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HABIT CLINICS
FOR CHILD GUIDANCE

CHILDREN’S BUREAU— U. S. DEPARTMENT OF LABOR

G5l 7
'S '8 c .

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UNITED STATES DEPARTMENT OF LABOR

F rances Perkins , Secretary

CHILDREN’S BUREAU

K atharine F. L enroot , Chief

HABIT CLINICS
FOR CHILD GUIDANCE

D. A . THOM , M . D.

Bureau Publication No. 135
(Revised 1938)

United States Government Printing Office
Washington : 1939

For sale by the Superintendent of Documents, Washington, D. C.

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Price 15 cents

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CONTENTS
Letter of transmittal__________________________________________________________
Introduction__________ ____ ; ------------------------------------------------------------------------ - Habit-clinic personnel and procedure------------------------------------------------The psychiatrist------ --------------------------------------------------------------------------------The psychologist___________________________________— .1 --------------------------The social worker_________________________________________________________
Habit-clinic procedure------------------------------------------------- - — -------------------Cooperation with other community agencies---------------- ------------------------The child and his personality----------------------The parent and the home------------------------------------------------ _ _ _ _ _ _ --------------------Habit problems associated with eating, sleeping, and elimination---------- —
Eating habits______________________________________________ _—
---------Habits of elimination___________________
Habits of sleep-------------------- ------- ---------- ----------- _ _ _ ------------- -------------------- :
Resentment towards frustration expressed in aggressive acts---------------------Anger and temper tantrums_____________________________________________
Destructiveness______________________________
Delinquency________
Retreat as a method of meeting failure______________________ ________________
Problems associated with the development of the child’s sex life-------------------Personality changes following illness and injury_____________________________
Convulsions, tics, mannerisms________________________________________________
The crippled child--------------Mental deficiency---------------Conclusion---------------------hi

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LETTER OF TRANSMITTAL

n it e d

S tates D

of L a b o r ,
C h il d r e n ’s B u r e a u ,

epartm ent

Washing ton, November 23, 1938.
There is transmitted herewith a revised edition of Habit
Clinics for Child Guidance, first published in 1923 as Habit Clinics
for the Child of Preschool Age, by Dr. D. A. Thom, director of
the habit clinics o f the Community Health Association of Boston
and director of the division o f mental hygiene in the Department
of Mental Diseases of Massachusetts.
The revision is an enlargement of the original edition, based on
Dr. Thom’s experience in the habit clinics over the past 15 years. It
is believed that the method developed by Dr. Thom and here set
forth will be of interest to all concerned with the physical and
mental health o f children.
Respectfully submitted.
K a t h a r i n e F . L e n r o o t , Chief.
Hon. F r a n c e s P e r k i n s ,
Secretary o f Labor.
M

adam

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HABIT CLINICS FOR CHILD
GUIDANCE
INTRODUCTION

Fifteen years have elapsed since the Children’s Bureau published
a report entitled, “ Habit Clinics for the Child of Preschool Age;
their organization and practical value.” This report was the first
o f its kind and embodied what at that time represented a fairly
comprehensive review of the organization and development o f the
first clinic in this country to deal specifically with the mental health
o f the preschool child.
Since the preschool period is the habit-forming period, this clinic
was called a habit clinic. It was felt that there was a real need for
this subject of the mental health o f the child to be presented to
parents, teachers, nurses, and general practitioners in a way that
could be utilized by these various groups in their everyday contact
with children. It was therefore not considered within the scope of
the publication to discuss the psychological mechanisms which mo
tivated the type o f conduct that brought children into conflict with
the group or rendered them unhappy and inefficient. The author
has repeatedly stressed the need of reducing mental hygiene to terms
that would have a practical value to those individuals making daily
contact with children. The last 10 years have borne witness to the
fact that those mental-health clinics which have rendered a real serv
ice to the community— that is, to the home; the school, the hospital,
the medical clinic, and organizations concerned with child welfare—
have survived. They have created for themselves a place o f im
portance in the fields o f parent education, pedagogy, and medicine.
It has now seemed wise to revise the report in order that it may be
more useful to those interested in this field.
In the revision the name habit clinic has again been used rather
than child-guidance clinic, as the publication is concerned primarily
with preschool children and many o f the problems of older children,
dealt with in most child-guidance clinics, are not discussed. The fol
lowing discussion will be open to the criticism o f being rather super
ficial and lacking the precise technique necessary for the solution of
many o f the more complex problems with which parents .are con
fronted. It may be said, however, that in dealing with these obvi
ously more involved situations, parents must necessarily seek help
from those who have had training and experience in this particular
field. Parents do not treat fractures or serious infections, nor do
they attempt surgical procedures; neither are they equipped to solve
the more serious problems pertaining to the mental health o f the
1

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child. Experience, however, has led us to believe that the parent, the
teacher, the nurse, and the general practitioner are in a position to
render valuable first aid. They can prevent the development o f many
serious mental problems if they are equipped with such knowledge of
mental hygiene as falls well within their grasp.
From a practical point of view there is a large group of cases which
will benefit from the understanding and guidance that can be given
directly in the home, where the problem originates. It is recognized
that there are exceptional cases so complicated and involved that they
will tax the skill and ingenuity of the specialist. The outstanding
question is how the clinic can best serve the community in which it
is located, the health agency with which it may be affiliated, and the
school and social agencies which are dependent upon it for advice and
treatment. Its function is not limited to the treatment of indi
vidual cases but should include, for educational purposes, the dis
semination of such knowledge as has been acquired by experience.
In the organization and development o f clinics it is necessary to
be practical, and this requires that one evaluate the total situation.
A physician, a social worker, or a nurse may complicate a home situa
tion instead of helping it unless the family rather than the indi
vidual is kept in mind as the unit. For example, it may be much
easier for the mother o f five children to wash extra sheets three or
four times a week than to bring a youngster afflicted with enuresis
to the clinic the same number of times. On the other hand, much
may be accomplished with only the minimum o f inconvenience to the
mother if a weekly clinic visit is made. Without minimizing the
value of intensive work or implying that one method will be applica
ble to every case, it may be pointed out that many o f the problems
presented at the habit clinics have been treated successfully by
merely directing attention to something that was obviously wrong
in the environment. In other words, there was no need to use a
pick and shovel when a rake would do the work. An important
causative factor may easily be overlooked by parents, a nurse, or
even the family physician, and yet be quite apparent to a welltrained psychiatrist.
Inasmuch as the behavior of the child represents the response which
that particular individual makes to his environment, the clinic must
have first-hand knowledge o f this environment. An irreducible
minimum for an investigation should be outlined and carefully fol
lowed in every case in order that important environmental situations
directly affecting the conduct o f the child may riot be overlooked.
This part o f the clinic program should be carried out by a welltrained social worker, who, by virtue o f her training, is in a position
not only to describe environmental situations but also to interpret to
the psychiatrist how these particular situations are affecting the child.
She must be in a position to evaluate the social, economic, cultural,
and intellectual level o f the child’s home and the surrounding condi
tions, the personalities with whom the child has to deal, and the
adjustment of these personalities to one another. She must bring to
the attention of the clinic the facilities in the community that can
be utilized in helping the child to make a better social adjustment.
In order to understand the behavior o f the child, an appreciation
o f the intellectual differences in children is also necessary. This

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part o f the program is in the hands o f the 'psychologist, who obtains
the information relative to the child’s mental equipment, his attitude
toward work, his ability to concentrate, and his particular interests
and aptitudes. The psychiatrist must take all the available informa
tion, together with the material gathered from his direct personal
contact with the child and the parents, interpret this information,
and utilize it in making a plan. This plan must take into considera
tion not only the particular problem for which the child was brought
to the clinic but the child’s adjustment to life in general.
Although a clinic for child guidance is concerned with the child,
the family must be considered as a unit. Where there is a problem
child, not infrequently the mother, father, brother, sister, or. some
other relative represents the offending aspect o f the environment.
It is likely that certain parental attitudes need to be altered. Per
haps the behavior o f a problem brother or sister must be treated.
A change in schools may be necessary. Foster parents may have to
be introduced as a temporary expedient. Possibly help must be
sought from social agencies interested in relief, placement, and obser
vation o f children under supervision. It is not unusual to find that
thé child who has been brought to the clinic is not the one who is
most in need of treatment. The shy, diffident, well-mannered child in
grave need o f help may have been left at home while his much betteradjusted, tempestuous brother who causes his parents annoyance has
been brought for help. It frequently happens that two or three
members o f the same family receive clinic treatment at the same time
or that several members of the same family benefit by the treatment
which one maladjusted member receives at the clinic.
Mental hygiene has made great strides during the last 10 years,
and the general public is very much better informed about the im
portance and value o f mental health. The time has already arrived
when the larger social agencies are finding it necessary to have upon
their staffs someone well trained in child-guidance work. Already
such agencies have clinics for both children and adults. It has be
come an absolute necessity for all organizations dealing with the
problems o f human beings, whether it is with reference to disease,
poverty, or delinquency, to have some knowledge of mental hygiene.
The necessity of recognizing the importance o f mental health has
been stressed by the leaders in the fields o f sociology, penology, in
dustry, and education.
There is still a long way to go, however, before parents in general
will be as deeply concerned over defects in personality and over
undesirable habits as they are over physical ailments. There are
advantages in small, informal clinics wherever they can be established
in the community as an adjunct to highly organized mental-health
clinics which are always available for service. The ideal place for
one o f these clinics concerned with the mental health of preschool
children is in association with other services for children, especially
general health clinics. A clinic serving preschool childreïi and some
older children can be assimilated easily by a health center and it can
operate as part o f the medical routine. There must be some more
highly organized mental-health centers here and there, with oppor
tunities for research work and training. A medical background
is absolutely essential to clinics interested in mental health. Every

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child must have a careful physical examination, and all abnormal
conditions having a physical basis should be corrected before any
attempt is made to interpret the symptoms on a psychogenic basis.
There is no branch o f medicine in which greater care is needed to
prevent the introduction of all sorts of quacks and charlatans than
psychiatry. The association of a mental-health clinic with a recog
nized medical organization stamps its work as part of a well-rounded
and well-qualified medical program.
The simplicity o f such an organization has much to recommend it.
It has the advantage o f offering to a community a service that is as
vital to its welfare as the school or the hospital. It offers to the
parent, the nurse, and the teacher valuable aid in developing a
happier and more efficient group of children. It permits the individ
ual child who is momentarily out of adjustment with life the oppor
tunity of understanding himself as well as being understood by those
upon whom he is dependent for his rehabilitation.

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H ABIT-CLIN IC PERSONNEL AN D PROCEDURE

In the routine clinical procedure o f the habit clinic the close co
operation between the psychiatrist, the psychologist, and the social
worker will be stressed repeatedly. Although each has a specific
job in which he excels, there is no sharp line of demarcation. In
fact, an occasional invasion o f one into the territory of the other
is to be desired.
It is the function o f the clinic and the purpose of the combined
groups to make a careful investigation and study o f the child’s
behavior, his mental attitudes, and his personality deviations, and to
evaluate his assets as well as his liabilities. It is the purpose of
such an approach to understand and eventually to straighten out
asocial and undesirable tendencies before they become a fixed part o f
the child’s personality make-up. I f this is done many children will
approach adolescent and adult life unhampered by the crippling in
fluences of their early training and unhappy experiences. There is
reason to believe that a relationship exists between the emotional
instabilities and conduct disorders o f early life and the problems
o f delinquency and neurotic disturbances later on.
TH E PSYC H IATRIST

The psychiatrist is the logical person to act as the director of any
clinic whose function is to study and treat behavior problems. He
is a medically trained person who has specialized in mental health.
Hence, he not only is concerned with behavior as it affects the in
dividual’s conduct in relation to the community but is also seeking
the motivating forces which lie behind those inner conflicts leading
to unhappiness and inefficiency. Only a medically trained person
who has also had training in psychiatry is qualified to decide which
cases need physical treatment and which cases can be helped only
by psychotherapy. He must also see that cases needing both types
o f treatment are adequately cared for.
The psychiatrist is dependent upon others o f the clinic group for
complete understanding o f the child. He needs information from
them in order to outline treatment and see that the child is properly i
supervised. Details of therapy may be carried on to advantage b y '
the psychologist, the social worker, or the speech worker, but the
final decision should rest with the psychiatrist. A well-organized
clinic group will have no difficulty in determining just where each
individual fits in best if the prevailing spirit is one o f cooperation.
The psychiatric interview must be so conducted that the parent feels i
at ease. (See case presented in section on Habit Clinic Procedure—
Interview With Psychiatrist, p. IT.) The psychiatrist should try to j
win the confidence o f the parent. This can be done only if the parent I
is convinced that the doctor is interested in understanding the prob
lems confronting the child and those o f the parents as well. It is
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fair to assume that if the parents are making mistakes in the train
ing of their children, they are not doing so willfully and viciously.
They are without doubt anxious to discover what mistakes they are
making and why they are, prone to make these particular errors.
It tends to build up a parent’s self-esteem and make him feel capable
o f carrying out the details of treatment if the psychiatrist and the
other clinic workers treat him as a responsible being. There is
danger, at times, that the psychiatrist will take advantage o f his
position as the one in authority. By a critical, unsympathetic atti
tude he will humiliate parents with all the obvious mistakes which
they have made. He will send them away from the clinic more dis
couraged and less able to cope with their problem than when they
came. It is a very delicate piece of work to deal with a mother
who has been a failure with her child (for this is often the problem),
especially if one has to point out the seriousness o f the difficulty as
well as the difficulty itself. It is in this respect that the habit clinic
differs from most agencies. Hospitals, schools, and many other or
ganizations have the law behind them, or if hot the law, the fear of
death or destitution, or an actual and conscious want, and they afford
concrete and tangible assistance. <The habit clinic has no definite
authority but has to depend for its cooperation upon the parental
instinct and a friendly contact, and its assistance is at times very
subtle and intangible.
The psychiatrist examines all the information which he himself
has collected from his interview’s with parent and child, together with
that obtained by the social worker and the psychologist, and from
medical reports. He then attempts to interpret the child’s behavior
in terms o f his personality make-up and his environment. Here is
where the psychiatrist tries to apply to this child his knowledge about
children in general. He is seeking to determine the hopes, interests,
ambitions, love attachments, grudges, fears, and disappointments
which have created conflicts within the child himself. He seeks to
discover just how these conflicts have affected the child and his re
lationship with the w'orld in which he lives. He is concerned with
what can be done with those environmental situations which create
emotional turmoil in the child. Parents are by far the most import
ant influence in the child’s environment, and so it is their attitudes
that cause the psychiatrist the greatest concern. The conditions
and relationships m the school and the neighborhood are likewise
important, as is the social, economic, and moral status of the family
in their particular community.
The relationship between the psychiatrist and the child is one that
requires time, patience, judgment; and understanding. The psychia
trist has no instruments with which to measure resentment, humilia
tion, fear, jealousy, and other less w’ell-defined attitudes which the
child may be experiencing. We know’ that the child who is in con
flict with himself and his environment is usually unhappy. He is
not satisfied with his lying, stealing, or truancy. Rarely is it an end
in itself; it is merely a means o f escape from some situation which
is felt to be intolerable. It is with these intangible problems that
the psychiatrist has to deal, using such understanding as his exper
ience, education, and training permit. Perhaps his success is due

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more to his inherent wisdom and ability to understand the motives
that actuate human behavior than to his psychiatric knowledge.
Both are essential if one is to succeed in being helpful to the child
in trouble and to his worried, harassed parents.
In the majority of cases the results are good. In some the im
provement is quick and very marked—in the mother’s eyes a miracle.
In others the progress is slow and the condition is complicated and
not fully appreciated by the mother, who takes the attitude either
that it is useless to come to the clinic as the child is not improving,
or that the problem is too unimportant to bother with. In either case
there must be frequent calls at the home in order to educate the
mother and insure the proper following out of the treatment. Sooner
or later these children show the effect o f the work done upon them,
and the mothers express their gratitude. It is in these cases that the
social services are most important, as the results depend upon careful,
persistent, tactful work that means not merely a series of calls but
a program o f education.
It is essential that the psychiatrist who deals with the behavior
disorders o f childhood should be optimistic as well as patient. All
too frequently many of the problems which are brought to the clinic
have been in the making for a long time. These habits have become
firmly fixed, and they are very much a part of the individual. Atti
tudes built up as the result of long-continued, unhappy experiences
are not eradicated easily. The psychiatrist must devote weeks,
months, and sometimes years to the treatment of a single case. At
times he must even acknowledge failure. Yet he must always think
in terms o f the future and in terms o f success.
TH E PSYCHO LO GIST

