madeunusu"i denrarr.. ls rrporr his po\vers o-[ adjustnrent. Here it indicates_,perhaps. u l\ 'pe of reactioir l-hich lntei in l i fe may be developedand utilizecl [o th. disadvantage of himself and all others concerned.

Isolated fezrrs are often foirnd to be due to threats thoughtlesslymade b;' pulents or other pegple who are concerned ryri-\ thlploblemof brealiirg sorne ttntlesir-rlble habit acquired by a child. This maybe seen in the case of GladS's.

Gladys was 3 yetrrs antl 1 rnonth old when she was first brought to theclinic by her mother becatlse of fears'

Birth was 3 weelis premature but normal. Her development was normalarid her health historJ, e\cept for pneumonia in infancy and several severecolds, was good. Sho rras still n'etting the bed at light and was receiving con-siclerable atterrtioD dtring mealtime aud bedtime. She slept well except afteran attack of felt, during which she would stand up in bed and cry for hermother. She often had "muscular spasnts," which came during the night' wak-ing her out of her sleep. At such titues she would scream violently, clutchaiher mother convulsirely, artd becorne limp after a few minutes. The phy-

sician who examined her repot'ted that these were not convulsions.Being the only girl and considerably yourrger than her two brothers, Gladys

was always the recipicnt of much atteDtion from the fnmily. Shc was, more-over, a much-rvanted child. her pareuts having iolgerl to have a girl for sometime preceding her birth. An atmospherc lvas built up in whic! "everybodyulwal* shushed for Glad)'s." She trecame self-confldent, happy, friendly, andirffectiotrate, rvith no fear of people.

Her clrief fear seetned to be of the r,'ind. As a srnrll child slte hatl beenin the habit of gettilrg up in bed during the ltight ttud her mother had triedto stop this by thteatelling that the wirld wonld blow over her and she woukl

set sick if she tlid uot stay under the coYers. She began to think of the 'wind

as a terrifying monster leaniug over her, and she would become especiallyfrishtened when she heard the autumn wind blowing through the trees. Thun-derstorms rvere terrifying to her. She was very much afraid of the vacuumcleanerr anrl aiwaJ's stayed on a chtrir when her mother used it.

During one of her "muscular spasms" the patient began looking arountl in herbedr.oom as if fearing some horrible specter. she gave her parents the impres-

sion that her acute ferrr was due to the imagined approach of some dreadfulmorrs'.er rvhom she referred to as "pain.", This child had at one time had the habit of pulling her hair out and chewing

it to such an extent that she actually had bald spots on her head. To break

her of this habit, a friend of her mother told her that "some awful thing"

rvould come and grab hel hand arvay from her head. Although at that time

she stopped pulling her hair, she began to have a contintrous fear of this

monster,

Arrother group of cases in whiclr fear pla;'s a very important partdtrr. ins the"earl-y part of the indivirlrral 's l i fe and is often carriedinto l ite adolesierrce and sometimes lreler completely eradiealed. in-cludes those cases in which some form of sex activity has played auart. Frequently sex problems are created in this rvay by the par-bntr . Orre ' l i t t le 'g i r l who $-as bat t l ing the problern of mastr r rbat ionhaonerred to l ive"near one of the State hospitals for {he insane, andit fuis f irmly impressed upon her that if she continrred the Sahit slewould evenfuall! end t]reie. She was taken around the institution

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lr] order that the threat might be more firmly imprinted upon hermind. The child rvas told that evervbodv rvould soon knolv whatshe was doing-that they could tell by h".. e*pr..sion ancl by thervay she acted. Other children are threatened with operations underthe same conditions. It is not unusual to fincl parentj mutilatine thefirrgers of ; 'orurg 5Jii id1e1, eit lrer by burning^them or by pric"kirrgthern, because , r f th is l rabi t .

It is liardly necessary to say holv acutely sensitized the young, im-mature mind becomes to the habit of sex lr.hen such drastic measuresare taken by interested but injudicious ltarents. Many of the inade-quacies of ic tu l t personal i t ies"u ldoubtedlv had thei r "or ic in in feel -ings o{ inferiori iy that rvere stimulateh during childTrood. Ap-parently er'erything is done to make these children feel that they aredifierent, and it is not surprising that they become shy, timid, andself-centerecl. Findinq themselries in association rvitli'others whoare qui te i r r to lerable to them, they seek sol i t r rde ard bt r i ld r rp infantasy a dleam rvorld in rvhi6h th"ey can lesicle unmolested.

The situation of the chil,C who fleei fr,om realitv and finils consola-tion for his feelings of inferiority in a world'of fantasy is welli l lust rated by t l re fo l lowing case:

Harry had Dot quite reached 10 years of age when he I'as tirst seen at theclinic. He n'as described by his grandmother as being a lonesome, friendlesschild. Slie stated that her eirrliest recollection of the boy rvas that of hearinghim teII her abont an imaginary ''friend boy" and that up to the time of hiscoming to the clinic his chief companions were yarious insects and imaginarychildren. He did rlot gct on weII with other children in school and rvas regartledas queer. He rvas very fond of old people and very sympathetic $-ith them,being "very much upset," for example, over seeing an old lady cryitrg in church.IIe rvas verl' respon-sive to music, singing church litanies to himself and im-provis ing sorrgs about fa i l ies.

In spite of the fact that this lad had a good intellectual equipment, rvith anintelligence quotient of 121, his adjustment to school had been rather poor.

The boy was very restless during his sleep, talking as if he werd fighti.rg'with someone, shouting, and tossing about, and occasionally laughing. IIisge'rreral health was good. He lived with his paternal grandparents, who hadadopted him and his sister at the time of the death of their parents. Thehome, although small (a three-room apartment) was comfortable but obviouslylacking in space for play. The problem presented was mainly one of with-drawal, daydreaming, and running away from life as it actually exists. Theboy had an unusually acute imagination, was very keen in his observations,and could occupy himself with his fantasies for hours at a time. He wouldcarry on imaginary conversations with a grasshopper, philosoplrize over thedifferent cloud formations and what they might mean, and discuss with hirnselfthe observations that he had made upon the different l<inds of trees and otherliving things. He appeared to be on intimate terms with fairies and hesymbolized them by taking a couple of match sticks wrapped il silver paperand describing them as the fairy king and queen to whom he would sine.According to his grarrdmother these imaginary figures became so real to hirnthat he would leave them with great reluctance, saying he $'as afraid to eoaway lest they be unhappy. He also had imaginary children as piaym;rtes.

During his ps)-chological exaniuation at the clinic he talked to himself agreat deal, seemed to be thinking aloucl, often about things that were irreleyantto the examination, His manner to the examiner was, however. responsiveand f r iendly.

After helping his grandparents to build up a rnore objective sort of existencefor this child by getting him promoted to the fourth grade where he belongeda.nd. by helping him make contacts with children in a "play group', who rveremore eongenial thnn those of his immediate neighborhood, the clinic Jvas ableto close the ease at the end of 11. months with the report that the child wasmaking a satlsfactory adjustment.

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PROBLEMS ASSOCIATED WITH THE DEVELOPMENTOF THE CHILD'S SEX LIFE

Parents who at some time have received help from the clinic inthe handling of a specific problem often come^to regJar.d the clinicas an educational center to which they _may turn for Jilvice and sug-gestions.on various.subjects. connect-ed -with child training. Th6-mry rvish guidance in choosing toys and play equipment oi sugges-tions for children's books, or- advice regaidiirg i child,s speecE?e-velopment, or help in considering a silmmer"calrp. No'less fre-Q.ug-n_!ly, how-ever.,. they want help-in handling some aspect of theirchild's sex education.

The question how reproduction occurs is one that every child withaverag_e.curiosity will ask sooner or later unless some experience hasmade him. lrldlly self--conscious and prematurely reticent. By thetime a child is four, he has probably as'ked about ihe oriein of babiesmany times. The answer given by the parents depend"s largely ontheir own sex adjustme't and their:attitude torvard the subiecT. "Thecliuic can be of great help, horvever. in sivins parents an onbortunitvto think out and talk ov-er some of the'conciefts q.hich th'ej' wish t"ogive the child.

The whole task of sex education can be made easier {or narentsif tfre;' are encournsgd Jo keep these two thoughts in mind I First,that they must be absolntely l-ronest- as far as'thev go at any orretime so that they will not be obliged to retract sonre "of their

-state-

ments later I and second, that, thev are tellinq the child about thenormal, natural process of reproduction and rbt about sexual inter-eourse. The young child has iro curiosity about adult emobional rela-lronshrps-or ttle.actual_process of conception. He is, hosever, viiallyconcerned and intensely curious about'his origin, arrd the facts areso simple and understandable if presented frfnkjv and unemotion-ally that the child can be completeiy satisfied. rf parents will answerthe question-of the_preschool

-child"about reprodubtion withoui mak-

ing him feel _that he has introduced an un6lean subject which onlynaughty children speak of, s_omething will have been accomplisheri.rt ls & reat acnrevement r-f t-he parent can rnake the child feel thathe.h3.s.brought. up one of the most interesting topics in tlie worldand if he can show the child, so far as his age-and intelrige'ce willpermit, why it is interesting.

The-know-ledge of reprodirction is in itself not so important as theattltude and emotronal response which such an apploach will fosterin the child. rn this connection the clinic catr 6.' of g:reat t"tp i"giyits pa_rents_ an opportunity to rehearse-at least I' ih"i" u."r,mrncts-what their own attitude and emotional response will be. ftis not enough for the clinic workers to teil a timid ancl inhibitedparent that he. must state the facts truthfully. for in that case thechnrc worker is actually being as evasi'e as many parents. The

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workers should be as frank as they advise parents to be. For manl-parents the experience of hearing another person speak of the sexorgans bv name, simpl_y and correctlv, is of the greatest benefit inhelping them to overcome self-consciousness in*approaching thesubject.

