Child Abuse and Nelle~, Vol. 3, pp. 1001-1083. 0145-2134/79/0901-1081 ~2.00/0. © Perlpunon Press Ltd., 1979. Printed in Great Britain.

MINOR N~J~LOGICAL DISABILITY AND CHILD NEGLECT - A CASE HISTORY

Howard Rober t s , Sen ior R e c l s t r a r and

V i r g i n i a E l l i s , Nursery Nur se /The rap i s t

C h i l d r e n l s P s y c h i a t r i c Day Hosp i t a l , S t . Thomas' Hosp i t a l ,

London S.E.1 .

The problem In t h i s paper , a family who r ece ived t r ea tmen t a t S t . Thomas' Hosp i ta l

w i l l be d e s c r i b e d . The family were middle c l a s s and c o n s i s t e d o f the mother, f a t h e r and t ~ sons a~e 2 and 6. There was an x i e t y about the care and pro6~wss o f the youn6~r c h i l d ~Jobn) and the mother was becoa tn~ a f r a i d o f he r v i o l e n t feelin6~s towards him.

Jo lmls f a t h e r had r a r e l y s een h i s own f a t h e r i n ~ l d h o o d , and as he saw h imse l f as a w a l l - a d j u s t e d adu l t , he concluded t h a t ¢htldTen did not need t h e i r f a t h e r s , and t h a t h i s son d id not need him. He was i n t o l e r a n t o f h i s sonO8 immatur i ty , and was c o n t i n u a l l y p a d i n g him i n t o i f : e a t e r independanoe. He r s s e n t e d t ime spen t wi th h i s son, and reKerded the ch i ld lwn 88 h i s w i f e ' s r e s p o n s i b i l i t y . This f a t h e r was re~arded by o t h e r s as a cold , immature uan.

The mother who f e l t t h a t she had f a i l e d to meet her p a r e n t s expec ta t ion8 o f her , saw h e r s e l f u an inadequa te adu l t . She thousht t h a t her tamaturit4r. r e s u l t e d f r o : he r owe :p ro tec ted chi ldhood, and was most anxious not to ove r - p r o t e c t her ova o h i l d r s ~ . She t h e r e f o r e expected from her 2 y e a r old son behav iour which would normally be expected o f an a d u l t . Thus, she co l luded wi th her husband ' s bohaviour , but f o r a d i f f e r e n t reason . While J o h n ' s b r o t h e r could apparqmtly cope wi th these p a r e n t a l ~ e x p e c t a t i o n s , John had a i i n o r n e u r o l o g i c a l l e s i o n which kede him demand more care from h i s p a r en t s than they would concede. The m o t h e r ' s i n a b i l i t y to s a t i s f y J o h n ' s demands increaned her feelinLm of failure and she in turn demanded more reassurance from he r husband. The husband could not t o l e r a t e t h i s , and he became more prone to tamper o u t b u r s t s . The mother became i n c r s a s i n ~ l y d e s p e r a t e a t he r i n a b i l i t y to he lp her son, and as her d e s p e r a t i o n became g r e a t e r , she became i n c r e a a i ~ g l y prone to v i o l e n c e .

The fmtil~'s solution The f a t h e r was convinced t h a t a l l problams could be so lved by the

i n t e l l e c t . He dec ided t h a t h i s wife and son were too dependant , and concluded t h a t h i s son~s behav iour was d e l i b e r a t e l y des igned to annoy them. He s u ~ e s t e d t h a t h i s wife should becoue more independent, and thought t h a t h i s son should be ignored . These s o l u t i o n s were r e a d i l y accepted by the mother and o v e r t c o n f l i c t s w i th in the family subs ided , althot~gh no communication now took p lace between husband and wife , and the c h i l d was slowly s t a r v e d , as he could not cope wi th feedln8 unassisted.

The t r sa tman t John had p a r t i c u l a r d i f f i c u l t y i n chewin~ and swallowin~ and needed he lp

p a r t l y f o r h i s l ~ n e r a l h e a l t h and p a r t l y to r e l i e v e m o t h e r ' s anx ie ty over he r i n a b i l i t y to manase him. The p a r e n t s needed to acqu i re more oonfidanoe i n t he handl in~ o f t h e i r oh t ld and i n a d d i t i o n , to d e r i v e more p l e a s u r e from family i n t e r a c t i o n s . This r equ i red suppor t and i n t e r v e n t i o n by an in tefgra ted t h e r a p e u t i c team o f ward s t a f f , day h o s p i t a l s t a f f , p s y c h i a t r i s t s and

~ aedi a t r i ot ane. i ) I n - p a t i e n t t r e a tmen t . I t was c l e a r whea~ the family were refezTed t h a t

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1082 H. Rober t s and V. E l l i s

John would re t u i r e bo th i n - p a t i e n t and day h o s p i t a l t r e a t m e n t . He was admi t t ed to a p a e d i a t r i c ward and e s c o r t e d d a i l y to the Day Hosp i t a l f o r s p e c i a l i z e d he lp . Although John was a c h e e r f u l , p l a y f u l c h i l d on the ward, initially he showed no signs of pleasure when his parents visited. The mother was a t f i r s t persuaded and l a t e r encouraged to he lp t he n u r s e s ba the and p lay wi th him. Gradual ly t h i s r o l e was t r a n s f e r r e d f r ~ the n u r s e s to t h e mother , and as t h i s took p l a c e John and h i s mother showed i n c r e a s i n g pleasure at her visits.