The duties o f a psychologist in a clinic devoted mainly to the prob
lems of preschool children are many and varied. What they are will
depend upon the problems of the individual children seeking clinical
help. At one time his function may be to determine the level of memtal development that the child has reached; at another, to throw some
light upon the reason for slow language development; or yet again,
to give advice upon some school problem, of which there are many.
Since the contact o f the psychologist with the child usually covers
a long period, he is in a position to observe any special handicap
that the child may have. Loss of hearing, defective eyesight, in
articulate speech is sometimes discovered; even a peculiar manner
ism may sometimes serve as a clue to some more obscure difficulty
which leads to the child’s being directed to the right sources for care
and treatment.
When one seeks to reconstruct the behavior of a child by the for
mation of correct habits, much depends upon the child himself. One
o f the first questions that confronts a worker is the native ability of
the child, or in other words, how much may be expected of him
in the reeducational process. It is to the psychologist with his
specialized training that one looks for an answer to this question.
The various studies made in recent years upon the development of
child life indicate that mental development proceeds in an orderly,
continuous way. A child must attain the lower mental levels before

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going on to the higher. By administering and interpreting many
standardized tests now available it is possible to determine different
age levels. Has the child reached a level that one o f his age usually
reaches, or has his mental growth failed to keep pace with his
chronological years ? On the other hand, has his mental age gone
beyond his chronological years? It is essential that these funda
mental questions be answered first, for many problems arise through
ignorance o f these facts alone. To expect a child to function on a
level o f which he is not intellectually capable only brings strain arid
stress to both child and parent. On the other hand, many problems
are often created by failure to recognize that a child’s mental de
velopment is beyond his chronological age. A few cases will
illustrate this.
Sylvia is a child whose mental development has not kept pace with her
years of living. A t 6 years 8 months she was brought to a clinic primarily
for her many fears. Fears of animals, of strangers, and of school were among
them. There were other problems of stubbornness, temper tantrums, and too
much dependence upon her mother. She had entered the first grade in the
public school but was soon excluded because of her peculiar behavior. She
gave no attention to the subjects presented but wandered around aimlessly,
talking to herself.
Careful study of Sylvia showed a high degree of mental retardation. In
most respects she was capable of doing no more than the average 4-year-old
child is able to do. Expecting her to hold her place with children some 2 years
in advance of her mentally, necessarily led to difficulties. Furthermore, in
the treatment of any of Sylvia’s problems one will have to keep in mind
the immaturity of the child and expect no more of her than she can attain.

Jean represents a child whose difficulties were due in part to advanced
mental development. Poor adjustment to kindergarten, a strong desire to
dominate, and resistance to authority were some of the problems for which
her parents sought clinical guidance. Although Jean’s chronological age was
only 5 years 8 months, tests indicated that she was over 8 years in her mental
development.
She wa recognized by both parents and teachers as a bright
child, but at no time had her true ability been recognized. It can readily
be seen why Jean did not find school work on a kindergarten level interesting.

Slow speech development is a problem which usually gives a parent
much concern. Many children are brought to a clinic for this rea
son alone. With such a case, the role o f the psychologist is very
important. It may even be that the problem is solved by the psycho
logical study alone, for tests may determine that the child has not
reached the mental age at which speech develops. The speech re
tardation may prove to be only a part o f the child’s general
retardation.
The services of the clinic were consulted in regard to Celia’s slow speech
development. She was 6 years 3 months of age and had begun her first-grade
work in school. From this she was soon dropped. Two older sisters were
spending much time trying to teach her but with little success. In spite of
their effort Celia had only a few words at her command. Her problem was
soon solved, for all tests showed that Celia had not reached the mental age
at which speech develops. Her slowness in talking could be explained by a
mental retardation below thè age at which a child begins to use language.

There may be other reasons why a child is not learning to talk.
Chief of these is deafness or loss of hearing.
Grace represents such a case. A t 4 years of age she had acquired scarcely
any vocabulary. Several tantrums at times made it difficult for the parents
to discipline her. In the tests that could be given her at the clinic she re-

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sponded like a child of average intelligence. However, her behavior suggested
deafness, and a hearing test was recommended. Audiograms showed that the
child suffered from marked impairment of hearing. In this case slowness in
learning to talk was due to deafness and called for very different treatment
from that of a child whose poor speech is due to mental retardation.

Proper school placement is o f great importance for the mental
health o f the child. School failure should be avoided whenever
possible. Formerly little attention was paid to a child until he had
failed two or three times. Attempts are now in progress to make
such adjustments much earlier, with the result that the clinic services
are often consulted when it looks as if the child will not make the
grade during the first year. In this way, failure, with its emotional
effects, is often averted. More enlightened mothers are even bring
ing their children to the clinic to determine their readiness and fitness
for school. For these problems the services of the psychologist are
very necessary.
Robert was a little chap whose age allowed him to enter the first grade.
His mother questioned his readiness and came to the clinic seeking advice.
A ll tests confirmed the mother’s suspicions. Robert was slow in his development
and was in every respect a much younger child than his chronological years.
T-Tia poor ability in some special things gave every reason to believe that Robert
would fail if he began his first-grade work at that time.

Proper school placement was a matter of concern to Richard’s mother also.
She was aware that he read well for a child only 6 years 3 months of age,
but she questioned his ability to do second-grade work without spending the
first year in scliool. The clinic was consulted. Richard’s advanced mental development, together with the fact that educational tests showed his prepared
ness for second-grade work, justified his going into that grade.
He was
advanced to the second grade, where he adjusted himself easily and happily.

These cases represent only a few o f the many problems coming to
the clinic in which the services of^ a psychologist are essential. Fur
thermore, because the work is varied and demanding, it is important
that only those who have had adequate training and experience
should assume the responsibility of doing the work. The qualifica
tions o f a clinical psychologist should comprise more than a Anere
knowledge o f the technique o f administering the tests and the ability
to compute the intelligence quotient. Determining the intelligence
quotient is but a small part of the psychological study and means
little unless interpreted in relation to good developmental, medical,
and social history of the child. Personality traits, handicaps, i f any,
and special abilities or disabilities also come in for study. Only one
who is familiar with these various aspects o f a child’s development
can ever hope to do justice to the child in such a study.
After the intelligence quotient has been determined, a question
which one may reasonably ask is whether the intelligence quotient
remains constant or relatively the same throughout life. Though the
constancy o f the intelligence quotient has been studied extensively,
the question is not definitely settled at the present time. The age at
which the psychological study is made will influence somewhat the
intelligence rating. To a clinical psychologist who has worked with
a young child before his language has developed to any extent it is
not surprising to find that the child has raised his rating perceptibly
at a later date. Also, a child from a poor environment may change
his scoring when placed for a while under better circumstances.

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However, an experienced worker will recognize the potentialities of
development and differentiate between what may be a permanent re
tardation and an underdevelopment due to poor environment.
The whole subject of a psychological study might be best under
stood by pointing out some of the many interesting facts that may
come to light during an examination. The first requirements are
proper rapport between the psychologist and the child and estab
lishment o f a proper attitude toward the tests in general. The psy
chologist gets his first knowledge o f the child from the way in which
the situation is met. With one child rapport is quickly established.
He comes readily and . alone with the examiner to the examining
room. He may be a little shy at the beginning but he soon learns
that the examiner is a friend and not someone to be feared. In a
short time he is very much at ease and complies with all requests.
He works with effort and persistence and meets the most difficult
test even though his efforts may not be crowned with success. His
attitude is one o f independence and o f meeting new situations alone
and unaided.
With another child the very opposite may be true. His mother
may have to accompany him to the examining room ; he remains fear
ful of the examiner throughout the examination ; he is never at ease ;
he responds to tests largely under protest; his effort is poor; and
when he meets the slightest difficulty he appeals for help. In fact,
his attitude is one o f dependence and a constant seeking for assist
ance. A t no time does he meet the new situation independently and
unaided. In truth, the response to the test situation may often be
an indication o f the way the child is meeting life in general.
When the child’s cooperation has been obtained, the more formal
tests are given. The object o f the standardized test is to determine
how the child’s development compares with that of other children
of his age. I f he has not come up to the standard, what are some
o f the factors that may possibly affect his future development? One
must allow for the premature child to catch up to his actual age;
for the child whose physical activities have been curtailed because
o f many illnesses; for the child with a birth injury ; and for chil
dren with other handicaps. Handedness also may be observed at
this time. A t an early age the child begins to show a preference
for the use o f one hand. Interference in the development o f the lise
c f the hands may work out disadvantageous^ to the child. The
little child who has been forcibly changed from the use o f the pre
ferred left hand to that o f the right is all too frequently recognized
by other signs o f difficulty.
Further insight into the child’s mental development is had by the
use o f language tests. There is no phase o f development that requirès
more careftil observation and study. To distinguish between good
all-round language development and mere superficial verbalistic
fluency is possible only to one who has a knowledge o f language tests
and experience with children who show various phases of speech
acceleration or retardation. It may be said that this phase of de
velopment can be most misleading. The child who speaks a great
deal and at an early age is generally regarded as intellectually supe
rior, but this impression may or may not be correct. On the other
hand, the child with poor enunciation and little facility in the use

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o f words is often considered retarded. These deductions may or
may not be true, depending upon the nature o f the language de
velopment.
The type of child who has only a parrotlike speech development is
well known to the clinical psychologist. He enunciates clearly and
has several language patterns. When using these freely and spon
taneously, and in the manner in which he has learned them, he seems
quite like the average child. He fails, however, when he is asked to
use these words in a new way or to show that he knows what they
mean.
Daniel’s history illustrates such a development. He articulates fairly well
and uses rather long sentences. His comments are usually built around some
personal incident or some object in the immediate situation. When Daniel is
asked to indicate the meaning of some word he has used, he is unable to do so.
A ll that a word seems to do is to elicit a response that has been learned and
associated with it. He apparently has ho grasp of its meaning. He also fails
when it is necessary to comprehend simple questions.
He has learned to
reheat 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 the
learning of the defective, who gets the repetitive learning but can do little
with his material in new situations. Daniel’s intelligence quotient falls into
the feeble-minded grouping.

Another phase of development often recognized in a young child is
that in which his information is much in advance o f his ability to
reason independently. This is often seen in an only child or one
who has been under the tutorship o f an adult a great deal. Such a
child may know colors and coins, may have a number concept beyond
his years, and may use pencil and paper with ease. In fact, he is
much at home with things that may be learned by individual help and
attention. It is when such a child is faced with a problem which
draws upon his own initiative and ability to reason independently
that he fails. His whole attitude is one of waiting to be shown
rather than of puzzling the problem out for himself. While the abil
ity to learn readily from others is a measurement o f intelligence, it
does not constitute the sum total of intelligence. Neither does much
learning make one particularly intelligent. It is not so much the
amount that the individual learns as his ability to use what he has
learned that is essential. It is in this respect that the overambitious
parent is often deceived. The mother, in her zeal to hasten the mental
development o f her child, sets about teaching him all he is capable
o f acquiring, often to the disadvantage o f the child. When the latter
has reached the saturation point, he gives the impression o f being
overstimulated and confused and o f possessing knowledge much in
advance o f his years but having little meaning to him. He has
learned facts, but his intellectual immaturity does not allow him to
use them well. This is the type of child who may have a very high
intelligence quotient at an early age, but whose intelligence quotient
drops perceptibly at some later examination. This child may expe
rience difficulty in adjustment to his early school work, the reason
often being that, through having much direction and supervision by
a second person, he has built up such dependence that he is inade
quate when this support is withdrawn and he is obliged to fit into
the methods o f teaching by group instruction.
78985°— 39----- 2

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A similar mistake is often made with the dull, slow child and
the feeble-minded. Refusing to accept consciously the fact of the
child’s mental inadequacy, the parent attempts to compensate for his
deficiency by forcing the rote learning. But the learning is not as
similated, and this becomes very evident when the child is called
upon to apply it in some simple reasoning problem. Instead o f
finding it aptly applied, one gets a regurgitation o f incidents and
facts, a talking about something, as it were, without any proper rela
tion to what the child is saying. In other words, he talks all-around
a question without in the end answering it. This type of child, too,
is well known to the clinical psychologist and often has accom
panying behavior problems.
Witmn recent years considerable study has been made of the socalled verbal, abstract, ideational type of child as compared with
the practical, concrete type. While little is known psychologically
concerning these differences, it is well recognized that such a d if
ference exists. One child has no difficulty in mastering- the symbols
required for academic progress and has no trouble in reasoning
out a situation not in the immediate present. In contrast to this
child is the one for whom all forms of symbolic education are ac
quired with effort or are not acquired at all. In the immediate sit
uation and in working with concrete material he is intelligent, but
he fails miserably in his attempts to meet academic requirements.
In other words, he has a type of intelligence which may adjust well
in a program that calls for the practical everyday duties o f life,
but will be very much out of step in a bookish, academic environment.
Again, this type may be recognized at a very early age and profitable
advice given with reference to educational plans, it the parent will
accept it. Too often this is not what happens. The plans and am
bitions of the parents for the child will not allow this. They tutor,
they drill, they nag, and they force, and all their efforts have only a
very detrimental effect upon the child.
One cannot hope to portray all the types seen in a clinical service,
and it is not the purpose of this writing to do so. Rather, the aim has
been simply to indicate the nature and variety of problems that a
clinical psychologist may meet and to emphasize the importance of
adequate training and experience. This work requires the ability
not only to administer the tests but also to interpret the results and
to recognize the various phases of development with their possible
relation to the problem for which the child is seeking clinical help.
TH E SO CIAL W O R K ER

The social work in the habit clinic is complex and varied. All types
o f problems are referred from many different sources. The visiting
nurse who finds a physically well child refusing to eat; a family-wel
fare worker who sees a mother so overwhelmed with the difficult be
havior o f one child that her agency’s help is of little value to the
family; the social worker from à child-welfare agency who seeks
help for a child with the problems of defective speech or continued
bed-wetting; parents worried and harassed by the ordinary, everyday
problems o f life as they are related to the child—all turn to the
clinic for assistance. Many of the children come to the clinic directly

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from a nursery school or a kindergarten. In these groups the teachers
often note the child who finds difficulty in making adjustment to other
children, who is obviously the victim of unwise training; and they
will guide the mother to the clinic. Probably the most satisfactory
referral is the one made directly by the mother who realizes that
her child has a problem with which she needs help, for cooperation
is then assured.
It is the social worker in her role as clinic manager who makes the
important first contact with individuals or agencies wishing clinic
help. She selects the cases which the clinic is best equipped to handle,
makes the appointments for attendance, and when the mother and
child arrive steers them through the routine clinical examinations
and interviews.
The social worker is a member of the team consisting of psychi
atrist, psychologistj and social worker, which makes a threefold study
o f the child. She investigates and studies the environment in which
he is living, including the home and the neighborhood, and especially
that most important part o f the child’s environment, the adults with
whom he comes in contact. She learns from the parents, the teacher,
and the nurse what has been observed o f the child’s personality, his
reactions to punishment, his choice o f playmates., his affections, moods,
impulses—whatever will help to make up a picture o f the child as
he really is. She is, moreover, in a position to obtain much valuable
information through visiting and observing the child informally in
the nursery, the nursery school, the school, the home, the settlement
house, the playground, or the community center. For in this way the
child may be observed at his play or occupation, quite at ease and
unperturbed, free from the fear and anxiety that are frequently
associated with the more formal clinic contacts.
To this cross section the social worker adds a longitudinal view—
she learns something about the family stock from which the child
comes, the conditions under which he was born and reared, his de
velopment, the accidents and sicknesses he has had, and his reactions
to them—everything that will help to explain the child to the psychi
atrist when he comes to the clinic.
When the child has been studied at the clinic and a plan of treat
ment has been made, the social worker assists in carrying it out.
The direct treatment of the child is carried on by the psychiatrist.
However, the success o f the program for the child of habit-clinic age
depends largely on the cooperation o f the grown-ups responsible for
his training. The father’s and the mother’s attitude toward masturba
tion, the method o f handling a temper tantrum, the teacher’s per
sistence in correcting a speech defect, may all have to be changed if
the child is to be helped. It is often necessary for the social worker
to explain to parents again and again the clinic findings, to show
them the important role each step plays in carrying out the plan o f
treatment satisfactorily. Reassurance and encouragement are often
necessary, since the task of supplanting poor habits with good ones
may prove a long and tedious process.
Frequently the plan for the child’s treatment involves some service
which the clinic is not prepared to give. For this reason the social
worker must be familiar with all possible resources in her community
and must know the type o f case that each organization can best serve.!