Clinic groups thrt f ind it impossible or impractical to srve thistype of help to individual parents may accomplish simila"r resultsby alranging to hlve part of a parents, conference or one of a seriesof lectures for parents devoted to this subject. Ihc clirfc mav Dro-vide th_e speakei or leader from its own sta?, or may sponsor p""'r"tr-tation bv an outside Derson.

Reproduction is a iopic to be neither ferrtur.ed nor ignorecl. Notall problenrs wil l be eil iminnted even rrhen reprodrreiion and sexare wisely presenterl to children, but the problems wil l be easier tomanilge, and parents wil l be in a far bettFr position to help if thel-have been accepted by the child as guides and counselors. it is toi-fylulu, indeedl that-some of the

-trb.,os regarding sex are being

lifted and tlrat older chiidrerr are l1o longer entirelv"denendent unoirthe parent and the home for honest i i formation regardinq tl iesevital matters. The preschool ehild, hou'ever, must sti l l de$end onparents_and-parents must thelefoie assrlme the responsibil i ty ofseeing that the child embarks upon life with a rvhol6some outlookand an_intelligent_unclerstanrlitg- of the process of reproduction.

fn addition-to helping- pa19.nts in the matter of iex education,the c l in ic of rers help- in-handl ing t l re val ious hrb i ts nnd l t t i t r rdesarising in connection n'ith the ihild's sex development. Commona,mong these is the habit of masturbation.

Moihers-of prohlem children frequently say that the habit of mas-tnrbation began at such an earlv dnte in"the"life of the chilcl that itis impossible to tell when it did start. One chilcl said that he had'(handled himself" ever since birth. Such statements bear lvitnessto the faet that the child may become an-are ut an errlv ace thfl,the can arouse pleasurable sensations by rnaniprrlati irs t l ie senitalsrrnd other erogenous zones. This awareness is risrrailr ' lrr ' ,,rrglit aboutby some externt l s t imulat ion such as mnl be currsed' rvhen. ' the chi ldis given a beth, when uncleanliness gives rise to va.rious irritations.when the child makes a rnther minrrte iuvestiqation of his ownbody. and all too frequentl. l ' when older children become curiousabout sex and make investigfttion of sinaller children. In certaincases.sexllal precocitp' has beerr delibentel.y stimulated by irre-sponslDle nursemalds.

It is not desired to convev the impression that masturbation be-gins so early in the great mrjolit l of'children. IVhen jt does beoinin thefe inrnratrrre years-it innaii,rbly lnsts a short t ime. It"niltrecur between the ages of 10 and 14.

- In fact it is so eonrmoir durl-

ing this period that a transitorv period of masturbation about theage of pubertv is genela l lv eonsidered qrr i f e r ronnr l .

The m ls l r r rbn to r t ' r c t i s us r ra l l v c r r r r i i e t i on bv i r r i t i i t i r r g t l r e ex -ternal geni ta ls .wi t i i the hand. bt i t cn i tdre ' oceasional l r - iGe st ick; ,pencils, and other_small objects for this purpclse. The"act is oftencomplicatecl-bv other_ manipulations rvhich irpl;alently add to thepleasure. Thumb sucki'g. rectal i*itzrtio'. airh mbbing the navel

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78 FIABI'I CLINICS F'OR CHILD GUIDANCE

are most comlnon, and any one of these acts may be performed aloneto the satisferction of the child.

Visits to the toilet are frequently events of great interest to clfl-dren, and it is not unusual to find that masturbation occurs only attlr.ese times. Not only tireir orvn visits to the toilet but those ofthe adult members of the household are of interest. One little sirlwas brouqht to the clinic on account of her interest in seeing peoplenude. SEe rr.rs accustomecl to secrete helself behind the bdd-or^inthe closet or to peep through the keyhole and put mauy other in-genious scherrres inlo operrrtion to see any of the adult members oft"he farnilv nude.

Other ihild.utr are unduly sensitive about being in the presenceof trny member of the family while disrobing, and at a r.ery earlJlage they rre rvhirt we commonly term "prudish" regarding the prob-lem of sex.

N{ost of these youugsters, from a therapeutic point of vierv, fallinto trvo gl'orlps: (1) Those rvho cling very tenaciously to thesepleasures and in fact to all the pleasures of their lives, and (2)those lvho give them up rvith little reluctance. I{embers o{ thelatter group- need iittle

-or nothing more than to have their ener-

gizing forces sublimated along some more desirable path, anil stressshould be ltrid on the development of some rterv interest rather thauon the undesilable habit. TIe treatment mllst be outlined to covernot a few cla,vs or a rveek but a periocl of several weeks. The par-ents' fears aird trnxieties over tire outconie of the habit musf betr,llavecl so tirat they can canv out the treatment without undue emo-tionl All that is "usuallv r6auired in such cases is to attract thechild's atteution with a pictt i" or a game rvhen he is in the act ofperforming the undesirable habit. Other methods that require in-leuuity may be used, such as directing tire child's attention to someiituation. even thoush it is only of passing interest, if it is sufE-cientlv uniclue to hold his attention for the moment. The habit. ofitselfi gradirally subsides. This habit in young children is nod soserious as in older children 'ivith whom masturbation occurs onlvin seclusion, for in the early years the asocial quality of the act isnot yet appreciatecl. Pa.rents may be tlssured that no undue anxi-ety regarding these cases is justified if the child is directed withintellisence.

Thelases that present the rnost difficult problem for treatment arethose of children rr-ho turn to masturbation onlv n'hen thev are inunhappy or desponderrt moods. Tlrey find in this habit a s"ource ofcomfort. and a comfolt which is alrr 'ays at hand. As they srou' olderthey mav corrl inue to indulge in the-habit much as chilhr-en turn tothumb sircking, especially aE a means of inducing.sleep,. They maynot experlence an.y partieular sex urge at the time. but they arebothered by a general, indescribable fe"eling of unrest, both physicaland.mentai-wh'ich they find can be subdued"if a sufficiently stiong sexfeelins can be stimulated.

The most practical method of treatment is as follows:(f) Careful physical examination to determine whether there are

anv r le f in i te sol l rces of i r r i ta t ion.i2) Absohrte clearrliness.

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^^J|]^5""*ledge of those with whom the child is making intimatecontacts.

(4) Knowing the child rvelI enough to be rble to understand hismoo0s rarl ly welr and appreciating the fact that r.astu'bation isfreqrrently sirught. as a retieat from

-unhappiness.

_r1} *,j:Hg..l^..fSiT and anxieties b? the pareurs and hctpingl}"n ^9*:*ty_e tli-at_ dang-ers to the. physicai ?.t'$ ;ilrl:;"ii:HilEof the child are more apT to come fi#-i;J;di";;;-;";;;;;; tli;ifrom the habit itself.

*.11 l it^.?,aT,TpJ to" dispense .rvith. arr urrdesirable ha bit sonrething

m.sr be substr tuted. for *hat . is being taken_away. Not only mus"tapp,r'oval replace disalrprovll. pleasf,re replace b"i","""d'-r.ervardreplace .punrshment! but some ver1. definite a'd tangible rnethod of::"^lirl"ltllg :iS"qI musr, bo p.r,esenred to ttre child* and presented.In s l l ( . l r l r \ ra .y i l ra t r t carr be ut i l ized.

, ( 'onsiderable exper ierrce has sho* r r that mecharr ica l apDl iarceswhrt 'h are r rsed for lest ra i ' ing chi rdr .en ar .e of l i t t le r .ahre r i r i less rhechi ld is at a ' age * 'he ' l re caTr fu i l l 'appreciate ' ;& t i l ; ; ; i ra int is: : iT.S-_" : :o

arcr can.dt 've lop a stn le.of r l ind in r r :h ich l re is c l r i tewrr . lng to cooperate rnstead of r .esent ing the t reatment . l f r .est r r r i r trs used,rorcfpJy the- sr t r ra l rorr r .esol r .es i tse l f in to an oDel) hat t le be_t$ 'ee ' the chi ld and. t l - re Parerr ts in * . l r ich both nre c ldonred to lose:.f,?:^1"-f"*!tt !1" ctiild clings to the

""a"siruni" ]r;;i;'l; ,"pi# iit l)ese ctrast lc measures.

, The follo'*ing _case is presented i' considerable detail because itbrulgs o..t several rnrpoltant p,olnts regrrdirrg the. ear.l;. deleloprrren[of sex interesr irr childrerr arid becurrse it is?t*tlre. .t-pii*t"a rryl:l]-lJ:jT. of an epileproid, chrrac.ter'. *'rricrr '' '"i in" .yiiipr"Jnr rrratolo l lg l t t the pr l t rent under observat iorr .

l'raDces, a 9-year-old girl, _-rvas brought to the clinic by a social worker fortrv, clefinite reasors: (1) Because of co'vursions 'vtriin-r.es".r^Jttc,a""pii"psyand (2) because of her precocious sex i'tcrest a'tl sex aoi"qi*i"i..., -*.hictrhad begu' when she was,,betrreen .b .arrrt 6 yea.s of

"c".

- iil"';;iria" trrutbrougirt the child to the atterrtion of the refci|rng ageucJ. was tliat the chiid,steacher found an obsceue picture in her possessron.

, Physicar_.filclings rvere_regatile, exceit for rr positir-e tubercurin test andthe "spells" r.vhich resembred petit-mar aitacks. rh" gy.r"cotuslcal;,r;inationthat 'was made on account of tire social hisror; incicii'tecl . ;;";;i,i;;;ourlt ofirritation_ of the genital organs. The child was \trell a"ruroii"a

.and rvettnourished.