The father was reluctant to come at first, but when he came he was also encouraged to play with John. At first he felt very awkward with his son, but when it was pointed out to him that John was imitating his behavlour and using him as a model, he rsco~lized for the first time the reolprQcity in the relationship. His interest increased, he became less self-consclous in his play with his son and for the first time seemed to derive some satisfaction in his parental role. (ii) Family therapy. Family therapy sessions were instituted by the psychiatrist. These puzzled the parents, as they felt that the problem was within the child and although they agreed to collect him when better, could not see much point in discussing thin6~ in the meantime. They did attend however. The sessions were characterized by a denial of all feelings positive and negative within the family. No one would admit to having f e e l i n g s f o r aDy~no, and they co dld no t accep t t h a t anyone aright have f e e l i n g s f o r them. The aim o f t he s e s s i o n s was to f a c i l i t a t e p o s i t i v e i n t e r a c t i o n s w i th in the f ami ly and to make t h e s e i n t e r a c t i o n s reward ing by drawing the p a r e n t s ' consc ious a t t e n t i o n to them. ( i i i ) D~y Hosp i t a l t r e a t m e n t . At f i r s t a ward n u r s e s t a y e d wi th John a l l day, bu t as h i s new env i ro r - , en t became more f a m i l i a r to him she was ab le to l eave him wi th the Day Hosp i t a l s t a f f . He came fou r days weekly, and was i nc lude d i n a smal l group of p ro - s choo l c h i l d r e n i n charge of a n u r s e r y n u r s e / t h e r a p i s t . He was demanding and a t t e n t i o n - s e e k i n g and was very anYtous. He fol lowed h i s t h e r a p i s t around, whining and o l i n ~ i n g to he r s k i r t . He u t t e r e d a few echoed words, bu t no spon taneous speech , and h i s d i f f i c u l t y i n chewing and b i t i n g - p r e v e n t e d him from s a t i n g s o l i d food . His r e s p i r a t o r y rhythm was poor ly i n t e g r a t e d with h i s o t h e r behav iou r , and t h i s exace rba ted h i e d i f f i c u l t i e s in swal lowing and speak ing . Co -o rd ina t i on and b a l a n c e were poor , and he was n e i t h e r ab le to k i ck a b a l l , nor put h i s hands t o , e t h e r to ca t ch one. He frequently fell over. He showed few signs of ima61nation in his a t t em p t s a t p lay and did not know the used n u r s e r y rhymes and games. His s o c i a l awareness was poor ly developed, and he made no a t t empt to p lay wi th o t h e r c h i l d r e n . Some p o s i t i v e a t t r i b u t e s were a l so noted d u r i n g h i s e a r l y days i n t h e Day H o s p i t a l . He d id f o r ex-~ple seam more aware o f h i s s u r r o u n d i n g s than i s u s u a l wi th m o t i o n a l l y d i s t u r b e d a h i l d r s n , and he was ab le to t r u s t t hose a d u l t s he came to know.

His mother visited daily. She was anxious and there was little sign of recognition when she and John met. She was encouraged to pick John up on arrival and to talk to him. She bec-,ne much more anxious when John wet his trousers, as she feared that if her husband discovered this he might reprimand them bo th .

Meal times were relaxed and at first food was m~shed very finely. Later he was allowed to play with pieces of food, and @Tedually after watching and imitating others, and allowing him to feed hie therapist, he started to feed himself. He became very proud of his ability to swallow, and swallowing was accompanied by a round of applause from other children in the 6"reup.

Re participated in group games and ~ongs, and this helped to minimize the other disabilities described above. As his co-ordination imnroved with euryt~my, his enjoymen~t of games increase~, ae became able to pAay DaAA games with other children and participated in their imaginary games. Later he both stirred biscuit ingredients and bit and chewed biscuits he had made.

His father attended occasionally. He expressed disapproval of the bad habits that his son appeared to be learning. John was for example allowed to make a mess with his dinner. Gradually however, he recognized the positive things that his son could now do, and he began to t~ke more interest in the treatment.

Minor Neurological Disability and Neglect 1083

The mother also appeared oblivious to the progress John was making, and daily discussions with hie therapist were therefore organized and she was encouraged to continue the Day Hospital activities at hone when he began to visit on weekend leaves. She was also encouraged to respond to his positive behaviour~ rather than his whining.

Gradually she became less anxious, as her skills increased. John's brother became Jealous of the attention given 1o John, and he was therefore invited to participate in Day Hospital activities. Later the parents took John hone for the weekends. Father was, by this timer proud of his son's progress, and saw himself as the person his son used as a model.

The parents started to enjoy playir~ games with their children at home, and eventually after six months John was discharged~ mother being told thst she oould~ if she wished ring the hospital when she was worried about his behaviour.

A okno wl a d 6 ~ e n t We would like to thank, Dr. EVa Frommer for her invaluable help ~

encouragement in the preparation of this psper, Mrs. Mary Reid for her assistance with the treatment and advice with the paper and Miss Eva G~erligs for typing it ~or us.