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A more complete physical examination may be necessary. Deafness,
for example, may cause temper tantrums or give an appearance ol
general retardation and must be ruled out before any plan can be
made by the clinic. Enuresis (incontinence of urine) cannot be
considered a habit problem unless no physical basis for it can be
found. Intensive neurological studies and an intensive investigation
of the endocrine glands may be essential. Only those most experienced
in these particular fields of medicine can be of real help to the child.
Camps or schools give a temporary change of environment which
is very helpful in determining the effect such a change^ makes in
the child’s problem. Even with a group of children of the pre
school age, the only possible solution sometimes seems to be long
time placement in a foster home. In such an event the child-placing
agency gives invaluable assistance. If, as often happens, the mother
is so preoccupied with some worry, financial or other, that she tai s
to recognize the necessity of help for her child or if her own worry
is adding to the child’s difficulties, the cooperation of a family agency
that can work out a budget and give supplementary relief or steer
the mother to a relief-giving organization is the first step in treat
ment. The social worker must know the clinic or agency^that can
best help the child, considering his age, his problem, and the family
finances.
„ ,
. ,
,£
Although the most important part of her work is the service to
the child who comes to the clinic, the social worker in the habit clinic
has other duties, among which the, supervision o f students who may
come to the clinic for practical training is important, The students
will acquaint themselves with the clinic methods by the study oi
records and through staff conferences at which the psychiatrist, the
psychologist, and the social worker present their parts of the inves
tigation and treatment. Study of the contacts other agencies have
had with new clinic cases gives the students the opportunity to learn
o f the community resources at first hand. Follow-up visits test out
their ability to make satisfactory interviews and personal contacts.
Finally, a few cases are turned over to the students, always under
careful supervision.
, .
,
,
The material which is gradually collected in the form ox records
is particularly valuable for research purposes, as it deals with young
children whose problems may be projected into the future and who
as a group lend themselves to follow-up studies and research. The
collecting and analyzing of such data as may be obtained should be
useful in showing' various trends and in evaluating results of treat
ment at the clinic when compared with carefully controlled un
treated problems o f a similar nature.
. .
. •
The amount of educational work which the habit-clinic social
worker can do seems to be limited only by the time which she can
give to it. That the child’s early years are important m his future
adjustment to life’s problems is still not widely appreciated. Talks
to mothers’ clubs, to groups of teachers, and to others interested in
child training, on the importance of mental health and the value or
the services of a child-guidance clinic, especially to preschool children,
are time-consuming but unquestionably another important part of the
job.

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With so broad a scope o f activities it is most important that the
social worker not only fulfill the usual requirements of education,
training, and experience but also have a sufficient reserve o f strength
and energy to enable her to meet numerous and varied demands
with skill and resourcefulness, to be ready to tackle a new situation
with initiative, and to be able to see the old problems with a fresh
point o f view.
H AB IT -C L IN IC PROCEDURE

Parental education may be said to be the backbone o f habit-clinic
procedure, supplemented by a direct psychiatric approach to the
mental health of the child in an attempt to understand his particular
difficulties in making the necessary adjustments to life. The sources
o f habit-clinic cases are varied. Social agencies, nursery schools,
kindergartens, private physicians, hospitals, nurses, and parents all
refer cases for study. As education in mental hygiene has become
more general and parents have become more concerned over evi
dences of maladjustment or inadequacy in their children, and more
enlightened concerning the environmental factors affecting conduct,
an increasing number of cases have been referred by the parents
themselves. Whether the child is referred by a nurse, a teacher, a
social worker, or the parents, the procedure is the same.
A visiting nurse entering the home of Mrs. S found the mother very much
upset, nervous, and agitated on account of having been worried all day by
her little daughter Mary, aged 2 years 2 months. Casual inquiry at this time
revealed the following fa c ts: The child was extremely disobedient, almost
to the point of being negativistic. She absolutely refused to respond to a
direct command and could be managed only by constant coaxing. Although
Mary had been weaned months before, the mother had resorted to the use of
the bottle in order to comfort her before her nap and before her bedtime, and
as a help in getting sufficient nourishment into the child to keep her from
losing weight. A t every meal the mother was put through the typical ordeal
of feeding the child herself, often being rewarded for her efforts by having
the child spit the food out on the floor. It was also mentioned quite inci
dentally that the child wet the bed every night and had done so ever since
the mother had resorted to bottle feeding.

With this information at hand, the nurse reported the situation
to the supervisor in charge of the settlement house where a clinic was
being held, having first interested the mother in the habit clinic and
what it is trying to do for this type o f case. The supervisor then
referred the family to the social worker of the habit clinic, who
within the next 2 or 3 days made a careful social investigation of
the home. The following is a brief summary of her report:
SUMMARY OF SOCIAL WORKER’S REPORT
Case o f M a b y S m it h
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 brick
tenement houses on each side, and one has the feeling that it is a congested
neighborhood, as the street is crowded with children, there is a great deal
of noise, and many people are hanging out of the windows.
The, patient’s family, consisting of father and mother, Mary, and a little
girl of 6 months, occupy a four-room tenement with bath, on the third floor,
for which they pay $20 a month. The house is very clean and is neatly
and prosperously furnished. It has a living room, a dining room, a kitchen,

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and a bedroom. All members of family sleep in one room. The patient has
8l crib by herself*
The mother is a slight, delicate young woman of 20, who enjoys house
keeping and is very much interested in her home. She went 2 years to high
school, then worked as a clerk before marriage, and has been married 3 %
years. She has a bad temper and is easily excited. She told the worker that
When the patient does not mind her immediately she becomes impatient and
f The f a t h e r ^ a Thortfw efi-built man of 24, who drives a garbage truck
for the city, earning $24 a week. He is in good health, is interested m his
home, and plays with his children. He and his wife differ in regard to fflv
cipline, he often telling the child that she can do things which-her mother
ha^The0 paSent’ was born full term, instrumental; one eye was black and blue.
Development was quicker than that of the average child. First tooth. Four
months
Walking and talking: Under a year. The patient has had no diseases
or convulsions. The only evidence of illness is that 3 weeks ago she had a
fever of 103 and was nauseated.
.
Habits— Sleeps from 6 : 30 p. m. to 6 a. m. Is restless and occasionally cries
out for mother in her dreams, awakens, but goes back to sleep again. No
night terrors. Has a 2-hour nap in daytime.
, . . a
Feeding.— She is not finicky but has a capricious appetite. A t different^times
refuses different foods. Always has to be coaxed and occasionally spits out
her food. W ill not drink milk except from a bottle. Is always given one when
put to bed.
Enuresis.-—W ets bed every night.
, . 1
I ragfgsg
Disposition.— Affectionate; demonstrative; generous; not jealous, pugnacious,
nor domineering; very stubborn and inclined to be negativistie. Always has to
be coaxed to do things ; is very disobedient.
Play life.— Enjoys playing with other children but can amuse herself if left
&l°8ummary^ T h e r e is no evidence of nervous or mental disease in the family.
The chief problems are refusal of food, enuresis, and disobedience. The mother
is excitable and easily loses patience with the child. The father seems sensible,
but the parents disagree in regard to discipline.

The mother was asked to report with the child at the clinic the
following week, at which time the child was immediately taken in
charge by the psychologist, whose report is here summarized.
SUMMARY OF PSYCHOLOGIST’S REPORT
Some 15 or 20 minutes before the psychological examination was begun,
friendly relations were established. The child, after an initial hesitancy
and shyness, quickly became interested in playing and enjoyed especially the
drawings of a cat with long whiskers. A s she is of that age where best exami
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 help
in the examination. The mother was quite interested, and excellent cooperation
was secured. She smiled encouragement from time to time and did_not let
Mary know when a failure had occurred. She wisely refrained from distractiner her bv urging her to do better.
i
.
Marv showed but slight hesitancy about entering the examination room. As
soon as she saw the pictures and the colors her self-consciousness disappeared.
The tests given her were presented as games and she quickly caught the P y
spirit and very willingly tried to do everything that was asked of her. The
mother, too, was pleased and incidentally quite surprised that the youngster
Hid things which she had never tried before.
Mary is 2 years and 2 months old. She developed rather more quickly than
the average child. Her first two teeth came in at 4 months. She said such
things as “mama” and “papa” at 6 months and a large number of words plainly
^ As Tar as formal tests are concerned, this child made a very good showing.
W ith one exception she did satisfactorily all tests that the average child of
2 does
Pictures took her eye, and she interestedly pointed to objects in the
pictures and named one or two in each. She quickly imitated such movements

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as raising arms and clapping hands and quickly carried out simple requests
such as “Bring me that ball,” “Now throw it to me,” and “Go over there and
sit on that chair.” Before eating a piece of candy, she removed the paper
in which it had been wrapped. Her one failure in the 2-year test was that
of copying a circle with a pencil. As her mother has never allowed her to use
a pencil lest she mark up the house, this failure is insignificant. She passed
four of the 3-year tests. She knew her full name and her sex and she took delight
in pointing out her eyes, nose, mouth, and hair. She pointed to shoes, stockings,
and dress, and was familiar with the names of common objects, such as penny,
a knife, a key, a watch, and a pencil. In all informational questions she did
exceptionally well.
Summing up results, we find that Mary has a mental age of 2 years and
6 months, as against an actual age of 2 years and 2 months, which
gives her an intelligence quotient of 116. Her developmental history, her gen
eral alertness and interest in things about her, her quickness in learning, and
her rating on formal tests show a child above the average in intellectual
equipment.
INTERVIEW WITH PSYCHIATRIST

Shortly afterwards the mother was interviewed by the psychiatrist,
and although the following conversation was not taken verbatim, it
represents what was said as nearly as can be remembered from the
notes dictated a few hours later :
D octor . I understand from Miss W , who visited you the other day, that Mary
is becoming quite a problem.
Mrs. S. She is, indeed. I hardly know what to do with her. She refuses
to eat anything, and she gets me so worked up and so tense inside that I go
into hysterics.
D octor . Then perhaps you are not feeling very well yourself.
Mrs. S. I am feeling all right now, but at times I get nervous.
D octor . Under what conditions are you most apt to get worked up, Mrs. S?
Mrs. S. Usually when I have had arguments with my husband regarding
Mary— how to make her mind and what I should do. When I am trying to
make her mind or take her food, he butts in and says, “Let her alone. Don’t
keep bothering the child.” And on other occasions when she is doing things
that he doesn’t like, he asks me why I don’t make her mind.
D octor . One may assume from the report which Miss W brought to me
that you and your husband get along very well, that you are both fond of
and very much interested in Mary, and that you want to do everything possible
to have her overcome these undesirable habits.
Mrs. S. Yes, sir. Mary’s behavior is the only thing over which we have any
arguments at all, and we both want to do all we can to help her.
D octor . Y ou know, Mrs. S, that a child of Mary’s age, especially a child of
Mary’s intelligence, has a very much better understanding of the ordinary
things going on about the household than you give her credit for. It is sur
prising how early a child learns that there is some doubt in the minds of her
parents 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 you
and Mr. S have a definite understanding about what you are to expect of
Mary. You know, too, that not infrequently parents are apt to discipline chil
dren in a rather erratic way. By that I mean that much depends upon how
the parent happens to be feeling at the time the child needs discipline. I f the
mother 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 parents
may speak of it as “cute,” and the mother may laugh at the child instead of
reprimanding her. On the other hand, if the same thing happens at the end.
of a hard day when the mother is worried and annoyed and somewhat out of
temper herself, the child may be punished, sometimes severely and out of all
proportion to what she deserves. O f course, you understand that I don’t
mean that is the method used in your home, but it is a method used in most
homes more or less. I just mention it so that you will understand better what
I mean by the importance of getting together with your husband and talking
these matters over.

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Mrs. S. Y e s ; I know lots of mothers who do just that— laugh at the baby
as “smart” one day and slap him for the same thing the next.
D octob . I would also call your attention at this time to something that you
probably know already, and that is, that it is very bad to have the parents
question each other’s methods of discipline before the child. It is much better
to have the mother or father carry out his or her own method, even if the
other parent is not in full agreement with what is being said or done, and then
discuss the whole thing in private after the child has gone to bed. It is only
in this way that the child learns that the parents are united in their efforts to
bring about the desired manners and habits. I think it is of the greatest im
portance that you talk these things over with your husband and have an agree
ment that will prevent any discussion of authority before the child.
Mrs. S. Yes, sir; I see exactly what you mean.
D octob . N o w we will discuss the feeding problem. I understand that Mary
has not as yet given up the bottle.
& >M
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 with it that I could
get her to drink it. I took her to the doctor, and he said if she wouldn’t take
milk from the cup, to let her have it from the bottle, and that is what I have
been doing the last few months. She gets the bottle every morning at 10 o’clock
when she takes her nap and every night when she goes to bed.
D octob . O f course, you appreciate the fact that Mary is old enough to give up
this bottle and that her clinging to these habits so strongly simply represents a
desire on her part to stick to those infantile methods which she should be grad
ually giving up. The feeding problem, and the bed-wetting as well, represent
habits that are quite normal for infants but that she should have outgrown
some months ago, and it is going to be a great deal easier to break her of these
habits at 2 years of age than it will be at 4 or 5. There is no better time to
begin than the present.
Mrs. S. I realize all that and am willing to do whatever you say.
D octor . Tell me a little about other difficulties with her feeding.
Mrs. S'. She absolutely refuses to take any food unless I feed her.
D octob . Y ou mean that you have to sit down beside her at each meal aud
actually take the food from her plate and put it into her mouth?
Mrs. S. Y e s ; and she even spits it out.
D octob . Then mealtime must be a very trying experience for you.
Mrs. S. Y e s ; it is the worst time I have.
D octob . Then let me tell you what I have learned from my experience re
garding children who cause so much difficulty by refusing food. In the first
place, we must remember that it is a very natural thing for all human beings
to crave attention, and tins is particularly true of children. The refusal of
food is frequently a method that children» use to get the time and attention of
the parents. At that time they become the center of attention, and it is a battle
of wits between the mother and child to see which one will win. The mother
frequently puts the food on the table with serious doubts and misgivings in her
own mind as to whether 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 until
you do eat it. You didn’t eat any breakfast and you cannot go out to play
until you have eaten your lunch.” This immediately puts the child in a rather
defiant mood. Even if it had not occurred to the child to refuse his food, this
in itself acts as a challenge. It is just as though there were a little play going
on, in which the child is taking the leading part— a situation in which both
children and adults like to find themselves. W e know that the child knows that
invariably, if he does not eat his meals at the regular time, the anxiety of the
mother will make her only too willing to provide food between meal hours.
So in this way the child is not only able to defy the parent and attract atten
tion and win his battle, but he is also able to get the amount of food which his
system requires. It may be that he doesn’t get the best type of food and the
kind best suited to nourish him, but he gets the food which pleases him most
and satisfies his hunger, and that is about all the child wants.
Mrs. S. But,, Doctor, if I let her go without her meals she will get so thin.
D octor . It will be hard at first; 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
lowing p lan : Place on the table a smaller amount of food than you would
naturally want the child to eat. This should include milk, cereal, fruit, and
whatever 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. I f the child is eating with
you and your husband, pay no attention whatever to her eating. After you
have 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 the
child has eaten. I f Mary has not been in the habit of having milk between
meals, under no circumstances give it to her.
Mrs. S. She has been having the bottle at 10 o’clock, just before she takes
her nap.
D octor . Then, under those conditions, I should give her an equal amount of
milk in a cup. On the way home, I should drop into the drug store and get
some straws and let her use those during the coming week. It will be
a step away from the bottle and will interest her in taking the milk from the
cup.
But to continue regarding the more general statements as to her feeding
h abits: Do not be concerned if she does not eat much for the first few days.
It will take a day or so for her to learn from your apparent lack of interest
in her eating that no one is very much concerned whether she eats or not. In
other words, try to get away from romance at her feeding periods. Mary will
soon find that she no longer occupies the center of the stage during the meal
hour. I appreciate that you will be just as concerned, but the important thing
is not to let Mary know it. The task I have outlined is a difficult one, I know,
but it is not nearly so difficult to manage now as it is going to be a year or
two from now ; and although the results may be discouraging at first, you may
be assured that in the end it will work out not only to Mary’s advantage but to
your own.
Mrs. S. W ell, I ’ll try this week and see if I can stand it.
D octor . I don’t want you to look for improvement today or tomorrow or the
next day, but I want you to think ahead 3 or 4 months and then picture Mary
eating in a perfectly normal, healthy way without causing you or the rest of
the family any disturbance. The only way to do this successfully, that I know
of, is to follow the plan that I have just outlined.
It is absolutely essential that you and Mr. S work together on this matter,
because if you do not cooperate the whole plan is doomed to failure, and this
first victory for Mary may work out to her disadvantage in later life. I am
sure you know many people your own age who are terribly finicky about what
they eat, having all sorts of digestive upsets, refusing to accept any suggestion
made by others— the type of person who is generally disliked and hard to get
along with. It is just such people that children with all sorts of finicky habits
are quite likely to develop into.
Mrs. S. I certainly wouldn’t like Mary to grow up like an old woman who
lives near us. She’s just like that, and nobody can stand her.
D octob . D o you think you will be able to carry out the plan I have outlined?
I mean by that, do you feel that you will have the courage to let Mary go
for a few days without what you feel is a sufficient amount of food in order
to make her appreciate the fact that whether she eats or not is a thing which
primarily concerns herself, and that going without food is not going to develop
a tremendous upset in the home?
Mrs. S. I think I see what you mean, and I surely will make every effort to
carry out your instructions and get my husband to also.
D octor . N o w , let us consider the problem of enuresis.
I understand that
Mary wets the bed practically every night.
Mrs. S, Yes, D octor; every night. It has been much worse since she has been
getting the bottle just before she goes to sleep.
D octor . N o w , since the time is getting short I want to outline a plan for
that with less explanation than for the feeding problem, as I think this is
a much more mechanical thing and will respond to treatment more easily.
Mrs. S. I have whipped and whipped her, and as it does no good I have
given it up as useless.
D octor . Y ou were wise in giving up whipping her for this habit because she
is undoubtedly in no way to blame for it, and it is quite an injustice to whip
children for things over which they have no control.
Mrs. S. I agree with that.
D octor . N o w , at what time does Mary usually go to bed?
Mrs. S. A t 6 : 30.
D octor . And at what time does she have supper?
Mrs. S. A t 4.