- The .chi]cl's intelligence quotient lvas fourrd to l,.e 111. Irental Iintlings gr*rledthe clfld 1 I'ear abor,e her chro_nological age, rvtrich garne

^ir-Jr ,*"ii?lrrig"u""qu.tierrt of 111 .' the stanfortr scile. ,tit'ttre test,s given rvere--rl-sponaeoto at about the same level except that for rote l'en)ory, *rri.t, ,ua*'pu"ucularlygood, and $at for Bractical judgment, rvhich *-rs bclos, her rrruniui;;;. She*'as much i'terested and e-ntered eagerlJ- i'to the spirit of the tests. she \\.asin the third grade at school and *.as calrnbre of .doiirg ,r',;"L-;;o; th" iu".og..'rhe tezrcher colsirlered the. r.lrilcl very'trrighi- but stateal that at times sheappeilred ertreurel l ' :rbsei l l -ruir ir lcr l .

T!e, nqr-en-tq reported that the cliild hatl "irnrnorar habits,', that she neversought girl friencls but was ahyaJrs in the company of boys,''s"O-ifrai-sie fradimrnoral relirtions rvith thelr.No inforrrration was obtainerl regarding the grandparents of tlre patient, buther father :rppelred to be a.fine, setf-reipeltirig nzrrr, ro'rro ,ras miLi""I .o"ryeffort to do a]l he courd fo'rhe' weliare ot-rris ia-ily. T'he crrild,s mother haddie_d-4 yea.s pre'i,us to the time ot ttre ciinic'isii. srr" rruii rr"*".,pilelticand hylrersexual to a rnalkcd clegree. Shc. tlied ert a psychopi_rttiic

-trosr]ital ina toxic ps-vchosis. The child's father had rnarlied

" .e..iiiii tii,o',i,,o ir\o .,.rl"

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IIABIT CI,INICS F'OR CHILD GUIDANCE

rnother seemed to be kindly and affectionate toward the child and interestedin her welfare. In matters of discipline concerning the younger chilclren, shereceived but little support and ercouragement from the three older marriedsisters in the family.

The child had been living at home rvith her father, stepmother, and brotherJohn, aged 13. l'he latte| was said to be a quiet boy but it was learnedthat he indulged in petty stealing anal had been arrested tr,vice. There rverethree older married sisters rvho continually interested themselves in thefather's household, much agirinst the rvishes of their stepmother and prob-ably to the disadvantage of the home. The father stated that none of hischildren seenetl normal. He had ahvays had difrculty in bringing them up.'Ihey were delinquent, misbehaved, and had bad reputations. On the wholethere seeued to be nothing obvious in the immediate household to account forthe delinquent tendencies of the children.

n'or the last 3 years Frances had interested hersell in boys, atthough accord-ing to her own story she did not exclude girls as companions in her eroticindulgences. X'rom the history it appeared that the patient had been moreof an influence on the envilonnrent than the environment had been uponher. The father stated that since the child n'as 3 years of age she had sho$'nan abnormal interest in sexual things and had beeu quite alvare of her ownsex feelings and how to stimulate them. When returning from the movingpictures she appeared to remernber nothing but the sensual aspect of the pic-ture. On several occasioDs the patient had been found in the cellar ofan unoccupied house, with three or four boys of her own age. She told herfather rvhnt had happened and shorved no sense of shame in speaking of theactive part she played in these episodes.

In the doctor's office she answered all questions frankly and showed herselfan extremely precocious inclividual with an intimate knowledge of sex affairswlrich could have had its basis only in personal experience. She made no effortto minimize her part in these eyents and voluntarily expressed a desire to over-come these hypersexual tendencies. She discussed the entire situation withoutem'barrassment, went into the minutest details. and discussed her innermostthoughts and dreams iD an interesting and enlightening way. She appreciatedrhe effort that she must make in order to overcone the cravings and desiresresponsible for her past diflnculties. She rvas also anxious to develop otherinterests to substitute for her erotic daydreams. At no time did she blameothers for her trouble, and she stated that she was extremely anxious to oyer-come her undesirable habits in order to make it easier for her stepmother, towhom she was apparently verJ'nuch attached.

This case presented trvo definite problems for solution: (1) The convulsivetendency and (2) the precocious sex interest anrl sex clelinquencies. Physicalfindings in the case R'ere essentially negative. l{ental findings indicated thatthe chilcl had more than ordinary intelligence. Eler teacher considered herbright. The delinquent beha-;ior might haYe been considered accidental inorigin and as being continued because of hypersexual cravings. Flome conrli-tions 'rvere not ideal, yet they n'ere not sufficiently difficult to account entirelyfor the strain of deiinquency found in this family. Associations rvere neithcrbettel uor worse than those found in many districts. Nothing in the mentalmake-up of the child or in the environmental conditions stood out distinctly asthe exciting factor of her difficulties.

The effect of sueh a series of experiences upon the development of characterand personality in the child is open to conjecture, The reason for the par-ticular experiences at such an immature age in this individual case may wellbe considered as environmental or accidental. The effect of such an experiencedepends upon circumstances and conditions that are beyond the control of thechild, and the solution is quite as dellendent upon aecident as was the originof the primary experience.

The fact that this child was of rather high-grade mental equipment and some-lvhat precocious in her interests other than her sex interests was indeed for-tunate, for the experience could be very \TeIl assimilated and digested by thechild, minimized by the parents, and perhaps turned to some good purpose.On the other hand, the habit might be repressed so compleiely as to lose its ownidentity entirely, only to appear in some quite pathologieal condition or somedeflnite asoeial act-:is apparently occurred with this patient in her hystericalepisodes. Again, the experience might be rather imperfectly repressed; anclcontinually anci persistently forcing its way into consciousness, might produce

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HAII IT ( ] I , I^ \ IUS FOR OHILD GUIDANCE

disintegration of the personality sueh as is manifested in many of the ps)'-chonenroses of the neurasthenic and anxiety types.

n'rom a physiologieal point of vierv it is not difrcult to conceive of such earlysex experiences as sensitizing the individual to subsequent emotional experi-ences of a sexual nature and producing a hypersexual individual 'whose sexualoutlet may be prostitution, homosexuality, or other perversions. Notrvithstandingthe faet that this tremendous physiological sexual drive may exist, it is notunlikely that such an experienee would produce a psychological repugnance tosex, the t$'o forces eombating each other and resulting in conflicts that tormentand incapacitate.

While the chiid is passing through these experiences she needs all the helpand understanding that she can get from those having the case in charge.To rvait 20 years and then begin philosophizing about the effect of such earlysexual experience and its relation to the nervous breakdown of an adult is ner-haps easier than to get a clear, concise picture of just what is taking place whenthe child is passing through the experiences. But there is no comparison in realvalue betli'een gaining information while the forces are operating and guessinglater what actuallJr happened, how the mental mechanism worked. and whateffects the experience had on the development of the individual.

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PERSONALITY CHANGES FOLLOWING ILLNESS ANDINJURY

Parents. are frequently inclined to blame al illness, an operation,or al accident fol some change in the behavior of the chiid. wheritr. careful exarnination and thoi.r-,ugh investiqation of all the facts sur-lounding the problern would indiiate that t-he illness or accident hasbeen to blame onl.y in so aitering the relationship of the child to hisenvironmeut as {o-allorv these pelsonalitv probleins to clevelop.. I l_ i. onl.v natural that parents are deepiv concerned u'het' a childis i l l , especialty if the condition is ar ail 6eiious. Their anxiety over.the welfale of the child is often out of all proportion to wh"at thesituation really rvarrants. whether the child his been cared. for atI rome or i r r a hospi ta l , the per iod of i l lne-s anr l con 'a lescence is onedur ing which t l re ent i re household revol res arorrnd the chj ld . Theother children are instructed to give in at all times to the ailins mem-ber. His ever ; ' want is ant ic ipated, and h is c lemrnds. h"owevernumerous and val ied, are sat is f ied at the ear l iest possib le moment.He is in a posi t io . t r to commandeer everyth ing in h is envi ronment and,needless to say, it is not an unattr.active siiuation in which he findshimself.

For the first time, so far as he can remember. he is the center ofattraction and attention. rre ne'r'er before appreciated just horv im-porta.t he reallv was. Before this illness [e rraa hail to Eive ancltake with the rest of the family. He had his responsibilitiei and hewas expected to "carry on" like the other childre.r itt the family. Hetook h is shales of purr ishrr rent and acceptecl i t , but now everyth inqhas changed to h is advantage. I t is ther i fore not surpr is inq t l ia t th ichild rvho finds himself in this situation should set an exisueratedidea of his on'n irnportance and that after he "has enjovEcl theseindulgences 9n +" part of the oversolicitous parents he shtiuld clingrathel tenaeiously to his nerv position. being ieluctant to give up th6svmptoms wnlc l t created l t .

_ A typical example is that of James, tvirose mother said, ,,James is very rest-less, cries easily. t\\'itches his arms and bod}. muscles, is very irritable, flies intotempers, and cannot sleep nights." This change appeared aiter lris return froma hospitai rvhere he had been treated follorving an accident. Fle became verysurly, aiways looked ugiy, seldom srniled, and appearetl unhappy ancl discon-tented. He had becorne so different since the accident that the boys startedto call him "Empty-head." The problem confronting the mother wai rvhethershe shoultl follo\v the advice of her lawyer and sue lor damages. no,rtunately.hotrever, her primary interest was in the recovery of the lad. rnquiry rer.ealetithat since the accident the routine of the household had revoh'erl around thepatient. Ever}' lvhim lvas gratified regarcling his food; other children lverenotified that they must accede to his every r,vish; all the toys rvere his to acceptor to reject; and the lad found himself in the limelieht.