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D octor . Then I would suggest that you follow out in detail this plan. Let
Mary have her supper at 4 o’clock, with such liquids as she is in the habit of
taking, bearing in mind that she is to take the milk from the cup and not the
bottle. Between 4 and 6 : 3 0 she is to have no fluids whatever. Before going
to bed she is to be taken to the toilet, and you must see that she passes her
urine. When she is put to bed make her understand that she is to be taken
up later on in order to prevent her from wetting the bed. W hat time do you
go to bed yourself, Mrs. S?
Mrs. S. A t 12 o’clock.
D octor . Do you mean that you go to bed every night at 12 o’clock?
Mrs. S. Yes.
D octor . Isn’t that rather late?
Mrs. S. W ell, after supper my husband listens to the radio until about
1 0 :3 0 . Then I make tea, and we have a little lunch, and by the time I get the
dishes cleared away it is about 12.
D octor . Then I would suggest that you make a tour of inspection every hour
in order to determine at just what time Mary wets the bed, and that at 10
o’clock, 3 % hours after she has gone to bed, you get her up, thoroughly awaken
her, and take her to the toilet. Make sure that she realizes why she has
been wakened; that is, that it is in order to prevent her from wetting the
bed. It is important that you do not pick Mary up in a semidrowsy state
and simply place her on the toilet; she must be awakened thoroughly and
given to understand exactly why you have wakened her. Then you can put her
back to bed and allow her to remain until you get up in the morning, which I
presume is about 6 o’clock.
Mrs. S. Yes, sir.
D octor. I am sure that if you follow out the instructions I have outlined
regarding the feeding and bed-wetting, you will be able to report considerable
improvement when you return next week.
Mrs. S. I hope so, for it makes me so much extra work to have her go on
this way.
. .
D octor . Before you go, I want to remind you again of the most important
and fundamental thing that I have said this morning, and that is that you
and your husband discuss this matter of discipline openly and frankly and
decide upon a plan that will insure cooperation. It seems only 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 you
follow out the plan that you agree upon. Under no condition allow Mary to
feel that there is any disagreement between you two as to what is best for her
to do. As soon as she finds out that the household is divided against itself
the battle, so far as you and your husband are concerned, is lost, and a great
injustice is done to Mary.
I see by the tests that have been worked out this morning that Mary is a
keen, bright little girl of unusual intellectual equipment, which means that
she will be all the more capable of taking advantage of any failures which you
and your husband make.
You may be assured we will do everything possible to help you during
the next few weeks, and there is every reason td believe that by Christmas
time Mary’s difficulties will be well overcome. Cafl you arrange to come back
a week from today?
Mrs. S. Yes.
I
,,
D octor . Then that will be all this morning. But the problem of correcting
her undesirable habits will have to be solved very largely by you rather than
by Mary. I should like to get just a bit acquainted with Mary before you go.

The mother brought the child into the examining room, but no
effort was made on the first visit other than to make friendly con
tact with her. She appeared to be a bright, keen little girl, well
developed and fairly well nourished. She seemed interested in every
thing in her environment. In running about she fell down and
knocked against a chair hard enough to hurt herself considerably.
She immediately began to cry, but it was not difficult to attract her
attention to something else, and the tears did not last long. Her at
titude in the clinic during the short period o f observation revealed

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nothing that had not been brought out by the reports of the social
worker and the psychologist.
Had this child been a year older, with her rather superior in
telligence, an attempt would have been made to interest her in keep
ing a record o f her success regarding both feeding habits and
enuresis. She would have been given a chart such as the accom
panying one, and every effort would have been made to arouse her
interest in obtaining as many stars as possible on her chart, which
she would bring to the clinic the following week. Not only can the
chart system be made a matter o f great interest to the child, but it
also serves as a detailed record o f what has been done during the
clinic intervals. That is, instead of having the parents report that
the child has done pretty well or poorly regarding such problems as
feeding, enuresis, and temper tantrums, we have a very definite
quantitative record of exactly what success has 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 visible
evidence o f approbation o f his efforts. Neither is there any reason
why such efforts should not be rewarded if conditions permit. The
incentive for most efforts, in either children or adults, usually re
solves itself into a striving for approbation or reward and it is rather
unreasonable to deny children the same approbation that most adults
are seeking.
The following chart shows how the record is kept:
Na m e :

Oct 5 to Oct. 12.

8 ally Jones

E V E R Y STAR M EANS SUCCESS IN EATIN G M Y MEALS.
Breakfast

Dinner

Supper

Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

However, it was not feasible to utilize the charts for Mary, as they
were beyond the comprehension of a child 2 years old; but if the
parents, who were keenly interested and who had at least average
intelligence, cooperated, there was every reason to believe that the
child’s problem would not be particularly difficult to solve.
An effort has been made in the foregoing paragraphs to give the
reader a fairly good idea of exactly what takes place during the
first visit in the case o f every child coming to the habit clinic.
Whether the problem is one o f enuresis, feeding, or masturba
tion, or whether it is one o f the more difficult personality defects—
such as jealousy, shyness, cruelty, or abnormal fears—extreme tact
and diplomacy are needed, in order, on the one hand, not to offend the
parents, and, on the other hand, to impress them with the importance
o f the mental side o f the child’s life. They invariably feel that they
have used all the patience and good judgment that might be expected
o f any one handling the problem with which they are confronted.
Thus it is necessary to generalize and speak in a more abstract way

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on the first visit than is necessary after working ^relations have been
established and the parents have developed confidence in the clinic.
It is essential in conversing with parents to explain the points made
by examples that are well within their comprehension. Care must
be exercised not to criticize harshly or unjustly, and it must always
be borne in mind that the interest of physicians is primarily therapy
and not science or morals.
COOPERATION W IT H OTHER C O M M U N ITY AG E N C IE S

It must be kept in mind that if children as a group are to benefit
by the available knowledge regarding mental health, every resource
of the community must be utilized to its fullest extent. It is of
paramount importance that every organization interested in the wel
fare of children should make a careful survey of what other organ
izations with similar interests are doing and of which activities have
been most successful. The value o f the resources which such agencies
have for supplementing the work carried on by a child-guidance
clinic cannot be overemphasized.
The available facilities which can operate independently or m co
operation with the clinic vary according to the size of the community
and the interest and progress that have been shown in the field of
child guidance. In urban communities there are usually many or
ganizations which are directly or indirectly concerned with some
aspects o f this problem. Some social agencies providing service for
children or families are equipped to do child-guidance work and
others have psychiatric social workers on the staff able to give the
treatment indicated by the study of the child made by a childguidance clinic. Public agencies such as the schools or the juvenile
court also may be equipped to provide child-guidance service to some
o f the children needing such service. In addition, there are usually
a great variety of agencies that can assist the clinics. Any wellorganized clinic should use all the facilities in the neighborhood that
are o f value in the treatment of the problem and that would help
the future development of the child.
In the treatment of preschool children health centers and nursery
schools and kindergartens can render significant service to the child.
These important centers o f training should be recognized by childguidance clinics for their educational value in helping parents to
understand that a child’s emotional life is as important as his intel
lectual equipment and his physical endowment. These centers should
also assume the responsibility of studying behavior problems in order
to treat the child with wisdom at a time when wise treatment means
so much to all concerned.
The public-health nurse, for example, is in a most strategic posi
tion not only to recognize undesirable habits and personality traits,
but in many instances to institute simple methods which will correct
these tendencies before they become firmly fixed as a part o f the
child’s personality. Every nurse should have some training in mental
hygiene. This is particularly true of those engaged in community
health work. Many of the simpler problems of eating, sleeping, and
toilet habits are matters of training which the nurse should manage
efficiently.

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Teachers in nursery schools and kindergartens should look upon
the development o f personality as an educational problem. They,
too, are in a unique situation and should render valuable service to
the parents and the public by detecting deviations from normal con
duct, whether it is in rate o f achievement in school work or whether
it has to do with the child’s ability to get along with his playmates.
They usually enjoy a friendly and cooperative relationship with the
parents of children under their charge and are often in a position
to know intimately the home conditions under which the child is
being reared. Herein liés the opportunity for much valuable work in
the field of parent education.
Older children and some preschool children may need service from
other types o f organizations. Important among these are case-work
agencies which provide service to children in their own homes and
assist parents to understand their needs, such as family agencies, chil
dren’s agencies, and visiting teachers in the schools. Some of these
agencies provide the financial assistance that is essential to the de
pendent family. Others place thé child in an environment best
suited to his need, whether this is a foster home, a special institution
or hospital, a nursery school, or a vacation camp. Clinics and hos
pitals carry out the examinations and treatments that are essential
to health as well as the follow-up service for the child who is in need
of medical care. Other agencies giving service to children are
those providing organized activities for boys and girls or opportuni
ties for recreation such as Boy and Girl Scout or Campfire groups,
Big Brother or Big Sister Associations, organizations for young men
or young women, recreational centers, organized playgrounds, settle
ments, and churches. Some children may need the special service
o f the school for social counseling, school placement, or vocational
guidance.
The work of a child-guidance clinic should be that o f a community
center. Only by intelligent pooling of all community service Can we
be sure that the child is receiving all the advantages which the com
munity has to offer.

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TH E CHILD AND H IS P ER SO N ALITY

Almost every discussion o f the child and his personality carries
with it a long dissertation on heredity which is likely to leave one
either in a state of increased perplexity or with some very dogmatic
ideas depending on the author. Some writers maintain a consistently
noncommittal attitude, and others state their views for or against
the importance of heredity with great conviction. Thus, lor ex
ample, John Stuart Mill made the statement, O f all the vulgar
modes o f escaping from the consideration of the effects of social and
moral influences on the human mind, the most vulgar is that o l at
tributing diversities of conduct and character to inherent natural
differences” 5 whereas Frederick Adams stated just as emphatically
that in his opinion both “ experimentally and statistically, there is not
a grain o f proof that ordinary environment can alter the salient
mental and moral traits in any measurable degree from what they
were predetermined to be through innate influences^
_
. 1
The consensus o f opinion o f physicians dealing with the practical
problems connected with the subject o f heredity is well expressed by
Kirkpatrick in the following paragraph:
From the individual standpoint, heredity should neither be ignored as of no
importance nor yielded to as inevitably fixing one’s destiny. Instinctive and
hereditary tendencies are the roots from which the physical, mental, and moral
life develops. Some individuals develop more readily and to a greater degree
than others. All are of the same human characteristics, but each may make the
most of his environment. Some cannot go as far as others in certain direc
tions nor as easily, but no one has exhausted his possibilities of development.
The practical problem is to expend our efforts upon the useful characteristics
which we possess in the greatest degrees.1

It seems only reasonable at this time when so much disparity exists
in the opinions of various writers on heredity that a conservative
point o f view, such as that presented by Kirkpatrick, should be
tentatively accepted. Such a hypothesis makes it possible to get away
from the pessimistic attitude to which the fatalist clings with undying
tenacity. Doing this is not seeking a fool’s paradise and becoming
oblivious to the biological facts o f life. Whatever may be the rela
tion between the germ plasm and the color o f eyes or the size of foot,
and whatever research may determine in regard to defective germ
plasm—how it affects the number, size, and distribution of brain cells,
evidently resulting in variations in inherent mental equipment and
setting definite limitations on brain development—no one, as yet, is
ready to say that personality and all its component parts are not
molded and colored by social heritage to a great degree. After all,
social maladjustments are more frequently due to emotional in
stability than to intellectual defects. More is to be gained by con
centrating upon the study o f environment and its effects on the dei Kirkpatrick, Edwin A . : Fundamentals of Child Study, p. 29.
York, 1917.

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H A B IT CLINICS FOR C H ILD GUIDANCE

velopment o f personality than by accepting a hopeless, fatalistic
theory o f heredity.
_ In the attempt to understand the child it must not be forgotten
that just as he has ears, eyes, a brain, and a heart, so he has instincts
and emotions. He has, for example, an instinctive fear of falling
and is afraid o f loud noises. He has an inherent hunger for seli>
expression that is constantly infringing upon a code of laws and
customs of which he has, as yet, no understanding. We must remember
that the child has plans, hopes, and ambitions; he has doubts, fears,
and misgivings; he has joys and sorrows, some very slight and fanci
ful, others very deep and real. This emotional life is thwarted and
gratified in much the same way at the age of 3 that it is going to
be at 30.
& &
With all these instinctive and emotional drives, which have much
m u T ^ ° n w^h those o f the adult, there is necessarily lacking the
stabilizing factor o f experience which can come only with years. The
cmld is confronted with many new situations to which there is a
definitely unpleasant emotional tone. For example, many o f the pri
mary experiences o f children with animals are accompanied by fear.
Jealousy is often aroused when the child first appreciates that the
mother is giving some o f her attention to other members of the
family. Anger is aroused repeatedly until the child appreciates the
reason for the acts which give rise to these emotions, and then suddenly and unexpectedly the emotional reaction changes. The child,
therefore, must be considered as an individual with all the equipment necessary for registering joy and sorrow, pleasure and pain, but
with little experience for properly evaluating the details of the situ
ation so that the quantity and quality of the emotion will be ade
quately expressed. Regrettable as it may be, adults all too frequently
stimulate some o f the child’s most undesirable emotional reactions for
arnuseineht, leaving permanent scars on his personality.
Childhood is not only the opportune time but the only time to inltiatB a 1Program of mental health. Seeds of pugnacity, selfishness,
and feelings of inferiority are sown early. They may not bear fruit
until later—perhaps, never; but if one expects to develop an ade
quate well-rounded, self-sufficient personality, one must plant the
seeds for it during the child’s earliest years and carefully nurture
them. The mental life o f the child is characterized by his tendency to
imitate, his suggestibility, his love o f approbation, and his marked
plasticity. These qualities, in association with his lack of experience
training, and education, render an interpretation of his mental
activity less difficult at this time than in later years. All these factors may be utilized to great advantage in our efforts to stimulate
mhibit, or alter his reactions to the problems of everyday life. In
to understand human behavior the thoughts and feelings of
the child must be taken into account. His daydreams become matters
of importance. More intimate knowledge of his mental life is needed.
It is necessary to take time to find out why he is queer, quiet, or re
served, why he is worried or sad. The situation demands the utmost
ingenuity and patience in assisting the child to solve his own problems and at the same time appreciation o f the fact that it would
be o f little value to solve them for him.

S?e

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TTA R TT CLINICS FOR CH ILD GUIDANCE

The infant at birth has no habits, and the habitual reactions which
he acquires in the process of growing up are dependent upon his
experience, training, and education. He seems, however, to have
certain inherent tendencies which manifest themselves at an early
age. Thus one child reaches out and embraces the world in a
happy manner and another withdraws and rejects all attention. Such
tendencies seem to be present at birth. Yet these so-called instinctive
reactions are all modified, either to the advantage or to the disad
vantage of the individual, through the effect of environment. Habits
represent the child’s responses to the innumerable, ordinary, every
day-life situations. Knowledge of an individual’s habits makes pos
sible a fairly accurate guess as to what may be expected of him in
ordinary situations. As Doctor Dewey has pointed out, habits are
not like a garment to be put on and taken off as the occasion de
mands, or as it pleases us. They are very much a part of us; we are
thé habit.
.
We begin to acquire habits at birth and continue to acquire them to
a greater or less degree, depending upon our plasticity, until the end
of life. The functions of eating, sleeping, and elimination become
habitual. We develop habits of conduct toward those in authority.
In some situations we acquiesce; in others we rebel. We h’ave habits
o f conduct which include morals and manners. Our mental attitudes
toward life are but habits of thought, and such traits as selfishness,
shyness, cruelty, and fearfulness are merely emotional ^responses that
have become habitual through repetition. Lying, stealing, and a dis
regard for the rights o f others are likewise responses to certain situ
ations, which through repetition become a part of the life pattern;
in other words, they are habits.
It therefore becomes obvious that habits considered in their broad
est sense are nothing more nor less than the individual himself, his
happiness and efficiency being largely dependent upon the habits
which he acquires in the process o f growing up.
Almost from the moment the child is born he is confronted with
all the varied life situations evoking what we think o f as adult emo
tional responses. The child does not advance very far in life before
he knows what it is to be jealous, to be fearful, to be angry, to love,
to hate, to feel inadequate, and to experience sorrow and disappoint
ments He is continually subjected to environmental situations and
personalities which stimulate these varied responses and lay the
foundation for mental attitudes which eventually become habitual.
The child is recognized as being amoral (without morals) at birth.
His responses to life are those that are essential to the preservation
of self. He reaches out for that which brings him pleasure, smiling
upon those who cater to his appetites, provide him with food, drink,
and creature comforts, and stimulate pleasant bodily sensations by
fondling and kissing him; and he rejects things and people not serv
ing his immediate needs. His demands for attention must be recog
nized; his attempts to exhibit an influence over his environment must
not be thwarted or there will be evidence o f resentment. He is, in
deed, a self-centered, egotistical individual who feels no responsibility
toward life except that of trying to satisfy his own needs. All that he
acquires in the way of ideals, altruistic tendencies, cooperation with
his environment, and desire to please must come from his experiences

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with life, and during his early years these experiences are to a very
large extent closely tied up with his parents.
It is therefore important that parents appreciate the raw material
with which they have to deal, that they know something about these
inherent strivings o f children, their emotional stability, and their
intellectual equipment. As time goes on parents should be in
timately acquainted with the personality make-up o f the immature
individual whose future life is so dependent upon their interest and
wisdom. They cannot afford through ignorance to twist and distort
the personality make-up o f the developing child through a domineer
ing intolerance or humiliation, or by teasing, ridiculing, and cheat
ing him, and destroying his sense o f security. The child subjected
to personalities that are egotistical, domineering, unstable, quick
tempered, and ill-mannered, has a right to become rebellious. It must
be kept in mind that the child is not satisfied with being simply a
passive part o f his environment. He is persistently reaching out and
struggling to make the environment satisfy his emotional needs. The
parents’ duty is to see that the emotional needs o f the child are satis
fied in a way that is compatible with the requirements o f society.
In any effort to understand the behavior o f children and to recog
nize the importance o f the part environmental factors play in their
conduct, it is essential to keep in mind the personality make-up o f the
individual child. No two children are subjected to the same environ
mental influences. The material situations may appear to be not
very different, but the personalities o f parents and others who are
responsible for the training o f the child vary widely, and these per
sonalities are the most important aspect o f the child’s environment.
To a very large extent the habits and the mental attitudes which
become incorporated into the child’s personality make-up are de
pendent upon the wisdom of the parents. They are the ones who
must prepare children to live in a world outside the home. They
must see to it that children are both ready and willing to make the
necessary adjustments to life as it really exists. In this outside world
the environment will not be altered to suit the child, as it frequently
is in the home. Parents themselves must keep in mind, and must help
the child to grasp the idea, that the individual and not the world
makes most o f the compromises and concessions when conflicts arise.

78985°— 39-------3

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THE PARENT AN D TH E HOME

The home must be considered the workshop in which the person
ality o f the child is being developed; and the personalities o f the
parents will make up, to a very large extent, the mental atmosphere
in which the child has to live. This mental atmosphere may easily
become contaminated and can be quite as dangerous to the mental
life o f the child as scarlet fever or diphtheria would be to his physical
well-being. Faulty habits are not infrequently due to the imitation
o f bad examples. Yet one is quite safe in saying that the mere imi
tation of the bad example is not nearly so dangerous to the child’s
mental health as may be the way in which the indiscretion is treated
by the parent. In any study o f environment, therefore, it is abso
lutely essential to have the fullest details possible regarding the
personalities o f the individuals with whom the child comes into
intimate contact.
Parents who are largely responsible for the inadequate develop
ment o f their children’s personalities may be divided into well-defined
groups. There is first o f all the mother who, although worn and
wearied by her routine household duties, tries to supplement the fam
ily income by putting in several hours a day sewing, washing, baking,
or scrubbing when she should be in bed. She has little energy, either
physical or mental, to give to any consideration of the welfare o f her
children. In striking contrast to her is the work-avoiding, dutyshirking, pleasure-loving mother who feels that her duty is ended at
the birth o f the child and turns over her responsibilities to a nurse
maid. Again? there is the mother with excellent intentions, whose
unintelligent interest is apt to defeat its very purpose. Usually she
is oversolicitous and caters to every whim and desire of the child.
All too frequently she is emotionally unstable and the child soon finds
out that she has no definite rules and regulations about discipline.
What is condoned today is punished tomorrow; and in spite o f his
ability to make rapid adjustments, the child finds it difficult or im
possible to follow a consistent line o f conduct. More pathetic than
any o f these situations, however, is that of the mentally defective
mother who does the very best she can with her limited endowment
and yet fails and recognizes her own failure.
So far only the mother has been considered but it must not be
forgotten that the father’s influence also must be considered. He
may spread peace and harmony where chaos was wont to prevail, or
he may disrupt and render chaotic that which was peaceful. The
stern, righteous, rigid father who dominates the household by fear,
is, from a mental point of view, perhaps the most undesirable. Yet
there is no reason to envy the child who has a quick-tempered, im
pulsive father always ready with a sharp word and a blow. Lucky
is the child who does not have his discipline handed out in an erratic
manner by an emotionally unstable father.

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Needless to say, the foregoing types fail to furnish the child with
the very companionship which he needs most. Cheerfulness, affec
tion, and kindly consideration; frankness and honesty in answering
questions, so that speech and action may be free and uninhibited by
fear o f punishment or silent contempt; manners and speech that are
not forbidding-—all these tend to play a part that cannot be over
estimated in the development o f the child’s personality.
To evaluate parental personalities requires more than a study of
the personality make-up o f isolated individuals; it entails a study of
a complex relationship between two human beings endeavoring to
carry out a very difficult task, usually without training or experience
and sometimes without interest or desire. One need not be surprised
that two such individuals do not always create a quiet, peaceful,
happy home in which the child will find everything necessary for a
healthy outlook upon life. Sometimes even an intelligent, welleducated man and woman with common interests will not make for
efficiency when operating together as parents.
Much sentiment has rightly been lavished on the home—the place
where the disheartened and the troubled find understanding and com
fort, the fortress where those in need may find safety and security
from a critical, demanding, competitive world. Unfortunately not
all homes serve this ideal purpose. All too frequently the average
person—man, woman, or child—makes less effort to keep up his mo
rale in the home than in the shop, office, school, and place of recre
ation. Too frequently the home becomes the reservoir into which are
poured all the resentment, disappointment, grief, and frustration as
sociated with the unhappy experiences of the day. A tired, harassed
mother finds in the family circle the only audience that cannot run
out on her when she recites her trials and tribulations. A father at
the close o f a trying business day settles down at home with no feel
ing but indifference as his contribution to the family circle because
he is preoccupied with expressing his grievances against those in
authority, his irritation with his fellow workers, his feeling o f failure,
his anxiety about economic security. It is not surprising that the
children in such a home soon regard it as the dumping ground o f all
unhappy and unhealthy adult emotions—a place used by all its in
mates in their efforts to air the grievances against a world that has
cheated them of something vital to their well-being. Such a home
finds it difficult to compete with commercialized amusements—
the dance hall, the night club, and motion-picture theaters.
Much good may come o f talking over personal dissatisfactions in
an orderly, intellectual way, but an unintelligent outpouring of griev
ances by a group of unhappy individuals seeking self-pity serves no
useful purpose. Children who see in their parents unhappy, de
feated, critical individuals do not want to be like them, nor are they
inclined to find in their own home an ideal pattern for the future.
Unfortunately there are parents who have to live on such a low
economic level that the problem o f bare subsistence is confronting
them at all times. When the clinic is faced with such a situa
tion a relief agency must lay the foundation for any improve
ment involving mental hygiene. There are also parents whose intel
lectual equipment is so low that it would be beyond their compre-

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hension to carry out even a common-sense program. For the problem
child o f such parents placement is absolutely essential. More numer
ous than any o f these are, however, the parents whose own lives are
so unstable emotionally that little or nothing constructive can be
done for the child or for the family until the parents have recovered
from their own mental difficulties. For this they need help, which
may be provided either by referring them to some adult psychiatric
clinic, or, if time permits and it seems wise, by treating the parents
as well as the child at the habit clinic.
The child looks to his parents for his sense o f security. In his par
ents he meets authority for the first time and his love relationship
with them is constantly being endangered. He has to recognize that
many o f his desires are unattainable. In fact, it must seem to him
at times that many o f the goals which he is pursuing belong in the
realm of the forbidden. He must learn to postpone the desire o f the
moment for that which his parents teach him is more worth while in
the future. The habitual reactions with which the child meets these
situations depend upon the wisdom with which his parents meet them.
Parents who are still trying to meet the problems o f adult life with
the same emotional responses they used as children will obviously fail.
Those who have had experiences deeply laden with emotion which are
incompatible with their own ideals and supposed adult maturity, are
suffering from a state of mind which necessarily affects their conduct
toward their children. When the child’s behavior sets off these po
tential emotional bombs, the task o f developing adequate habits in
the child is indeed a problem. The wise parent will make an effort
to understand his own emotional life as well as that o f the child.
The following case is a good example of a mother who brought a
child to the clinic when the child should have brought the mother.
A woman about 40 years of age brought her little girl, 7 years old, to the clinic
for examination, stating that she acted like a child 4 years old. The mother
was unable to give any concrete examples of the child’s immature acts. As far
as could be discovered the child had no bad habits. She slept and ate well and
was frank and honest. She would have liked to be affectionate if her mother
had permitted her to be. She showed no cruel tendencies, and about the worst
the mother could say w as: “ She takes up with any child she can find, regardless
of creed, color, or nationality. I will not stand that.” The mother stated that
she would not permit her child to associate with the Catholic children in the
neighborhood and that the Protestant children were not good enough.
The patient appeared to be a bright, keen, alert little girl, who answered all
questions quickly and accurately. She manifested an interest in the examina
tion and in her surroundings. She had an intelligence quotient of 98. As far
as the history obtained from the mother and the examination of the child were
concerned, there seemed to be little evidence to indicate that the child was either
abnormal or unusual.
The mother was interviewed again, and it was ascertained that the child
was not wanted, that the mother and father had been quite happy until her
birth, and that she was looked upon as a stumbling-block to their happiness and
economic success. The father’s attitude toward the child was one of indiffer
ence. He rarely gave her any attention. The mother stated that she was not
fond of her because the child was hateful and always made the mother regret
being kind to her. When the mother and father were together they both ignored
the Child, and she was sent off by herself and not permitted to play with other
children.
Further investigation of the case by the social-service department of the clinic
revealed the following fa cts: The mother was looked upon in neighborhood as
being “different.” Although she was very affectionate toward her husband, the
neighbors stated that it was not unusual for her to tell the child that she hated
her. It was later ascertained that until a year before the patient was born

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3 11

the mother was looked upon as a very desirable neighbor. About that time she j
went away to live with a man who had been a boarder in the house and re
turned to her husband only after the authorities made complaints. Shortly
after her return the patient was born. Since that time the whole situation had
changed.

One o f the most pernicious influences to which a child is subjected
is that o f persistently interfering members of the family group.
Grandparents are perhaps the worst offenders in this respect, although
other relatives may complicate the problem o f bringing up children
quite as much, if they are so inclined. This is particularly true, of
course, if these individuals are living in the same household, but
not infrequently their influence is felt even when they reside at some
distance. Too much streess cannot be laid on the necessity o f having
the right to discipline the child vested entirely in the parents. Noth
ing does more to lessen parental authority than to have some line of
action which the parent has decided to carry out questioned in the
presence o f the child.
Another situation frequently arising with reference to the problem
o f discipline is that brought about by the divided household ; that is,
the inability o f the parents to agree upon any plan of action for train
ing the child, each one forming as the occasion arises a spontaneous
judgment entirely on an emotional basis. Much o f the difficulty aris
ing because o f divided opinion regarding some particular act o f
the child might be avoided if parents themselves could get some
clearer idea of the relative importance o f so-called misconduct in
children. For example, all too frequently the same punishment is
meted out for some quite accidental offense, such as breaking a
window with a baseball, as would be given for some obviously vol
untary, malicious act involving cruelty.
For the child who has the misfortune to have a physically handi
capped parent—especially a mother—it is very important, on the one
hand, that too much stress should not be laid upon her incapacities,
and, on the other, that the child should appreciate at the earliest
possible age the burden which the parent is carrying and the con
sideration to which she is entitled. One frequently sees problems of
delinquency arising under these conditions because the parent has
been physically unable to “ make the children mind.” Much can be
done by appealing to the child’s spirit o f fair play, especially when the
object of his sympathy is always before him.
A ll too often adults are prone to utilize what appears to be the
most potent means of obtaining obedience from the child; namely,
fear. As this is one of the most primitive and easily stimulated
emotions it is used more freely perhaps than any other. “ I f you
don’t stop crying. I ’ll go back to the hospital again,” is a threat of a
convalescent parent. “ Don’t touch the telephone,” a mother remarks.
“ It will bite you.” “ The policeman will get you if you are not
good.” “ The doctor will put the stick down your throat if you
don’t answer his questions.” Fortunately for the child’s peace of
mind he soon finds that such promises and threats are not to be taken
seriously, but unfortunately he is unable to distinguish between the
persons whom he can trust and believe and those whose advice and
warnings are simply idle prattle. Consequently he is likely to de
velop an absolute disregard and disrespect for the opinions 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 know
they cannot keep or which they have no intention of carrying out is
perhaps the origin of the absolute disregard for truth and the ex
aggerated suspicion seen in many children at an early age.
“ The doctor has a lot o f nice things in his bag which he will give
you if you stop crying,” one mother was overheard to say. She fol
lowed this up with the statement that “ Mother is going to buy you
heaps of pretty things as soon as the doctor is through,” and made
other promises which obviously she had no intention of carrying out.
The parents who take time to understand their child, who know
his responses to praise, blame, rewards, and punishments, and who
are affectionate and tolerant without being unduly sentimental and
spineless, are the ones who will have the most to offer their children.
The child imitates the habits and attitudes of his parents. They
are a constant source o f suggestion to him at a period in life when
he is most plastic.