_ After a careful physical and neurological exanination had been macle, it wasplanned to change the regime of the householcl. The mother lvas to rr.vert tothe old plan of naking the cirild give antl take and batfle for ri-hat he coult.l getwith the rest of the children. In just 1 montir his mother repor.tecl tirat he lvas

!tt

,I

I

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HAI] IT CLINICS FOR CHILD GUIDANCE 83

13,',',i-"li:#",i?iiT,i"1J,?',:S.".*,Ji.i 3f:i''1.:iLif ,"",i'n'jll.iJ'i"#Ti"Y?:which rvas so appal'ent rvhen he first came undel observation'

Manv of these lrroblerns might have. been avoided hld the parents

"p;'#i".e';;i \;1,;; ,il tnft nttention might rnean to tlre clrild.

The most r'r'ortant p;;^;i;;rf ilh".t". is fhe convalescilg period'At this time the pu""[i. -""J;J th" best judgment to avoid not .^lyD'olonsins rtie ilt'*ss'6,i1';;;;ti;t;tiiiudes 5rr t1e pa't of. tlre cliltlil"#;-',fi"" 1r"".r

".t;iri"n - tu.,."- trouble later. Quarrelsomeuess,

;;;l;ily,';;]n.r,ii"r.,,ai.;t.i;.".., .uleruress. rempers. irnd rnany otlerun(leslrcl,,te p*r.rttu,,fY:-rt"iit *oy hrr'e tlreii ' origirr dtrring the con-

valescent period'"ll it,oudt, many of these perso'ality clta-'ges_have a _tlefirrite psy-

"h;li;;i;;T;;.i;. it trrs bcerr^recogrrizecl withi"n the last.10 yerr,rs that

;fi ';-;;. ;i ';;; 'k;; ;;; '";;i i6 c;a'ge a'e t5e result o{ encepla-

itil.. ' Til."";il;g;; mlar. nianifest t5emselves i11 I deep rputhy or

" --rf..i '[yf]-rli.?iiitV chr'acterized by irritrbilitv. destructivettess-,

and not i.freque'1; 't 'y;i;i;;i

["ui1r*t." Occrsionilly de]usions and

[uh""i""l.ty' u*-p"ii"ti"", &re also associated with them' Such

fl ni;t,i:TU:ll!.l,tr*$,r,;H'1,;JiL'-t'iiqr";ln:1tr::f L1.ih;|"";;;'ili';;;;',-; ''i,*u6" of cases in which the attack \\.as so;iil;hJiil;;ils;;r.;i e"cep\aritis rnas not made but rvhich weren.'r:*"i-f ' ," i".. follorled bv rnarked change in personality'""iili;';;i;t sho.ld f.'r..pi tir *ind. in-making a diagnosis and plan-

"i;;J;;Lrii. Oir"io"ii-n t6" ordinary clini*c measures carried out

#'f ;;;il;ilei""l-1"'t"i ;."uty ,u"o'tstruction of the environment do

i"i'"i"t'.rl"ffo-alle.the condrrct of these children. The treatment to

;;#ll;,d;""r;;;; ir o".-of t"Lducation under^ adequate supervision.' i"itir"""".i;;,,"ti;;";li;t ;";y arise with reference to .personality

"ft""G "".1 itt"l" ."tutio" to atcidents is brought about when parents

iffi;?h; "t

p..i""ilv;f5ffiG illness and a&idents for undesirable

;:ffi;i;"":"'ffiilTht -.tnu" of-u" 8-y_ear-old child gave -a history ofirru

"fril.i'r Lvrtts .#ii;g; 6"ittg

"t,,61,- and other aiocial conduct as

h:f$Jlif"llxi:r:l=j'ls*';ntl'.il'$1"i"::f i'l;q=ffi ll,".Iilii;;;;in;i;"" "u""ol"a,

nlii:"u"it, that this child had been a serious

iii,l,i,rl,;r*"Th;;;;t;;noit, utta on the street for se'eral yearsl that[--ir*. **il known;; tli;'police a'd the truant otcers; and that.Ttfr."eh iir"-"""1a""i iifif'and the attention which the child re-;;ii;;j";"y'd;; ;-;!g""-t"a the situation, it could in no wav beregarded as the cause'^'

t;A;;b[cliv certa'in peculiar personality traits are. developed by

"hi,#;;;h''."if;;'l;;tir srrch cilronic dislases as diabetes and car-

ai""- """aiiil"r

*fri.fr" hn"" fi-itud their activities .ald prevented

ffi;'il;;'p"tti"ip"ii"g. il a nor*al rvay rvitb children of their

;;;'";;-;;.f il "liir,t;d

irho have been the victims of illn_e_sses like

i;f;"]?; ;;;t.i;- ;r.hi.1, l"*," physical handicaps. . ITsually, ho.v-

;;;;. 'th;.; "hii,i;; '

;i i" .". ri.iai'opped !y infantile parals'sis in

ffi "'J"l'i"""tr"'ffii'Tilll'#:'lli,n':i;illi'iJ"iTi"i{rtill;3"xi"{present at such u"

"u'iiy

";g"-th"i ih-ittittt learns"to live with the

fli#irity d;-th; ;;;)t b"!ir'i'g. Furthermore, the handicap is

.'- :-a-

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g4 TTABIT CLTNTCS FOR ('HrLD GUTDANCD

of such a nature that his contemporaries make certain allowancesfor it. The cardiac and diabetic

^children. horvever. have no such

obvious defect. Children with heart conditions beconie overwhelmedby their inability to compete with other children after thev haverecovered from the disabilit.y and so mav develop a feelinE" of in-feriority. But the diabetic

-child is more likely io become"critical,

irritable, r'esentful, and defiant unless wiselv"managed from thebegiunirrg of his ilhress. These personality tr-aiLs are "not character-istic of the respective illnesses, but thev aie observed with sufficientfrequency to be worthy of comment.

It should alwa.ys be remembered that everv familv has its ownhistory and its oi'n assoeiations *'hich color its attiiude i' a rrensituation._ Prolonged and exaggerated soiicitude over a child whois ill with measles may seem qirite out of proportion to the causeuntil one learns that ari older c[ild lost his lieaiinq followins an at-tack of measles. ft is importrnt to get a completE historv i"n orderto interpret these situations correctly-and arriv^e at a practical thera-peutrc approach.

The following case, discussed in sorne detail, is of interest in thisconnectton.

Randolph was referred to the crinic at the age of B years because of apersonality change first noticed on his return fiom the hospital, where hehad been confined with diphtheria. rre was quarrelsone and had frequenttemper tantrums, during which he ilrrew himleff on the floor and kickedand screa_m-ed for long periods. At night he refused to go to bed unlessaccompanied by his mother, and occasionally he had night teriors. rn addition,-be'was capricious about food and hac developed the habit of soiling himselfdaily.

This boy's birth and early development were uneventful except for a mildatiaclr of scurvy v'hen he was a year old, and the attack of diphlheria alreadymentioned.

The father had suffered a nervous break-down a year before. Although hewa! occasionally irritable he was, on the whole, a generous and consideratefather and an excellent provider. The mother rvas well mcaning, but highlyneurotic and unstable and she had many superstitious interpretaiions of thLsimplest incidents. An older boy had died of diphtheria and she had not fullyrecovered from her sorrow, a faet 'which had considerable bearing on heipresent condition. Besides a younger brother there was in the household thematernal grandmother, who interfered greaily with tbe disciptine. Accordingto the mother the grandmother "would turn the house upside down to pieasEthe children, as she hated to hear them cry.,'_ Prior to the boy's illness his mother lad notieed nothing peculiar in hisbehavior, but following his return she had observed a decided cfiange. Ele wassullen, irritable, seclusive, and unreasonable. rre expected more thin his shareof attention and went into a tantrum when it was not forthcoming. He wentto the rvindow every night before retiring and, looking upx.ard, bade goodnight to God and his older brother-a practice whieh his mothei considereduncanny.and unexplainable. Ee had not been permitted to play with theother children in the neighborhood because of his peculiaritiei and becausenone of them were his age. The mother complained that it was impossibleto have the child remain in the bedroom alone before going to sleep-he beggedher to remain with him to make sure there were no wolves outside the door.Ile entertained this constant fear of having wolves enter the room.

on his first visit to ure clinic the boy refusecl to leave his mother or mpermit her to enter the examining room without him. When she left he flunglimself upon the floor ancl remained there in a rigid state until her return-.She then picked him up and allowed him to bury his head in her bosom,simnlating a nursing child. He later began to pout and talk in a babylikefashion but refused to converse with the examiner.

The intelleetual equipment of this boy was about average. Ife had anlDtelligence quotient of 98.

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I{ABIT CLINICS X'OB CIJILD GUIDANCE

lfhis is a case which superficially would impress one as having all the essen-tials of an early mentai aberration, were one to base one's conclusions entirell'on the mother's interpretations and flntlings without further analysis of thesituation. Indications which the mother accepted as being highly ominous werereally nothing more than would be expected in a child of this particular make-up living in such an environment and influenced moreover by a factor whichwill be mentioned shorUy.

The mother, grief-stricken over the death of her older son (who had rlied whilethe patient was convalescing), attempted to compensate for her loss by in-dulging the patient to an unlimited degree. Everything began to center afoundhim. He was the one attraction in the house and all the members of tlrehousehold exhibitecl their joy at his recovery. The child saw himself in thisprominent and not unpleasant position and it was not long before he tookfull advantage of it by making numerous demands which the family readilygranted.