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H AB IT PROBLEMS ASSOCIATED W ITH EATING,
SLEEPING, AN D ELIM INATION

The physical well-being of the child is largely dependent on the
efficiency of three fundamental organic functions; namely, eating,
sleeping, and elimination. These functions become controlled, and
regulated by habit, and therefore habits of eating, sleeping, and elim
ination are the first to receive attention. The mother of the newborn
infant is confronted with the dual responsibility of supplying proper
nourishment and helping the infant to develop desirable habits for
taking this nourishment at such times and in such ways as will best
serve his physical needs. Almost at once she must also teach him to
sleep at regular hours and without special attention ; and, a little later,
she tries to establish regular toilet habits. When these habits are
properly established at a reasonable time, the child has been provided
with a lasting foundation for both mental and physical ¡health.
It is in connection with these simple physiological processes, how
ever, that many of the initial mistakes in child/ training are made,
either because parents ignore their importance entirely or because they
become unduly worried and anxious over the difficulties encountered.
The consequences of ignoring an undesirable habit are not always ap
parent. The immediate effect may be trivial compared with the ulti
mate results. On the other hand, oversolicitude on the part of parents
introduces into their relationship with the child an indefinable some
thing that the child assumes to be doubt, misgiving, or weakness, and
that prevents him from looking to them for guidance, an essential
factor in child training.
The methods recommended for establishing satisfactory habits in
infancy are discussed elsewhere.2 The discussion here is rather based
on the fact that mistakes are made and undesirable habits formed,
Inasmuch as these undesirable habits cause parents much concern and
interfere with normal personality development, the habit clinics can
be of valuable service to the community.
E A T IN G H AB ITS

No problem causes parents more concern than that o f the child who
has difficulty in taking and digesting his food. The more common
feeding problems are refusal of food, sucking of food after taking it
into the mouth, regurgitation, and vomiting. The fact that parents
develop a marked anxiety with reference to these difficulties makes
them oversolicitous, and this, in itself, is a most important factor in
perpetuating the difficulty. A part of the body which is easily af
fected by emotion is the gastrointestinal tract. Physiological research
has established the fact that emotions of various sorts, such as fear,
anger, and excitement, directly influence the flow o f digestive secre
tions. It is therefore not surprising to find that an organism so
* See Infant Care (Children’s Bureau Publication No. 8, 1938), pp. 44-49.

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highly developed, yet so unstable, as that o f the nervous system o f the
child may very clearly reveal the relation between psychogenic and
physiological processes.
It is usually not difficult to pick out those children whose loss o±
appetite and inability to digest and assimilate food are due to psy
chogenic rather than physiological causes. Nevertheless, it is essen
tial to have these cases clearly differentiated by careful physical exam
inations. Many children who come to the clinic because of difficulty
in feeding are not poorly nourished, anemic individuals. On the con
trary, their physical condition is frequently such that one sees little
cause for anxiety until the history of the case is presented. In such
cases it is found that although the child’s intake of food is fairly
good, the food is o f such a quality and taken under such emotional
stress that it fails to serve the child’s needs. The mother states that
the child absolutely refuses to take food unless she sits down by his
side and actually carries out all the necessary motor processes to get
the food from the plate to the child’s mouth, and even then she may
have to tease, coax, threaten, and sometimes punish the child in order
to make him swallow the food. After satisfying herself that the
proper amount of food has been taken by the child, the mother is nat
urally quite dismayed to have the food vomited before the child leaves
the table. When one considers the effects of emotion upon the process
of digestion, it is not surprising to find that under emotional strain
the stomach rejects the food.
. t
A somewhat different problem is presented by the child who be
comes antagonistic toward certain types o f food—as, for example,
soups, cereals, or vegetables o f a special color. Such antagonisms
persisting over a long period o f time may have been aroused by in
judicious methods utilized the first time the food was presented to
the child. There is no doubt that parents sometimes make a great
mistake in forcing a child to eat some new food which they consider
absolutely essential to his well-being, the parents themselves being
dominated by the idea that unless they are successful at the first
attempt the battle is lost. Under such conditions there is apt to be
a very unpleasant emotional scene which will linger in the mind of
the child and be recalled the next time the food is presented. It
therefore seems wise to guard against making an event o f introduc
ing a new article of diet into the child’s menu. The food should be
presented without cqmment and without any evidence of doubt in
the mind o f the parent or nurse that it will be eaten. But if, for
some reason known or unknown, it is not taken at that particular
meal, an unpleasant scene should be avoided and it should be pre
sented at a later date without comment or show of indecision.
A certain amount o f manual dexterity is required before children
are able to feed themselves, and all too often parents find it easier
to feed the child than to teach him to feed himself. Feeding is one
o f the first complex acts which the child is called upon to do for
himself, and it is not surprising that he accepts this new responsi
bility with a certain amount ox reluctance. Usually, however, suc
cess brings with it a kind of satisfaction which stimulates the child
to make further efforts toward accomplishing the task.
It is o f paramount importance to avoid discussing the child’s
feeding habits in his presence. Such discussion tends to fix the

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event in the mind of the child and make him cognizant o f the fact
that he is the center o f attraction during the meal hour. Many chil
dren find that a negativistic attitude, not only toward feeding but
toward sleeping, playing, and general obedience, is one way o f
attracting the attention which they desire.
Once the physiological causes o f loss o f appetite and malnutrition
have been eliminated, it invariably works out well to serve the
child only a small quantity of food, first making sure that it is well
prepared and then allowing a sufficient period o f time in which to eat
it slowly. I f it is not eaten, the food is removed at the end o f that
period without any ceremony, this procedure being repeated for a
series o f meals. Under those conditions much o f the drama in which,
the child delights is eliminated, and much of the unpleasant emotional
reaction produced by creating an antagonistic attitude in the voungster is avoided.
Some o f the cases illustrating the difficulties associated with feeding
will give more detail regarding the importance o f neither directing
the child’s attention nor arousing his antagonistic attitude toward
his food and the necessity o f allaying the doubts and fears in the
minds o f parents so that they may at least appear less concerned.
Allen was brought to the clinic at the age of 3 years with the following
history: Birth was difficult, necessitating the use o f instruments; birth weight,
10 pounds; breast-fed; normal development; no illnesses or diseases. A t the
age of 2 he was treated with radium for a persistent thym us; at the time of
the clinic visit he had enlarged adenoids and tonsils.
According to the mother this child never slept restfully but tossed and
twisted about in his crib, often talking and crying out. He was extremely
finicky about food and had marked likes and dislikes. He did not care for
milk and refused vegetables, but he would sometimes eat seven apples a day.
He was fond of meat, which was given to him occasionally. He never wanted
the food set before him at mealtime.
He was considered somewhat shy and diffident, especially with strangers
and adults. He played fairly well with other children on the street— usually
with girls about 2 or 3 years older, but also with boys when he had the
opportunity. He was fond of throwing a ball and wanted to be doing just
what others were doing in games, He was very active. He was very fond
of his mother and was often called “mother’s boy.” He wa.s chummy with
his father and most considerate toward his sister, 2 years younger than he.
He was very selfish and most reluctant to divide things with others, always
keeping the “lion’s share” for himself. His mother stated that he was very
stubborn and would not do as he was told, being, in fact, more likely to do
the opposite. She punished him at times, but she believed that a more effective
method of discipline was the threat to lea,ve him.
A t the clinic the child was keen and responsive. He answered all questions
quickly and in detail, cooperated well, and was interested in the tests. He
enjoyed being the center of attention and was very pleasant and kindly about
it all. He paid much attention to his mother and little sister. H is intelligence
quotient was 130, and his mental capacity 1 year ahead o f his chronological
age.
There seemed to be nothing unusual or significant in the home situation.
Both parents were fairly intelligent, very friendly, and cooperative. Although
the father was an occasional drinker, he never came home drunk, nor was he
a man of dissipated habits. The parents were working together for the good
of their children. The father’s salary was adequate. The family occupied
a four-room apartment which was in good condition and well kept. The
furnishings were of the average type.
Summary.— It appeared that this child, 3 years 4 months of age, was of
rather superior intellectual endowment. H is environment presented nothing
outstanding in the way of a social problem at the time of the examination.
The principal anxiety of the parents was the feeding problem, the child being
poorly nourished and underweight, extremely finicky about food, showing

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strong likes and dislikes for various articles of food. The child was stubborn
f n T v e r f negatfvistic. He rebelled against authority whenever he was
^ T h e ^ s ^ a n ^ m i f s t h£>ortant step in the treatment of this case appeared
to be the regulation of the sleeping hours, it being perfectly ob\ious that a
child of 3 years should retire before 10 p. m. The mother was instructed
that before any improvement could be expected th®f c^
mu|u b^ a s awaraed
go to bed at 7 o’clock and have at least 12 hours of sleep. She was warnea
of the initial difficulty in trying to put this new program into eperation and
was given a careful explanation of how much easier it would be to institute
such T ^ o g r a m at this time than 2 or 3 years later. Her cooperation was
t t m f n £ t * e p necessitated a rather long, detailed explanation to tte mother
of the means and methods which children use at an early age to obtain their
own wav
The futility of trying to get the child established on a proper diet
while giving him apples and candy whenever he refused to take milk and
vegetables was pointed out to her. She was also advised that just so long as
stubbornness served the child as a means of obtaining what he desired ju g ; so
long would he utilize that method; and that it was extremely important
fo? him at this age to learn that whining and rebelling would not serve as a
method of gaining his own ends. A diet was carefully prescribed, and the
mother was instructed to place only moderate portions of food before the child
at° each nmal. She agreed that the food should be left before him for a period
sufficiently long to permit him to eat slowly, yet not long enough to permit him
to play with it, and that it was then to be removed. She also promised that
he would receive nothing between meals except the extra milk which was
prescribed in the diet because of his being underweight. The parents were in
no way to concern themselves With what the child was eating. A careful
record of the success or failure of the treatment was to be kept on a chart.
The entire plan was explained to the child as simply and concisely as possible.
The results in this case alternated between success and failure for 5 months.
Cooperation of the mother during the first part of the treatment was not all
that had been hoped, but each time She returned to the clinic, regardless of
whether success or failure had been reported, renewed efforts were made to have
her carrv out in detail the plan outlined.
.
. , .
A t the end of 6 months the following report was m ade: The child is doing
remarkably w ell; eats all vegetables including carrots, spinach, and string
beans; still has a strong dislike for milk but takes one glass per day.
A
month later the report read: “ Patient continues to take his food without diffi
c u lt y has shown marked physical improvement; takes great interest m pre
senting his chart, which shows a perfect record for the la s t ^ weeks; is much
less negativistic; is no longer sh y ; and takes great pride in telling the physician
° f W ithThe establishment of proper sleeping hours and feeding habits, the child
became more obedient and less selfish and lost many minor neurotic manifesta
tions. such as nail biting, whining, and restlessness at night.
.
.
.
Comment.— This case is particularly interesting because success in treatment
came only after a period of 5 months, during which time the outlook seemed
rather discouraging. It emphasizes the importance of persistent and continued
education of the parents in a certain group of cases wj i f re, C00Perat?;?“ 1S m ^
of the best and where suggestion is not accepted readily by the-child. The
results, however, justified the efforts.

Barbara, aged 6 years 9 months, was brought to the clime by her mother
hppause of Dersistent vomiting and enuresis.
>
,
j ,
The child’s history was as follow s: Normal birth, full term. Development
retarded;w alk in g delayed until child was over 2 years of age; speech still
quite indistinct; teething delayed. Illness included pneumonia at 2 months,
whooping cough at 2 years, influenza, and chickenpox. Child subject to
C°The*S <ffiild slept and ate well and had no history of any undesirable habits
with the exception of enuresis both day and night and persistent vomiting after
meals, a habit which began about 4 weeks before the first clinic contact.
The child was described as shy and unwilling to speak unless,
^ ’
even at school. She frequently hung her head when spoken to by her teacher

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and refused to answer. She was extremely selfish and was jealous of the other
children. At home she was quarrelsome, but outside the home she got along
without difficulty. She seemed to have a normal interest in other members of
the family with the exception of the younger sister, Susan, toward whom she
was very antagonistic.
A t the clinic she seemed to be a dull, apathetic child who hung her head
and refused to look at the examiner. She was lacking in self-confidence and
displayed absolutely no interest in her surroundings. One felt at once that
there was a problem of mental deficiency. This impression was borne out by
subsequent tests and psychometric examination, her intelligence quotient being
64, which seemed a fair indication of her mental equipment.
The home environment was poor. The family lived in a very narrow tene
ment street. They had an apartment of three rooms which were very untidy,
with dirty clothing lying about on the floor. The hand towels and dish towels
were very much soiled. A pail in one corner of the kitchen was used as a
toilet. The mother and the youngest child, aged 2 years, shared a double bed,
and the father, the patient, and Susan slept in another double bed. They had
lived in this place for 5 years. Although conditions were extremely poor, they
had shown considerable improvement during the last few years. Previously
the family had lived in one room and was very much in debt. The father had
been drinking; the mother had taken no interest whatever in the children. At
the time of the clinic visit the father had stopped drinking, the mother was
taking more interest in the children, and they were no longer in debt.
The patient was brought to the clinic because of persistent vomiting, which
began about 4 weeks prior to the visit, and for enuresis, which had been almost
continuous since birth. No attempt had ever been made to establish a routine
that would break up the latter habit.
It was not difficult to determine how the vomiting had its origin. The
mother was pregnant and had been vomiting during the preceding months,
frequently in the presence of the child. How much of the behavior of the
child was imitation and how much was stimulated by the physiological re
action of seeing another vomit was difficult to say. However, as soon as the
mother was instructed about the necessity of seeking privacy during these
vomiting periods, and after it was explained to the child (although she was
mentally deficient) how unnecessary it was to persist in this habit and how
foolish it would be for her to continue to take food if she persisted in throwing
it up immediately, the problem seemed to be solved, for within 2 weeks the
vomiting ceased completely.
Further investigation showed that Susan, 2 years younger and of higher
intelligence, was also troubled with bed-wetting at night. The routine correc
tive measures were at once instituted for both children. A chart system was
introduced and rivalry was stimulated between them. The results in both
cases were extremely satisfactory.
Another youngster was subsequently added to the household, making four
children in all. When the oldest was just over 7 the mother found it neces
sary to go out to work and took a job cleaning a theater at night. She left
the house at 1 0 :3 0 p. m. and worked for 8 hours, sleeping most of the day.
She well represents the type of mother who is worn and wearied by toil and
who has little to contribute to the welfare of the home. She was, however,
extremely grateful to have her burdens lightened as much as they were. Both
children continued to visit the clinic at frequent intervals, the mother feeling
that they were more easily disciplined when they had to make a report to the
clinic occasionally.
Comment.— The interesting point in this case is that it shows how important
imitation is in the mental development of children and also that feeble-minded
children do respond well to the simple training method.