At one time the family had employed a maid who bad nightly threatened thechild with a wolf story before he went to bed. She used this story in an at-tempt to hurry him to bed and always rvarned him to remain in the roomlest he be captured by the wolf. This bit of information revealed the originof his fear of wolves.

Later it had been the grandmother's privilege to prepare the patient forbed. She would undress him, hear his prayers, and, before putting him tobed, take him to the windo\T and have him bid good night to lris deceased brother,who, she explained, was watching over him with God. When the developmentof this particular practice was explained to the mother she no longer lookedupon it as being a mysterious procedure but realized that it was simply whathis grandmother had taught him.

Much of the success of the treatment in this case rested on the mother'sacceptance of modern methods of dealing with the child's problem and thedestruction of many of the superstitions which had previously handicappedher. After a short psychotherapeutic talk she was found to be most coop-erative and willing to carry out the treatment in detail.

A chart was given to the mother to help her solve the feeding problem,and measures were taken to desensitize the child to fear of wolves. IIe nolonger was to assume the role of invalid but was to take his place in thehousehold on an equal footing with his younger brother.

The child nlade three visits to tlle clinic. On his last visit his motherreported that he $'ent to bed unaccompanied, that he no longer talkecl aboutwolyes, and that he had earned his complete quota of stars on the chart. Hismarked aversion for milk had been overcome and he dranl( it unprotestinglywith every meal. The family was leaving for a summer resort where it washoped he n'ould be given a wider opportunity for contacts with children ofhis own age.

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CONVULSIONS, TICS, MANNERISN4S

\\'hen one considers that rnore than half of all individuals suffer-ing from chronic convulsive clisorclers in adult life. the so-caliedepileptics, had their f irst-convuision prior to the fourih year of l i fe,the importance of convulsions in chiidren becornes apparent. Thi;does not rrrean that the isolated con'ulsion u'hich .oir-uti-.. ushersin an acute infectious disease in children need be taken too seriouslyor cause parents r rndue an-x iet_y. Anv chi ld . hol 'ever . who h ls "a

series of convulsions or is prone-to rcrrci to infeetjon.. fails. and enro-tional stresses and strains by having a convulsion is in n6ed of thebest meclical attention.

. A.studv t-as made.of a.group of chilt lrcn under 4 vcars of age whohad been pat ients in hospi ta ls and had suf fered { rom eonvnls ions asso-ciated with acute infcctions, spaL,smophil ia, gastrointestinal upsets,r ickets. and whooping corrgh. 'These'cases ' r , i lere carefu l lv fo l lurvedup to d iscover thei r subsequent h is tory. A surpr is ins lv la ise numberof these chil, l 'en eventually died of

'convulsidns ana -anv of those

who were still living continued to have convulsions or were mentallydefic'ient. Tb-e inLplication of this study is that convulsions iirch i ldren shoul t l no longer be looked r rpou is a mere inc i i lent in thei rmedical h is torS'nor a i something th i t happens to every chi ld , l ikeal ) rmrease rn t t 'nrpernt l t re or a gastro in lest iur l u l lset . The conr .u l -sion itself rnust rather be considered as a certain criterion of the in-herent instabil ity of the nervo.s s-ystem. somt' children are so in-herently stable that the eonvulsioni ass<.,ciated with actual irritationof _the lrervolls systern (such as is seen in encephalit is) mav subsideancl lea'e no i l l effects. This indicates that thire is no weil-definedlimit to the amount of brain irritation that mav occur without 1eavingill efrects. rt appears that sorne nervous svstems are capable of withlstandlng a rather. severe disturbance such as r,vould natirrallv be pro_duced by an acute inflrrmmatorv conclition of the brain. oiners wrttsuccumb to a rniid infection oi a sllght tr.auma. leavins behincl anincreused instabi l i tv which r .esponds more or less per iodTcal l l to theminol v ie iss i tu t les of l i fe and mani fe. ts i tse l f in eoi rvuls ions. "

- t r ' r -om the standpoint of .prevent ive me, l ic ine i t does not r r rat terwhether th.ese early convulsions arc of psychogenic or of biochemicalorigin. Ttt.rg, seems. to be l itt le doubt in thE mirrds of those mostinterested rn tlre subject of epilepsy that each convulsion par-cs theway_for the .succeedilg one, and-t[at the path beeomes d"epe' andthe l ine of demarcation sharper ald rn_ore easilv tra'ers,,d'bv theexcess of liberated nervous

"."jigy.- For this reason it is tremendouJv

ipportant for the future welfar-e-of the child that a careful investigaltion be made. bv both clinical examination aud laboratory tests,'todetermine the e-xciting factor in the procluction

"ilh*'inJantilsconvulsions.

, rt, is lmportant fo-r the pecliatrician and the psychiatrist to workhand in hand. The {ormef u-srrallv sees the chirci over a sh,rt periodof t i rne. but i t is an extrenre l r - important t i rne rvherr the , rn. l " i i rableforces, r,vhether they are psychogenic or chemical, u"" op""uii"g. The

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HABI'I CLINICS !'OR CHILD GUIDANCtr

latter, on the other haucl. sees the child over a longer period of tirle.but invariablv at a period somen'hat renoved frorn that in which theexciting factors actirally operate. Until a better n'orking kno'n-ledgeis obtained of the baflling phenomenon called epilepsy, it is especiallyimportant for tire psvchiatrist and the pediatrician to cooperate andi..o have a clear knol'ledge of each otherts technique. In almost everycase of a convulsive disorder it is necessary to look for both a pre-disposing ancl an exciting factor.

There is no group of cases toilay more rrorthv o{ the attention ofthose best quaiifieil in the practic,e of medicine'than those of earlyinfantile convulsions. ft has bcen said that ((the chi1d, for the first5 years of life, is an organism so tender. ."o easily broken, so easilydtrmased. that it needs all the care that first-class intelliqence cang i ve i t . t t

Susan, a poorly nourished and underdeveloperl girl, 6 years of age, wasbrought to the clinic by her mother for a serie-q of problems of rvhicli faiutingspells -were the most important.

There was no history of epilepsy or mental or nerrous diseirses in the family.The child's birth and early development had been normal; she hacl had thcordinary diseases of childhood. There was Do historl' of convnlsions, but themother stated that the child, since she was 8 months of age, had had spelisduring rvhich she had momentaril)' lost consciousness. These faintiug spelis.so calleil by the mother, usually took place n'hen the child founcl herself in anydifficult situation. When threatened with punishment she would fall to the floorirr an apparent faint. She would hold her breath and get blue in the face.The mother would then pick her up, fonclle her and put hvr on the bed. andthe episode s'ould be over. At other times these "fainting spells" rr-ould follorrotte of her temper tantrums. She would lie on the floor, liic'k, and yell, holdingher breath for varying periods and apparently losing consciousless. She might,however, have one of the temper tantrurns $'itirout the faintiug spell.

The mother stated that the chitd was very affectionate but domitteetilg. Shealways warrted "to be the tross," whether at home or at play. autl trstral'ly gother own way. She was extremely stul)horn &nrl rvheti t"efiist'rl she rpspondedin the manner ah'eadr tlescribed. She nras said to bc friettdly ald generous.She rvas iealous to tlie extent that -she demanded at least a,q lnuch attentionas \i'as giren to the other cliiltlren in the famill. l 'he mother repeatedly stated,"The child must have her own way. The only way to manage her is to givein to her."

Com.ntent.-The foregoing history, in association rtith the negative physicalexamination, stamped these "fainting speils" as belonging to a psychogeniegronp of reactions. It seemed quite ohvious that the child rvas ntilizing tltismethod to gain her own way. It is alrraS's difficult in a citse of this kincl todivorce the physiological aspects from the purely psychological. Fol exautple,the effect on the oxygenatiol of the bloocl of holding the breatlt might irr itselfproduce tnconsciousness. This case lva-s stamped as being psychogenic by thefact that the treatment, n'hich tlealt eDtire)1'rvith teachiug the mother horv todexi $-ith the child during one of these "fainting spells" or ternper tantrtms.comDletell relieTed the slmptom-s. At the tiure of the hst r,isit the chilil haclnot had a spell for orer 2 years. although she occasi<tutlly met an unpleasantsituation with the crucler methocl of tittrtrums.

The case of Theodore may nlso be mentiotred. l'he child, aged 2 years and 5months, was brought to the ctinic on account of selere temper tantrurns. whichonly recently had terminated in convulsious. When one consider:d the completedisintegration of the mental life of this patient as indicated by riolent temper,insomnia associated n'ith night terrors, enRresis, pugnacity, extreme jealousy,selfishness. destructiveness, and masturbation, it was not very difficult to explainthe convulsions as one of the numerous manifestations of an inherently unstablenervous system. This manifestation at times might follo\r'the sexual excitementof masturbaton or the extreme emotion attachecl to a temper tantrum, antl atother times it might be the manifestation of more detrnitely physiological causes,

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sueh as would be associated with excessive fatigue, lack of sleep, or markedindiscretions in diet. The treatment had to be directed not toward the convul-sions but rather toward rehabilitating the individual as a rvhole.

Billy, aged 4 years, was brought to the clinic because he was extremely stub-born and diffcult to manage and s'as seemingly quite insensitive to the praiseor blame of those in his environment.

In this case the first convulsion occurred at the age of 13 months and wasassociated rvith an acute infection of the influenza type. Since that time thechild had liad nine convulsions, occurring at intervals approximately 6 monthsapart. These convulsions had invariably been associated with some acuteillness. One spell was associated rvith an acute febrile condition which Iastedseveral da)'s. One occurrccl after circumcision. Several others were in :rsso-ciation with definite gastrointestinal upsets at the hospital. The convulsions inthis case never occurred with any emotional experience, but aiways at suchtimes and under sueh conditions that it was difficult to determine the excitingcause,

Another important factor in this case was the fact that the child was re-tarded mentally. When the convulsions begin at such an early age mentalretardation is common. Mental deficiency of this type should not be lookedupon as congenital or due to defective germ plasm. It must be assumed thatthe child whose nervous system is so unstable that he reacts to an acute in-fection with a convulsion is somewhat handicapped from the start, but thatdoes not by any means indicate that he would have been mentally deficient ifhe had not had the convulsions. Many of the physical abnormalities seen inchildren, such as monoplegias and hemiplegias, are uot congenital but appearduring the first 2 years of life, following convulsion. This is a practical as weIIas an interesting point to be kept in mind n'hen considering the general subjectof heredity.

The treatment in such a case, so far as the convulsions are concerned, isobviously not one of psychotherapy. A special regime should be institutedin which the amount of physical and mental stress should be definitely limited.Diet is of paramount importance and one should avoid all the more indigestiblearticles of food and the methods of preparing food whieh rencler it less digest-ible. Tea. coffee, and other stimulating as vvell as irritating articles of dit:tshould be eliminated. Constipation is invariably found in tbese eases andshould be guarded against. It is best eombated by a carefully selected diet,which should include much fruit, green vegetables, and bread made of wholewheat. After such a case has been carefully studied to eliminate every possiblephysical cause, and the proper regime has been instituted, it may also beneeessary to use some drug. Itle treatment of such cases should always bedirected by a frhysician.

There are many and varied physical manifestations indicatingdisturbance of the nervous svstem in children. and from the besin-ning all such symptoms shorild be considered'as haviug a physTcalbasls and shoulci be^referred to a phvsician. Chorea is on6 of fhg mostcommon examples of what an inf^ection mav clo to the nervous system.especially in i child who is inherentlv uristable. Chorea is usuallyasiociate? with rheumatism. and the svmntoms are undoubtedlv du"eto a mild form of meninsitis. Motor "uniest and. mental irritabilitvinvariably precede the cFaractelistic, involuutary movements n'hicirinvolve the arms, legs, and frequently facial muscles. These move-ments mav become verv violent at times and the child will throrvliimself about in a manier that mav do him boclilv harm. Althoushit is nolv generally recognized thit chorea is due to an infecti6n,fatigue and excitement markeclly exaggerate the symptoms.

H-atit spasms sometimes preient a-iicture ttrat iJ eloselv allied tochorea, bui the muscular invollement ii less extensive, usrraliv afrectingonly one group of rnuscles of either the uppel or tlre lorver extremityl

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The spasm mav take the form of blinkine the eves. wrinkling theforehead, and riiaking a pulling movement 6{ tt"te ficial muscles."espe-ciallv thtj nose, l-hich-result in leculiar grimaces. Spasms of spittihg,coughing, and peculiar types ofbreathiri! are also obierved frequently.\Vhen these involuntarv movements have been present over a periodof months or years, they frequently resist treatnre,nl and an absolutecure is not always possible. This accounts for the fact that manyadults are stil l afficted with habit spasms that 'rvere acqrrired duringearly life. There is undoubtedlv a pledisposition on the-part of somechililren lvhich permits the ordiharv stredses and strains

^of everyday

life to throrv the coordinating mechanisms of the brain out of adjust-ment. The first evidence of-this instabilitv may be precipitated bvfright, grief, intense anger, or physical fatigue. These habit spasmsare*not'infrequentlv see'ti iir childien when ihere is a historv oi nro-longed mental exeition, as for example, the child who is "subje'ctedto a school program plus outside activities such as music and dancinglessons that make uir an inteilectual and physical load beyond hiiability to carry. Thise symptoms are but the first evidence"that thechild-is workiirE too hard.

^

C)ne must keep in mind, however, that in dealing with these prob-lems it is not the symptoms but th6 child who nedds treatment, audevery effort should be made to determine the emotional stresses towhich he is beins sub.iected. Such an investisation leads in variousdirections. The ?iscif,line in the home muy be too rigid I an ambi-tious parent mav bc pushins the child too hard: the child mav be suf-fering from exiremd anxieTv in his personal relationships with histeacher or over failure in his work. Often teasing and bullvinE bvhis contemporaries supply the answer to the proble"m. Besid'ils tires"emore obvious situations, fears and anxieties of which the child isnot aware rnay be operating below the level of consciousness. Thesymptoms are of such a nature that parents are sometimes worriedand irritated and are prone to put considerable pressure on the childto make a greater effort to overcome vrhat they Consider an unattrae-tive habit. They do not realize that the more'conscious the child be-comes of his diflicultv the more likely it is to be exasEerated. so thatnagging. scolding. and punishment are not only useliis but fiarmfrrl.Uncler a physician's direction the child should be removed from theirritations of his environment. He should have complete rest, andgeneral routine measures for building up physical liealth, such asfroper food, sleep, and elimination should'be put in force. After thea-cute symptgms -h.lyg subsjded, it_ mav be necessary to make importantchanses in the child's dailv routine.

Th"e earlv manifestatioris of these involuntarv muscle spasms areoften detected in a clinic .when the child is broucht in for sbme otherleason. It is rluring the earlv and incipient stafcs of these emotiona]upsets that valuable preventiire work can be donri. These problems inthenrselves are not serious medieal problems, but certain ati.itrrdes thatdevelop around the problem have important implications. The childmav beeorne very silf-centered, shy, and diffid'ent, showing markedfeeling.s of inferiority y.!i-ch lead _him to refrain from entdring intoactivities with other ehildren_and prevent him from developrng anormal, healthv outlool< upon life. Early recognition and treitnrentnre theretore rmperatrve.

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THE CRIPPLED CHILD

The \Yhite Ilriuse Conference on Child Health and Ptotection iu1930 callecl attention to the fact that i(there are more than 10,000,000children in the United States r-ho are (handicapned'-in the sensein which the term is here used-i. e.. chiiclren whohre blind and par-t ia l ly seei r rs . deaf and hard of hear i r rg. cr ippled. l ' l ro are menthl l rdeficient or-disordered. rvho ale sufferirrg fiCIn tuberculosis. cardiacor parasitic diseases." u' This is a l'ery cdnservative statement, yet itindicates the magnitude of the problem and is a challenge to llioseresponsible for rFhabil itating, so far as possible, the ph.vsically andmehtall l ' handicapped child]' The probiem is further complicaterlwhen consideration is given to the interdepenclence of the phl'sical,intellectuoi. and emotioial aspects of life arid the extent to rv^triltr ttreindividrral 's personalit; ' , his general outlook on l ife. and lris capacitvfo_r happineis and effi i : iencl: may be materially and permairerrrl l 'a.frectec{ by the rvisdom with which handicaps ire treated in earlilife.

The efiect of physical disease, injuries, and accidents on the per-qgnallt l ' of the inciividual has alreadl been discussed 1pp. 82-b5;.The clironically i l l and the pennanentl"y phl'sically haudic^afped hallesome general broblems lhat are not i lniiki ' thos6 found in'nersolssufleri ig fronr-acute conditions. thoush it mrrst alwavs be tak'en jntoconsiderlt ion that a particular handicap may exert"a specific effecrupon tlre persorrrl i tv-nrake-up of a particutar individual. The factthat ore's mood or i 'eeling of n'ell-beins is rffected bl the conditiorrof the bodil l ' organs-thal is, the functi6ning of the l i i-er, the gasrr.o-intestinal tract, ihe thyroid gland, and so forTh-is so q'ell ' unclerstoodthat it needs no further di"scussion. It is not so comrnonlv under-stood, horvever, that emotional responses to'vvard life, such as .ruor.y.grief- ol anger. aflect the {unctioniirg of the bodily organs; that higirblood pressrrre, indigestion, diarrhea, pains, or hyperacidit.y mar-'bethe resirlt of r iove affair ', a disastrous sipeculation,"o'" the losjof a'job;and that cause and effect can be derionstrated, whether from"thepoint of view that feeling tone is afiected by phvsical ailments orvice versa. The rvhole pioblem may become i-erv much invoh'ed,but. for practical purpos6s it is important to keep"in mincl that thepat i -err t 's -meut a l a i t i tu t le toward h i i i l l r ress or h is phvsical l randicapis of p_atanrorrnt importance-so importarrt, in fact.^that this attitudein itself may. aceount for so-called frersonaiity charrges arrcl for mrrchof the resulting incapaeity.

During the iast 2 ?trecades the attitude ton-ard the cripnled childhas graduallv changed. Societr'. fanril ies. and intl iyiduali have beeuin tli-e past father frone to r-ieb these unfortrrnate indir-itlrrals svm-patheti iallv vet pes-simisticall. l ' , acceptins them as responsibil i t ies'forhome and init itutional eare whb rrer-e ent-it led to kindlv consideratiolr

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and ad.equate clstodial supervision when facilities l'ere ar-ailable.ittirt ttrd development of improved surgical techuiqrtes, deformitiesancl resultinE ha^ndicaps har.e^been great'l-y reduced. This has meantih;i *rl;i;-"ttita".tt \oho **". sul[ering from a form of physicallrand.ican nret'iortslV considered penrtaneut have had complete colrec-tion of

'thi,t deforfritv. Other ihildren whosc deformities could rrot

Lre correcred have hah nolnral function restored through treatmenLso lhat the deformitv is no longer_ a_handicap. With,better insightinlt_r the incapacituting aspects of the metttal a.ttltude to\raro rnehandicapped. efforts hive 6een made to consider the individual as a*itot" uird to find sonre life occupation in rvhich his defonnity wouldbe minimized and his assets giveh the fullest opport-unity. for exprs:-sion. This attitude on tire part of societV toward the cnppled clrtldlras opened many new channels through-which the handicapped in-dividiral has beei able to find adequate*outlets for his potential physi-cal achievements and his emotional and intellectual satisfactions.Parents, havinq been awakened to this new social optimism in regardto the handicapped child, have felt less sensitive about these rtn-fortunate memb,6rs of the family and as 3 grgup are seekil-g allavailable a.ssistance as soon as thev recognize the ploblern' Undersuch conditions we have a riqht to anticipate earli6r recognition oftho child's needs, better medicll care, irelp-and guidance il-the selec-tion of a vocation. imr,rroved mentil atlitudes on the part of thohandicapped child,'andin general an increase in his happiness and.efficiencv.