Carrie came to the clinic at the age of 5 % years. Birth and development
were quite normal. There was nothing of significance in her history nor in
the physical examination made at the time of the first visit to the clinic.
The patient was brought to the clinic by her aunt, who stated that she would
not eat unless fed, that she held her food in her mouth, and that she persisted
in regurgitating it. When left alone at her meals and told to eat she invariably
hid the food and told fanciful tales about what had become o f it. On one
occasion when she was told to eat her breakfast, she hid the food on the attic

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stairs and said she had eaten i t W hen taken to her uncle’s store and given
crackers she secreted them on her person and then threw them away, some
times hiding them behind barrels in the store but always insisting that she had
consumed them. She was said to be able to play all day without food. There
was, however, no difficulty in getting her to eat ice cream and candy.
The child’s father and mother had both died during an influenza epidemic,
when she was 2 years of age. A t that time the patient had been taken by the
aunt and uncle, with whom she had continued to live. These relatives were
apparently devoted to her and were as seriously interested in her welfare as
ip that of their own child. At the time of her parents’ death she had not
learned to feed herself, and the struggle to teach her had persisted ever since.
She had formed the habit of not eating unless her aunt sat down and fed
her, which meant cutting up the food and conveying the morsels from the plate
to her mouth. More recently the child had begun simply to hold the food
in her mouth, refusing to swallow it. The aunt reported that breakfast was
a daily ordeal, as she felt that the child must be forced to eat before going to
school. She further stated that Carrie had gone beyond all limits of the nor
mal hunger period for the ordinary child. Except for her capriciousness
regarding food, there seemed to be no undesirable habits. She slept well, was
ordinarily obedient, had well-established toilet habits, and seemed to have no
particular defects in her personality make-up.
A t the clinic Carrie did not appear at all undernourished and seemed to be
happy and cheerful. Her only comment regarding not eating was as follow s:
“I dream of a beautiful fairy in yellow who told me that I should not drink
milk.” After having a careful physical examination, however, the child did
drink a glass of milk and eat a half slice of stale bread without any hesitation.
The aunt was instructed not to be so solicitous over the child’s meals. She
was told to prepare the food and place small quantities of it before the child,
telling her that she would have 15 or 20 minutes to eat her meal and that it
would then be taken away and she would have nothing else until the next
meal. She was strongly urged to carry out these instructions faithfully until
she came to the clinic the following week.
The problem was also discussed with the child, an effort being made to
impress her with the importance of taking her food at regular intervals and
also of eating it without assistance from her aunt. The following week the
aunt reported to the clinic that the patient got along well for the first 4 days
after their visit but that since then “has been carrying on pretty much the same
way as she always has.” She found it more difficult to discipline the patient
than her own child and clung tenaciously to the idea that she wanted to do
for the child what the child’s mother would have had her do. One could see
that she was activated by the idea that she wished to avoid showing any
partiality toward her own child.
The family lived in a comfortable, sunny apartment, which, however, was
kept in an extremely untidy state. When the social worker visited the home,
the table was piled with dirty dishes and half-eaten food, and such food as
could be seen in various pans looked most unattractive and poorly cooked.
The floor was unswept, and there were large pails full of unwashed clothes
standing about. The aunt’s clothing and person were dirty, as were those of
the children. A t this time the aunt felt that she was at the end of her re
sources with regard to the patient and said, “ I wouldn’t mind trying to feed
her if she would only eat what I feed her.” Yet she seemed glad to have the
child as a member of the family, in spite of her difficulties. She felt that the
child had been spoiled by her own parents, who had lost an older child as
the result o f an accident when the patient was 1 year of age. This had un
doubtedly made the patient’s mother very solicitous and anxious, and the
child had been permitted to have her own way. The aunt stated that she felt
the child’s difficulties with eating were getting worse, rather than better.
It seemed impossible in this particular case to organize the child’s routines
in a satisfactory way in her own environment, and an effort was therefore made
to remove her from her surroundings until normal eating habits could be estab
lished. This was accomplished by sending the patient to live with another
aunt in one of the nearby suburbs when the aunt with whom she had lived
went to the hospital to be confined. W hile living in the new environment she
did extremely well and no eating problem was evident. Shortly after return
ing home, however, she resumed her old habits. Attempts were made to persuade
b(oth the aunt and the uncle to have the child go to the study home of a local

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child-welfare agency for an extended period, but their attachment to the girl
and their inability to appreciate the gravity of the situation made such attempts
futile.

HABITS OF ELIMINATION

The function o f elimination frequently becomes the center o f
undesirable behavior, ranging in seriousness from simple delay in
establishing toilet habits to serious neurotic manifestations and per
versions. The most common problem concerned with elimination is
enuresis, and as this is the type o f behavior for which habit training
is particularly important and with which it is very successful, the
discussion will be largely limited to this.
Enuresis may occur both day and night. It occurs in both sexes
with about the same frequency. It may begin in infancy and last
until the sixth or seventh year, or it may cease at the end o f the
first year with the condition returning at indefinite periods and lasting
from a few days to a few months at a time. Doctors Holt and How
land state, “ Probably the most important cause is habit, resulting
from poor training. Habit is often a potent factor in continuing the
incontinence, even after the primary cause has disappeared.” 3 It is
with this group o f cases that the habit clinics are concerned.
Before starting to treat enuresis as an undesirable habit, it is, of
course, necessary to eliminate, so far as possible, every organic cause
for the condition. Conditions affecting the bladder, acute inflamma
tions, and calculi are the most common causes. An adherent prepuce
(phimosis), a narrow urethral meatus, or local irritations from worms
or fissures in the rectum may be the cause. Enuresis may be associ
ated with a highly concentrated acid urine when the fluid intake has
been insufficient, or it may be brought about by increasing the fluid
intake, which naturally increases the amount o f fluid to be excreted.
The more general conditions, anemia, malnutrition, and an unstable
nervous system (of which enuresis is only a symptom), should receive
proper consideration.
After all organic conditions have been excluded as causes o f the
enuresis there still remains a large group o f cases which are dependent
upon faulty habit formation for their cause and persistence. Even in
those cases where definite physical causes have been found and cured,
the condition may persist from habit.
There are certain general principles that may be applied in every
case o f enuresis. The child should so far as possible be following a
regime that is free from any excessive mental strain. He should have
a simple, bland diet and definite hours of sleep. Routine measures
should be instituted to avoid constipation and to stimulate free elim
ination through other sources than the kidneys. One o f the first and
most important steps in the treatment o f enuresis is to interest the
child in making an effort to overcome the habit. This should be
brought about by appealing to the child’s love o f approbation rather
than through punishment or humiliation. The chart system has been
utilized with success in this connection. Not only does a chart serve
to keep a definite record of the child’s achievement during the interval
that he is away from the clinic, but in a way it serves as a motive for
-A B oft, L. Emmett, M. D., and John Howland, M. D .: The Diseases of Infancy and
Childhood, p. 647. Tenth Edition. D. Appleton & Co., New York [19331.

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the effort needed to overcome the habit. The child keeps his own chart,
makes a mark for each day and night of success, and over each mark
a star is placed. In a certain group of cases, suggestion, when the
child is going to sleep at night, has worked well. The mother sits
down by the bedside o f the child and just as he is about to fall asleep
she has him repeat over and over again, “I am not going to wet the
bed.” This suggestive treatment is similar to hypnotism, which has
been used successfully in many adult cases and which lends itself quite
easily to home treatment.
Not infrequently one finds that parents for one reason or another
have taken for granted that a particular child will continue his habit
o f bed-wetting long after the time when he should have been trained
to the dry habit. One mother stated that she herself had wet the bed
until after she reached of age o f puberty and for this reason she had
ignored the problem in her 7-year-old daughter. Another mother ex
plained that the child had inherited weak kidneys from the father’s
side of the family, the patient’s grandfather and father having both
been troubled in this way. A third mother reported that none o f her
four children was “ dry” before reaching the age o f 5 years and that
she just assumed that the patient, who had come to the clinic because
o f night terrors, should also be wetting the bed at 414 years o f age.
Such an attitude in parents invariably prevents them from starting
on any intelligent plan o f training; indeed, they often seem to get
a feeling o f satisfaction when their half-hearted attempts at training
fail.
.
.
.
It is not unusual to find children reverting to the habit of enuresis
despite adequate training. A little girl, 4 years old, who became
intensely jealous of the newborn baby, began wetting her bed and
her clothes again after having overcome this habit more than a year
before. Another little girl who was devoted to her nurse began
wetting the bed when the nurse left her to care for a younger child.
Peter, aged 6, found that the bed-wetting o f his younger sister, aged
4, got so much attention that he began the same performance after
having been perfectly trained for 3% years.
One must keep in mind that there are many emotional and en
vironmental situations which are related to enuresis, especially in
those cases in which the child has been “ dry” for a long period.
Notwithstanding the fact that punishment and humiliation are not
usually successful as methods of treatment, it is perfectly fair and just
to impose upon the child a certain amount o f care and responsibility
which go with looking after the soiled linen. Such tasks as putting
the clothes to soak, airing the bed, and washing off the rubber sheet,
should be handed out, not as punishment, but rather as aids to correct
a difficult situation. It may, however, provide the essential motive
if the child is to take the problem seriously enough to make it worth
his while to get over the habit.
It is also wise to point out to children the disadvantages asso
ciated with the habit o f bed-wetting. It prevents overnight visits to
friends and relatives and perhaps riding on trains. It is frequently
an obstacle to the child’s privilege of having overnight guests or of
going away to camp. These disadvantages should be presented as
reasons why every effort should be made to overcome the habit and
not as threats against its continuance.

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Daniel, first seen at the age of 5 years 2 months. Born at full term ; birth
weight, 7 pounds; breast-fed; development normal.
He was in the habit of going to bed at 6 p. in .; slept alone; was restless only
on rare occasions, when he would talk during sleep. He was not finicky about
food; had a good appetite and no history of constipation or indigestion.
His mother stated that trouble began when he was 2 years of age. A t that
time he was very ill with pneumonia. Following this illness he began to soil
himself and wet his clothes and his bed. This condition persisted for 2 years,
but for the last year and a half he had been troubled with enuresis only at
night. This occurred about 5 nights out of 7. The mother stated that she
had spanked him, rubbed his nose in the urine, and deprived him of things, and
at the time of her clinic visit she was refusing to give him clean pajamas over
long periods of time, trying to impress him with the fact that he must learn not
to wet his bed.
The child was generous and friendly, liked other people, played with other
children, and was not jealous. He was inclined to be obstinate and could not
be driven, but could be easily disciplined if coaxed. The child had no particular
fears and enjoyed playing outdoors with other children. On the other hand
he spent much of his time playing dolls with his little sister.
In his psychological examination he received an intelligence quotient o f 92.
He was fairly cooperative but inclined to be boastful, constantly saying, “I
can do this,” “I can draw that.” He was particularly interested in drawing. In
fact, it was difficult to hold his attention because of his interest in making pic
tures. He was attending kindergarten and preferred going to school to staying
at home.
The home environment was quite satisfactory, the family occupying a small
house consisting of five rooms. The home was clean, tidy, and attractive; each
child had a room to himself. The mother was interested in her children and
ambitious for them, looking forward to getting a larger house and a yard for
them 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 adequate
salary. The two children were both in good health and enjoyed each other’s
company. The mother was in fairly good health at the time of the visit to the
clinic.
Summary.— Child, 5V2 years of age, with an average intellectual equipment,
coming from a good home, troubled with enuresis 5 nights out of 7, with no
other undesirable habits.
The treatment, to date, had consisted of cruel
humiliation and severe punishment.
The fact that the patient had been treated at numerous clinics led the mother
to believe that the case was hopeless. She maintained that she had carried
out all the directions given her by the physicians, but in spite of this the enuresis
continued.
The boy, as seen at the clinic, was attractive and bright, interested in his
environment, and anxious to demonstrate his ability in printing and drawing.
He discussed his problem openly and frankly, without any apparent embar
rassment, and expressed willingness to cooperate. Physical examination and
laboratory examination of urine were both negative.
The routine treatment for enuresis was outlined as follow s: The patient’s
diet was to be simple, free from spices and sweets, with only a moderate amount
of m eat; his evening meal was to be served at 5 p. m., after which he was to
have no fluids. He-was to retire at 7 p. m. He was to be taken up, thoroughly
awakened, and sent to the toilet at 8 :3 0 and again at 10, and then permitted
to sleep until morning, when he was to be awakened at 6 o’clock. Stress was
laid on the fact that the child must be thoroughly awakened and made to realize
why he was being aroused. The mother was warned to be sure that the child
voided when he was taken up. A chart was then brought out and given to
the boy, and the method of keeping the record was carefully explained.
The child responded to his part of the program with much enthusiasm, but
the mother showed considerable skepticism about the routine outlined. They
returned to the clinic 1 week later, and at that time it was apparent that she
had not carried out the directions, in spite of her statements to the contrary.
She had instituted her own treatment with kidney pills. She was, however,
prevailed upon to continue the prescribed routine for a month and was requested
to visit the clinic each week. The report of the next visit to the clinic read:
“ She is much pleased with the change that has taken place in the patient, feel-

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ing that the chart brought it about. She is anxious that the younger child,
aged 2 % years, be admitted to the clinic for the same trouble. She states that
she did not continue to experiment with a patent medicine but decided to follow
the advice given.”
The next time she brought both children. She reported that the bed-wetting
had completely ceased and that she was greatly relieved.
Comment.— The only comments that need be made on the above case are in
reference to the tactfulness necessary in getting cooperation from the parents
and in making them feel that, although they have tried various remedies at
different times, they have perhaps never put into operation any plan that took
into consideration all the aspects of the individual case.
This case of enuresis was uncomplicated by any other nervous symptoms
or undesirable habits, and it is worthy of note that the enthusiasm which the
child showed in keeping the chart was, in itself, favorable from a prognostic
point of view.
Another case of this type was that of Ellen, aged 3 years 9 months when
first seen at the clinic. The patient was born at full term ; birth and develop
ment were norm al; she was breast-fed to the age of 11 months.
The child’s hours in bed were from 7 : 30 p. m. to 6 a. m. Sometime previous
to the clinic visit she began waking up during the night; she seemed frightened,
cried out, and talked about soldiers. She had always been finicky about food.
She would not take milk until she started attending nursery school, but she
had since developed a liking for milk and ate everything except meat. She
did not eat between meals.
The patient was very shy and said nothing in the presence of strangers but
clung to her mother. She was very quiet, and her mother stated that she
was capable of entertaining herself. When younger, she had had a very bad
temper and had frequently gone into tantrums. She was extremely jealous of
her younger brother. This jealousy was carried so far that when her mother
had first begun to nurse him the patient had not lost an opportunity to slap
or otherwise bother him. She did not care to play with other children and
was self-centered and retiring. She was obedient and rarely had to be dis
ciplined. Her play life was occupied largely with her dolls, occasionally with
her brother, and rarely with other children.
The patient had an intelligence quotient of 84. She attended kindergarten,
where she was getting on fairly well.
The home consisted of a five-room tenement on the second floor of a threestory brick building. The family had lived there for 8 years. It was clean,
and although in poor condition, well furnished. The patient had a room to
herself. She was more attached to her father than to her mother and lacked
normal interest in her brother.
The problem as described by the mother was enuresis, which occurred both
day and night. This condition had persisted since birth. For a long time
there had been difficulty in sleeping. The child was put to bed at 7 : 3 0 p. m.
and usually went to sleep within half an hour. She woke up at 1 or 2 a. m.
and then every hour thereafter until 6 o’clock, when she insisted on getting
up. This wakefulness, accompanied by crying, had become a very disturbing
factor in the household. For the 3 preceding weeks the child had developed
an unusual fear of soldiers and upon waking cried out in fear, saying, “Don’t
let the soldiers get m e !” The story was that she had been taken by her mother
to see some soldiers drilling. This had alarmed her for some unknown reason,
and since that time she had talked constantly about soldiers, saying that they
were going to take her away. W hen she awoke at night she cried out to her
mother, “ Close the door, the soldiers are coming!” She refused to go into any
room alone since this event and wanted her mother constantly by her side.
She had become much afraid of the dark.
A t her first visit to the clinic she was extremely shy and would have nothing
to 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 this
timidity the first clinic visit was unsatisfactory.
Routine measures for the enuresis were instituted, however, as described in
the preceding case, except that the child was permitted to go to bed at the usual
hour of 7 :3 0 , was awakened at 10, and was permitted to sleep until morning.