The riiost important therapeutic contrib,ution that can b-e given tothe crinnled ctritd is the assirrance that there is a place foihim inlife. th'ai he has a contribution to make to justify liis existence, andthat effort on his part is worth while. Only in this way can,the willto attain the maximum desree of independence be established vithinthe child. When this is ac"complishecl ihe handicapped individtral nolonser ind.ulses in introspection and self-pitv but tirrns his attentionto the outsidE world. where he can norv find guidance and direction inpreparing himself for a life of usefulness.

-It must be kept in mind

iha[ the attitudes which the cripp]ed child assumes toward his handi-cap will invariably be but a rehection of attitudes shorvn- by thoserliih whom he comes in contact during his early 5'ears. The-parentrrho is constantlv remindins the child that he cannot do this or thatbecause of his limitations ir the dansers involved will contributelittle toward helping him build up the attitude of confidence which isessential if he ii to" utilize his aisets to the fullest extent. On thoother hand, if the child is reared in an environment r.vhere his physi-cal limitations are relesated to the background. where he is beingconstantly presented wlth opportunities- and iasks that are weii'within his abilitv. and where his attention is focused toward in-tellectual interests, he soon learns that there are many ways andmany opportunities by which he may compensate for his particularmanv oDportunltles oy \rntcn ne mnv compensate ror nrs parlhanciicarr. Ever.1' hanrlicnpped child should be not onlv lermittedbut encourased tb do everythinq he can possiblr do for himself. andbut encouraged tb do everything he can possibly do for himself, andthe assistanEe that he receiyes Should be timited onlv to those tasksbut encouraged tb do everything he can possibly do for himself, andthe assistanEe ttrat he receiyes Should be timited onlv to those tasksthe assrstance that he recerYes s-hould be rrmrtect onry rc f,nose tasKswhich are definitely beyond his ability. Only in tlis way will heshlch are dennrtelY oeYonct nls aol lr tv. (Jniv ln rnrs waY sl l l neattain that sense oT noi'nralitv and inilependence wlrieh is" esserrtial

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92 HABIT ULINIUS FOI' CI{ILD GT]II]ANC!]

to his ultirnate success. The child lvho has acquired a healthy atti-tude torvald his handicap and a sense of independence wili einbarkupon the tasl< of fitting himself for life with confidence and coluage.'flte nert important step perhaps is that of selecting a voca-tiorr. Here again guirlarrc-e autl ti 'aining are inrportanf,' and theproblem of detErmining the lvork which is best suiteci to his farticrrlurabilities arrd in which his handicap will be least in evidence neeclscareful consideration. The rvise counselor wiil realize that the rvorkshould be selected with the idea of giving the individual not only theopportunity of doing his. particuTal t-ask efficientJ.y but ahd themaximum arnount of emotional satisfactiorr.

Especially careful consideration should be given to the type ofvccation selected for the handicapped child. One natulallv-s-elec{sa field of training that offers op-portunity for subsequent "employ-ment. fnsofar aslt is humauly poisible. tli is particulai sroup of jh-dividuals must be safesuarded irom fiilure. They ar6 inriariablysensitive and are inclined to compare themselyes. tb their o'wn dii-adr-antage, rvith those unimpaired^by handicaps; irnd tliey are prorreto thinFin telms of what t^hev misht have aihieved wer"e it not fortheir handicap. It is. lherefore. iilrportant that thev attain successregardless of irhat the job mav be. This is essential"if confidence isto-be acquiled and if thev ar,i to become self-sustainins in the fieldof induslry. It is obviorislv more difficult for the haidicanped tothrow asirle training in on-e activitv and start over in soin^cthinsnew. No efiorb is tod great nor time ioo precious to spend in helpirr[the handicapped child to overcome thode difficulties and surmbrrn-tthose obstacG which obstruct the path to a happy. useful. productivelife. Every handicapped child mirst be considered as ari individrralneeding special considtration. These children should not be lookedupon as cases to be dealt with in any routine, mechauical rvav. as olre.mient deal rvith a piece of defective machjnerv. Thev ar6'hurrranbeines strtrgglinE to^ make a place for thenrselv6s in an"environnrenbin wlich tliey will meet keen competitiorr, under couditions wbich,to say the le"ast, call for all the hi:lp thai science and human con-sideration have'to ofrer.

One need not look far afield to find shinins examples of the vic-tory which.modern surgery, wise counseling,-and v-ocational guid-ance, associated with confidence and courage, have won for tlrehandicapped child. Many. of these individuils have reached peaksin their achievements, not in spite of their handicaps but because ofthem. Man.y of these voung people have been sfimulated to sreaterefrort, have-acquired a finei ienie of values, have been aror"rsed tohftier ambitions, and have been generally stimulated in the right,direction by viltue of their handiiiap.

It is inriiossible to la.y down specific rules and give definite in-folmation on how to dil 'ect the activities of anv iriclividrral hantli-capped child. Keen appreciation of the desireil objectives and ofthe fact that the case involves a human beins and not iust a de-formity rvill do po"\ to help thc handicapped-child deveiop to lrishighesi degree of usefulness from a ph3'sical and an economic poin0ofniew. It will also create in him a-tti[udes toward himself anil theyo-rld that will gi'r'e him assurance of his own worbh, a feeling ofindependence, an-l a sense of security about life in general.

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MENTAL DEFICIENCY

Although the problem of mental deficiency is not one of primarycorlcern to the habit clinic. it is an important problem of childhoodand one that is clirectlv relhted to beha^vior proble^s. Imbeciles andidiots are obviouslv cises fol institutional

^care. but liisli-slacle de-

fectives must often be cared for in the community. Tlie siiciai mal-adjustments of the latter group are clue not to the mental defect assuch but rather to the accompanying mental instability. Since theadvent of so-called inteiligenci oipslchometrie tests, tlie large num-ber of mental defectives in the population has become more apparent,and it is rerlized that but a limited lurnber can possiblv be c^nied forin institutions. As a group they are, *oreofer, neither bad, norvicious, and they may senre a yely useful purpose in the industrialworld.

tr{ental tests are of real value in determinins within reasonablelimits the intellectual lord which anv child is capable of carryins.Tlte resrrlts of such tests should receit'e serious considelrtion. ho#-er-er', only when t-he tests have been both given and interpreted byone who is expertlv trainetl.

In testing t^he pieschool chilcl there are several points to keep inmlnd:

(1) Considerable time is required to establish frienclly relation-shibd with the child.

(2) I" addition to having the child in a cooperative state of mind,it is frequently essential tb get the intelligert cooperation of thdnrother.

-The ;hild who embdrks upon a psJ'cholosical examination

a{ter having just overheard his mbther iay, "He" is stubborn andl'on't do a thing unless f am right with him," has been given everyincentive to do iothing whetherThe mother is'present or iot.

(3) It is absoluteliessential to have a cliriical psvcholosist whohas sufficient imacinition and flexibititv and has Lah suffiEient ex-perience to eiicit tiie chiidts rnaximum efiorts and to evaluate the re-sults. IIe must keep in mind that these children have not had thestandardized training of the school. Chilclren of preschool age whocome to the clirric are often sliy and reticent, rfraid of new suriound-ings, indifrerent, or inatrcrrtiv-e. Thev may come from homes rvhereliitte train-in-g oi stirnrilation has been offered them. There may belanguage clifficulties. Giving rneutal tests by any rule of thumb istherefole even less l,racticalirith the preschdol child than it is witholder children. If t 'he1' are so applie<I, a shy, diffident, rrnstnble childof srrperior intelligenc6 rnny ap1fuar backwai"S or er-en'defective.

(a) In spite of 'the

advairceiihat have been made in rests to meas-ure the inteliigence of p_reschool children, there are still relativelyfew that are st"andardized. Nonlanguage fests are practicallv essen-tial, and in checking test results a'cer'iain arnount^ of leelviv mustbe given the examiirer. thus allowing for the child's intereJts and

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activities at home and for his fund of gener,ar information, rf itappears worth while to make a psycholosi-cal e-xamination of a child.ql fg!! a sarnple as possible shouid be inade of all his abilities a'idisabilities.

The advantages of these examirations may be s'rnmed up brieflyas follows:

(1). urfortunate and deficient home traininE is shown bv theseexaminatio's at an age when those trends of "mental devel"opmentwhich ale strrnted can be st imulated. rn many cases this impl icslhe .possibility of prevgtlling _speciar disabiliti6s ;"d i"a;"=li'ti"sspecial abilities. The ehild who shows rrnderdevelopment in i"dc,allional or r-erbal fields can be given special storv-iellin'E a,lvantases__can be read to more. The chird witli inferior "manual-ability ca-ri begiv.ql qgr.q and better_opportunities for manual;;;[.-

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.^(2) clrildrerr who haie unusual precocitv of a ipecialized tvne(for music, color, and so_ forth) or_of a gederal sort'may have ih^isprecocrty appreciated and developed.

(3) childrerr examined before starti 'g public-school work ca' bepul rnto special classes to see how muc6 bf tne retardation is realand how mrrch. apprrent, thus avoiding the rrndesirable sequelae ofea'ly.school failul'e,.tlre clogging of nor"mar primary g""d"q ;a-th"stulting of a precociorrs meilil l i iv.,, (1).,Ii is esse,tial for success?ul^therapy with neurotic childrenthat their inteliigence be.knorv-n. obviou^siy the feeble-minded andthe precocious cainot be given the same treatinent.

A careful ps5'cliologic[l exarnination should be considered au im-pott?l.rt and. essentral .part o! gvery attempt to under.stand a childand.his partic.lar problem-. rt is irirportanf to t eep ln ,,' ind thai-rheclrnrc has llot orrLy an oblrgation to the defective child but also aresponsibility to the famiiy iri which that child lives.

-jf is in.""riobli,

necessary to.pornt_out_to parents that the home and the lives of thlenormar people rn that home cannot be built around the feeble_mindedchild. Parbrrrs of. mentailv defectiv*

"tiita.*" ;; ';;; inclined toa,ccEpt,the diagnosis rcgardiess.of how thoroughry itu .u." has been

srucrre(t-; or 1r tney-accept Ure- dragnosis t-hey are prone to seek everyavailable source of help. This State of mind .itt"" iuuJr-l; ';;;-stanl .pu'suit of a cnre for something that is incurable. The emo_!,_::3lll o":r *{-g}gl}t palguts feel that there must U. u" op""ul;o", uctrllg, or.som-e br!.ot medical magic that will create or reitore whatnevcr exisled. {lris tragic, and }athetic situationf ho*e,:*",

-i. ;;;a-lleviated by offerirrg faise hope.' All too tr"quuniiv orrentd de"oie

their time ahd practicalry all iheir _availabi; ;;;;i t6"u.lai"e th"home around rhe abnormil chird. This defrives ii,;;;;l ' i i i i iar.,iin the home of the opportunities -to which they are eniiu"a u"a uJthe same time creates in them_ jealousy, rescntnient, and other unde-sirable nelsorrality traits w.hich preveirt huppy +"riiiV

""iuti*Jiip..rt, is ilre duty b.f- rhe clinic tb iee that physicallv and--m;;i;h"heaithy.children with pgte-ntialilies for woltir-#hit" u'""rri.*-"iri.li:lnot neElected because of the undue sentimentality of the parents fci.the meirtally defective child. }yhat.r,."

"un be done for the defective

child must "be d.one f1'."a"qr"1"^*.ifroar of .a"""1"i""-#d traininc.Direction as to how this tr;inin$ may be best ottai;;d;; t&i;;iby the clinic or othe. sor,rrces tliat aie availablu i" irr"-to--.i"i{,.

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l{AilrT cl,tNrcs FoR cHrr,D GUIDANCTJ 95

Extensir-e srrlgical and medicai procedtires are rarely called for afterthe child has had a careful physical examination and the necessarylabolator5' tests. rn ortler to hellr t lrese distralrqlrt parents to mcerthei r probleur in an in te l lectual .a iher tha 'an ef rot i< inal -sav and tosrfeguard the inte'e.rs.of the horne, the ctinic mrrst pr.esent the prob-lem to them with absolute frankness, regardless of fiow difrculisuchfrankness mav be.

Ihe followi'ngjas.e, although not belonging to the preschool gr.oup,rs an example of what ma-y happen to t-he mentallv defective"chiic[who is also the victim of unintellfuent parents and a-sordid, immoral,poverty-st ricken envi ronment.

A girl 13 years of age was seen in jail while being held for trial because shehad pushecl a little boy 4 years old into the watei, causing his death, Thefamily background in this case was particularly bad; poverly, ignorance, anclvlce each played a part. x'or a long time the girl had been recognized as amenace to the community, and efforts had been made by the Society for thePreyention of cruelty to children to have her cared for in an institution. Themother' however, resented any interference from outside, and the case was aI-lowed, to drift along, one unhappy incitlent following another until this finaltragedy, whlch demanded the attention of the law.- rt_was said that 2 years before, while bathing, this girt had hekl a youngster'shead under water until the youngster was nearly drownetl. A year'befoie shehad voluntarily hact sexual relations with a man. At frequeni intervals lessserious incidents had been brotight to the attention of the tamily and varioussocial organizations,__In the psychological examination she gracled at a mental age of gy2 years.rrer emotional reaction during the examination, however, was"a fair c-riterionof her irresponsibility,

when first visited in the jail she was very much eoncerned over the faetthat she was being detainecl and could not go to the beach with her aunt.she showed little or no concern about the death of her playmate or aboutwhat w_ould even_tually happen to her. she did, however, manitest some anxietyover what the deceased lad's older sister \\'ould do to her, as the sister hadthreatened her before she had been sent to jail

At the time of the next visit she was very rnuch upset because she was rrotallowed to have the papers in order to read aboul herself and what hadhappened. rt was almost impossible to hold her attention on any subject. shewould constantly revert to the fact that,'she wanted to read about herself trurtsee what it said" and "the other prisoners who had the papers wouldn'f perrnither to see them." The laek of normal emotional response and the absenec ofconcern regarding the youngster whose death she had caused are characteristicof many of the h,rgber-grade mentally deflcient individuals, and it is this insen-sitiveness to praise and blame and laek of ability to learn from previous ex-perience whlch make them _a -m-enace to soeiety ind require some- type of in-stitutlonal tralnlng for an in.rlefinite pertod. Niany of tirese inoivioiit., nooo-eve-r, eventually become stabilized through institutional care and are able tomq_Ee- satisfactory adJustments ln the community in later life.

This case i,vas dlsposed of by eommitment to in institution.

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CONCLUSION

The malerial as presented indicates two things: First, that there isstill much to be leirned about the art of trainins chilciren and thatwe are still in search of rnore adequate ways of dvercoming undesir-able habits and straightening out twisted personalitiable habits and straightening out twisted prthat there is an orderly, systematic, scientific

ies; and second,that there is an orderly, systunatic, scientific approach to these prob-Ienis which will produc6 itrc.easir-tgly satisf^aitory results as ourknowledge advances.

Habits of eatins. sleeping. and elinrination are of fundamental im-poltance in tlie divelopnren-t'of the child's earlv life, ancl it is nroundth"r" tro"*ul function's that many more serio"us difrculties occur itrlater life.

It has been pointed out that there are inherent difrerences in theway children are constituted mentall-y as well as physically. There-for'e, it is not reasonable to expect all" children to ine"et the same typeof life situation in exactlv the same wav. In fact. it has been shownand demonstrated by cas6 material thai their responses may bo verydiverse. One child fights while another flees I one basks in the warmthof attention ancl alfe"ction while another is'made self-conscious anduncomfortable bv the same experience I Johnny worries over anYminor deviationirom the famiiy moral'c''de while Tommy rejoicdiin his success in outwittins his p'arents. his teacher. or the pblieemm.The point is that each chiid is in need'of personal'studv aird invcsti-gg,tioh, and no general scheme for handling problems 6f behavior isIikelv to be of anv sreat value.

Tfie attitudes df "pu.ents rvhich may result from their own iu-adequate training arid unhappy experidnces in life have been shot'nto be among the most detrimental influences to the child during theformative vears. and much that is of value in clinical anC. educationalefforts resfrlts from helping parents 'rvith their own personal plob-lcms as thev are reflected'-iri their attitudes toward the children.One must continuallv remind those dealinE with parents that it isnot sufficient to point out the faults in their"attitudis and techniques.'[ 'hev rnust alsobe made to understand whv thev persist in carrvirrsout fhese attitudes in spite of the fact that [h"v Laoe been confroirtedu'itlr failure over a pe^riod of vears. The point is that parents ;rrequite unconscious of ihe fact tiat they are ieacting on ari emotionalt,ntLn" than on an intellectual level. "

ft is, therefore, important that the existing emotional attitudetoward'the child ihouid not be exaggerated by the parents' visit tothe clinic. It requires nice iudgmeAt to impiess the parents withthe necessity of giving serious co--nsideration tb the mental health ofthe child iri ord6r to-avoid difficult problems latpr on while at thesame time giving them understanding and confidence to replaceworry and anxrety.

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HABIT CLINICS F'OR CHILD GUIDANCE 97

., T4" re.spo'sibility for the mentai health of the chiid must rest i't4e lrancls of parents, teachcrs, nurses, and the familv phvsicirrn.I'he. same .cooperative spirit in the management of the chiid,s be-havror as is evident in dealing with physical jrealth and educationwill contribute much to the.fut-ure hap'prfress.and efficienct ;f-; i;"S;army of children who would otherwis6'embark upon life h"a,iaicappEtby habits, attitudes, and personality traits nliich result in-a^eiin_quency,,pecq,liar soc_ia.l behavior, antagonistic attitudes torvrrd par.-ents and_s^ociety, and in an introspectiie, analr-tical approach to'ljfeyh,g.g i"l{ rF always so much in the f'reground that if prevents tlrerndrvtctual rrom gettrng the proper perspective of his enviroilmeutas a whole. 'r'hese'crstortions in outlook, 'rvhen thev are not causedby mental disease, are inva.riably the prohuct of wliat the child hasacqurred_{rom hls ss1ly tt.uili"g and experience. rnsofar as possible.it is the duty and responsibility of parerits to see that the earl'y caree'of the qhjla i. so guided and-planned that he will avoid th6 shoalsupon which many are wrecked.

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