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The mother was instructed to take the child again to see the soldiers^ drilling
and allow her to observe them as closely as her fear would permit. The
mother was told to assure her and to instruct her about soldiers.
A t the end of the month the mother reported that the child had shown con
siderable improvement and had not wet the bed for 2 weeks, had slept better,
and was no longer afraid of soldiers. The fact that the mother had taken her to
see the soldiers drill every day seemed to dissipate her fears. The child was
more friendly toward the doctor but was still shy and bashful.
Improvement continued during the summer months, and in September the child
entered kindergarten. The teacher reported that she got along well, showed
normal interest, and adapted herself to the school work. She enjoyed the asso
ciation with other children, was quite unselfish, well-mannered, and obedient.
The mother reported that the patient was getting along very well— that she did
not wet the bed and that she had no difficulty about her eating. She no longer
entertained any fear that disturbed her either day or night.
Comment.— It was interesting in this case to note the degree to which this
child was able to make satisfactory adjustment to.both home and school condi
tions. She became relatively independent of her mother and interested and
affectionate toward her little brother. She was sleeping well, her appetite was
good, she had no difficulty with enuresis, nor was she any longer disturbed by
fears and terrifying dreams.
Although it was impossible in this particular case to determine the under
lying cause of the terrifying wakeful periods, it is of interest to note that
many favorable changes took place subsequent to, if not simultaneously with,
the treatment of the enuresis. This happens so frequently in the treatment of
this disorder that it leads one to believe that the feeling of inferiority and
shame associated with enuresis in many cases colors the entire mental life
of the patient. It is of practical importance in the treatment of mental
problems where enuresis happens to be one of the symptoms (inasmuch as
enuresis is one of the most trying problems to the parent, although one of the
most easily curable) to institute treatment for the enuresis at the earliest
possible date.
H AB ITS OF SLEEP

Most of the problems that arise in relation to sleep are brought
about by poor training or lack o f training on the part o f parents.
Children frequently get the idea that bed is a place to be avoided,
because it has been used as a means of punishment. When Mary is
naughty, she is threatened with being sent to bed. Tommy, on the
other hand, is told that if he is good he may stay up a half hour later.
Both attitudes imply that bed is a place to be avoided.
A sleep routine should be established to which parents and child
will conform, for there is no demand made upon the physical well
being o f the child in which sleep and relief from physical fatigue do
not play important parts. The tired child is usually an unhappy
child. Tantrums, enuresis, stammering, various mannerisms, and
numerous other physical and emotional problems are frequently
caused by fatigue due to insufficient sleep.
The importance o f sleep should be taken for granted, neither fea
tured nor ignored, and the parents’ attitude should be precisely as it
is toward the meal hours. The hour for retiring should not be per
mitted to be a time for “ putting on a show” and getting attention.
The child will soon learn that after he has been adequately prepared
for bed, comfortably tucked in, and had his parting “ good night”
said, the ceremony is over and a belated request for a story, a trip
to the bathroom, or another drink o f water is just a way o f trying
to get attention or exert a little influence over the solicitous mother.
Yielding to such requests is the beginning of an indulgence on the
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clinics eor child guidance

part o f parents that may cause them much trouble later and create
in the child a feeling o f dependency that will prove a real handicap.
The overtired child or the child who is said to be suffering from
growing pains may exhibit considerable restlessness—tossing, turn
ing, twisting about, and complaining o f not feeling rested the next
day. These periods o f physical unrest need not cause parents undue
anxiety. They are indications that there is need for more rest, less
violent physical exercise, and perhaps a warm relaxing bath before
retiring. Night terrors, so called, are a matter o f deeper concern
because they are invariably related to some disturbance in the psychic
life o f the child. There is no doubt that many fears are planted
during the early life of the child, are awakened by subsequent ex
periences, and eventually play an important part in producing night
terrors. Children should not be threatened with violence o f one
kind or another for indiscretions, because the anticipation o f punish
ment, like threats from other children, may lead to serious disturb
ance o f sleep.
Not infrequently intelligent parents create sleeping difficulties for
the child by reciting to him, just before he retires, stories that are,
tinged with the mysterious and the unexpected. They often leave
him in suspense in some very exciting part o f the story in order that
a happy experience may be anticipated the following evening. It is
obvious that such a proceeding is unwise for the imaginative child.
The mental activities created in this way often prevent the child
from going to sleep and frequently create both motor and mental
unrest. Many programs presented over the radio at the present time
are o f this nature and lay the foundation for a bad night, which is
followed by fatigue and irritability the next day. Many children
have strange, vague, ill-defined worries and anxieties over death,
sickness, school, and parental relationships. Strong emotional ten
sion is associated with these worries and they assume undue pro
portions in the mind o f the child after he has withdrawn from the
day’s activities which have been demanding his attention. Threats
o f punishment, fear o f being deserted by parents, or o f being sub
jected to bullying and teasing by other children, and many other
everyday environmental situations which threaten the child’s security
are subjects that are worthy of investigation when one is endeavor
ing to solve a problem related to sleep.
As the child advances to the age when he is able to read and com
prehend sensational newspaper headings relating to lurid tales of
murder, suicide, robbery, immorality, and other topics that excite
curiosity, a new factor is introduced which often disturbs his mental
life and results in sleepless nights. Fortunately, much o f the material
derived from radios, newspapers, and other contacts which the child
must make in his everyday existence, does not register on his mind
before his fifth or sixth year. A ll these new avenues of enlighten
ment make a valuable contribution to mankind in general, but they
are a menace to a certain group o f highly sensitive, imaginative
children. It hardly seems necessary to mention that fear stimulated
by putting children in dark closets and down in the cellar, by threat
ening them with unusual punishments, and by scaring them with
weird tales, is cruel and vicious and leaves scars upon their mental
life that are rarely completely healed and that may lead to the most

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c l in ic s

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violent type o f night terrors. Some children are extremely sensitive
and sympathetic to the worries and anxieties o f parents, and during
periods o f extreme economic depression, when the security o f the
entire family is threatened, when there is grave illness in the home,
or when undue emotional tension exists between parents, a state of
mind is created in the child that frequently prevents normal sleep.
Besides creating a happy^ carefree, unperturbed state o f mind for
the child before retiring, it is also important to provide proper sleep
ing arrangements. The bed itself should be neat, clean, and orderly
in appearance, with clothing suitable to the season. In other words,
it should have an inviting appearance. The room should be well
ventilated but not necessarily cold or drafty. The shades should be
drawn so as to avoid bright early-morning light. Some of the minor
details such as the type o f night clothes, placement of-bed, and ar
rangement o f furniture can be left to the child when feasible. The
act o f retiring should be taken for granted, featured neither a§ one
o f the crosses that children have to bear nor as an unusual privilege,
but as one of the events that take place in the routine of a happy
day. The matter o f adequate sleep is a subject that cannot be ignored
in any consideration o f the mental and physical welfare of the child,
especially during the first few years when habits are being estab
lished. Sleep is nature’s way o f conserving the child’s energy against
the demands made upon it by rapid physical and mental growth.
John, a 2-yearmold boy, was referred to the clinic because of irregular sleeping
habits, enuresis, soiling, irregular and finicky feeding habits, and disobedience.
His birth and development were normal, and his intellectual equipment was
average. His parents were young and unintelligent. He had developed into
an undisciplined and untrained child.
The mother had never made any
attempt to train the child to toilet habits, and the irregularity of his eating
had been taken for granted. In other words, the child ate when he felt hungry
rather than when food was served to the other members of the family. His
mother could not remember that the child had ever slept well. She stated that
he was put to bed at 7 o’clock but rarely went to sleep before 2 or 3 in the
morning.. He insisted on getting out of bed and going into the living room
to join his parents. In spite of their efforts, which were undoubtedly feeble and
misdirected, he would stay up until 12 or 1 o’clock. He rarely slept later than
6 :3 0 in the morning, at which time he would get up to have breakfast with
his father. He then returned to bed and slept until 12.
The child was irritable, demanding, and extremely difficult to get along with
Whenever he was crossed or an effort was made to get his cooperation in doing
something that did not please him, he would c r y ; and at the age of 2 he had
already found that tears were apt to get him out of many difficult situations.
The mother was a weak, negative sort of individual, entirely lacking in
imagination, who took little care of her own health or personal appearance,
and who was a poor housekeeper and a bad manager. She was inconsistent in
her discipline, so that in one mood she tried to control the child by cuffing
and slapping him and in another mood she would indulge him in everything.
When she slapped him, he slapped back; when she was resentful, he, too, was
resentful. In other words the mother had settled down to a rather childish,
infantile, emotional level, as was shown in her efforts to control the child with
threats of the doctor, the nurse, “the cop,” and anything else that might for
the moment have affected the child’s conduct. The problem was obviously one
of parental education and of getting the child into a nursery school where he
could live in a well-organized environment for at least part of the' day.

Sarah was a tall, undernourished girl just under 5 years o f age. She was
brought to the clinic by her mother because of night terrors which had existed
since infancy. For the first 6 months she had been difficult to feed, became

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much undernourished, and had suffered from constipation; otherwise her de
velopment was normal.
The feeding difficulty had, however, continued to
manifest itself in indifference to food. She apparently enjoyed the attention
that was associated with being fed by her mother, who indulged her in this
respect.
This child, only 5 years of age, was frequently allowed to stay up in the
summertime until 9 :3 0 , although she did go to bed somewhat earlier in the
winter. Retiring was usually accompanied by a good deal of talking and laugh
ing with her brother, who slept in the same room. The mother stated, “Nearly
every night Sarah has night terrors. After a half hour to an hour of sleep
she starts screaming and will yell out, ‘I won’t do it,’ ‘I don’t like you,’ or some
other similar expression.” The mother found it difficult to awaken her during
these times. There was usually a short crying spell, and then the child would
finally settle down and go to sleep. These episodes would be repeated several
times during the night, but the child would have no recollection of terrifying
dreams nor could she remember much about what had happened during the
night. These night terrors were invariably worse when she was sick, but the
mother had been unable to associate them with any actual experiences.
The mother described Sarah as “a high-strung, nervous child.”
A t the
clinic the psychological examination showed that she had a superior intelli
gence, rating 2 years above her chronological age. Her cooperation was excel
lent and her general behavior indicated excellent training and manners. The
home from which the child came was above the average economically and
culturally, and the parents were rather superior intellectually— in fact, the
mother was “an amateur student of psychology and child training.” It ap
peared, however, that the parents’ influence on their child had been counter
acted by that of the grandmother, who was said to be psychotic and who in
sisted upon “ smothering” the patient with her affections and attentions, which
the patient resented. The relationship with her grandmother was of such a
nature that this ordinarily quiet, well-behaved, sensitive child resented it and
made every effort to repel the grandmother’s advances by assuming a dom
ineering attitude herself. The mother was advised to regulate the patient’s
routine so that she would have adequate sleep, more rest, and regular m eals;
to eliminate so far as possible the contact between the patient and her grand
mother ; to see that the child was kept interested and occupied; and to secure
the cooperation of her maid in this plan. The child was placed in a kinder
garten in an effort to provide a routine suited to her needs, and to bring her
in contact with intelligent and unemotional adults as well as a normal group
of children of her own age. The mother reported at the end of 2 months that
the night terrors had disappeared.

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R ESE N TM E N T TOW ARD FRUSTRATION EXPRESSED
IN AGGRESSIVE ACTS

The ways in which the behavior o f children brings them into con
flict with their constantly changing environment are many and
varied. Equally numerous and varied are the causes of this behavior.
For example, a child may present a picture o f restlessness, destruc
tiveness, pugnacity, and marked impulsiveness, with other evidences
that he lacks normal inhibitions. Such behavior may have its basis
in certain organic defects either inherited or acquired at an early
age, mental deficiency being a classic example of this group; or it
may be a reaction to physical limitations associated with diabetes,
infantile paralysis, or cardiac conditions. Not infrequently acute
inflammatory conditions of the brain or its coverings resulting in
meningitis and encephalitis (commonly known as sleeping sickness)
are followed by such disturbances in the child’s behavior, due to im
pairment of the normal processes leading to inhibition. Very often,
however, these difficult behavior problems are not due to any of the
causes mentioned, but are the result of poor training or lack of train
ing. In this case one sees an undisciplined child who undoubtedly
has the ability but has never learned the necessity o f exerting what
are commonly known as will power and self-control.
Nor is the behavior of the child always constant. For a period,
at least, offensive attitudes may alternate with defensive, and the
child may put up a good fight against personalities and situations
that are too strong. There may be vague, intangible situations which
are overpowering to him. Rebellion may be of no avail against the
subtleties of a persistently oversolicitous parent. The child will
finally succumb to defeat and accept a plan o f life ill suited to his
needs and necessitating much in the way of fantasy to make it tolera
ble. What appears to be simply an undesirable habit such as enuresis
may have its roots deeply seated in jealousy. Cruelty may be re
garded by the parent as “ just ordinary meanness” when actually it
is an unconscious protest of the child against his own inadequacies.
The sullen, unhappy child, apparently lacking in affection for any
one, may be crying aloud for someone who will take time to find out
what his emotional needs really are and to see that some effort is
made to satisfy them.
The varied responses which human beings make to life do not lend
themselves well to any rigid classification. Because there is wide
diversity in the constitutional make-up of individuals, and because
these individuals are called upon to adjust themselves to environ
ments that are varied and constantly changing, situations are created
which are necessarily extremely variable and complex. It is with
great difficulty and always with more or less danger that broad gen
eralizations are set forth to be applied to the individual case. Every
child must be considered as a living organism struggling to make
47

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such adjustments to his environment as will permit him to survive
and enjoy natural growth and development and to accept and con
form to the restrictions which society imposes upon his behavior.
Acquisition of the personality traits that lead to conformity is in
sisted upon by those who are responsible for the orderly growth and
development of the child. It is the function of child training, so far
as the wisdom and ability of parents permit, to see that the child, is
mentally and physically equipped to meet the world outside the home.
Society'deals harshly with those who fail to recognize the necessity
o f subordinating self to the social group. Unfortunately, force
rather than understanding is too frequently exerted m efforts to
make children conform. Fear is often in the foreground of most
parental and social doctrines. The child is taught at an early age
that the way of the transgressor is hard, and yet in spite o f all this
pressure exerted from without, the world is full of unhappy, in
adequate, poorly adjusted individuals who have not profited by their
early training. The question arises whether education should not be
substituted for fear.
From the clinical point o f view there are three distinct groups 01
problems of this kind: (1) There is the group represented by the
child who because of certain limitations o f intellect, physical detects,
or emotional instability will be a problem regardless of his environ
ment. (2) There is the child who, in the process of growing up,
goes through phases involving certain changes m behavior which
cause concern to his parents. These situations are not so much the
problems o f the particular child as problems o f a particular stage
o f development, and. if handled wisely, they need cause but little
anxiety. (3) There is a type o f child behavior that is only a symp
tom o f a problem environment. Many of the cases referred to clinics
fortunately belong to this last group. Constructive effort to change
the environment and give the child a better understanding of his
difficulties is invariably helpful in these cases. Examples will be
included in the following discussion.
ANGER AND TEMPER TANTRUMS

In considering such aspects o f conduct as temper tantrums it is
necisarv to appreciate filly the different planes upon which moral
conduct yis enacted in relation to the age of Ihe
staf?e o f social development.4 Those who deal with children are
concerned very largely with conduct carried out on a low moral
Pl During the early years of life no moral judgments are formed and
the chil<f does not think o f himself in relation to others. The child
i s f u X n ^ t a l l y selfish and e lo q u e n tly interprets everything in
terms o f self his own acts as well as those o f others being evaluated
b v “ L a m o l t o f pleasure or pain they bring to him .. He must
t e r n by experience that a certain line o f conduct is a paying pro™speak, and that another line o f conduct is not; and by
“ paving” one implies a gain to the child in pleasure and comfort
W ith proper training and in the proper environment the average
child soonPlearns that conduct carried out m consideration o f those

L to

•No more practical exposition of this¡ subject 1)»S been p r e s « . « tba# » a t «* r n t.
William MacDougall in Ins Social Psychology.

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■with whom he comes in contact in his everyday experiences brings
him more pleasure and less pain than he would otherwise have. He
does not take long to learn that certain experiences are associated
with definite pain—for example, touching the hot stove—and ordi
narily he can learn in the same way that little or nothing is to be
gained by what is commonly called a temper tantrum. Such a
tantrum has been described by a parent as follows: “ The child lies
down on the floor, yells, kicks his heels, and throws his arms about
with the intention o f inflicting bodily harm on those who come
near him.”
The tantrum is, o f course, purely instinctive and must be met on
its first appearance in such a way as to impress on the child not only
that nothing will be gained but that such action is positively pain
ful in its results—painful in the sense of bringing a definite loss
or o f being similar to the experience o f putting his hand on the hot
stove. This crude and more or less undesirable method o f directing
and inhibiting conduct during the early years o f life should be dis
carded as soon as possible in favor o f appealing to the child’s love
o f approbation, which manifests itself early. Here the attempt is
directed toward influencing the child’s conduct by appealing to his
desire for praise, on the one hand, and his desire to avoid blame, on
the other. With children who have reached this stage o f develop
ment it has been possible to utilize in the clinics a chart system to
give the child tangible evidence of the approbation o f the doctor,
the parents, and others whose praise he most desires.
Temper tantrums, as was said before, are usually physical mani
festations of the emotion o f anger, which may be stimulated when
any of the varied instinctive reactions are thwarted. It is important
to know this when attempting to understand the tantrums of the
child, because it is necessary to determine the cause of the anger,
which many parents say they are unable to account for. It is only
after the child, through training and experience, has developed
various means of meeting and overcoming his difficulties, that the
emotion of anger ceases to be one of the most dangerous stumbling
blocks. The instinct of pugnacity, of which anger is the associated
emotion, is essential in the development of most successful individ
uals. It is the driving force to which much of the success in human
affairs is due, and it should be controlled rather than stifled, if it is
to work to the advantage of the individual.
In every case that involves outbursts of temper it is absolutely
essential to study the environment in which the child is being reared,
in order to know under what conditions, in what places, and with
whom these tantrums are most common. It is of equal importance
to make a careful personality study of the child in order to under
stand as fully as possible the conflicts that he has and the purpose
that these emotional upsets serve. It is futile to treat each outbreak
by punishing the child or by permitting him to gain some undesir
able end. Either method is doomed to failure. Such conduct must
be interpreted in terms of the child’s experience, if his personality
is to be molded so that he will be capable of making a satisfactory
social adjustment in later life.
Harriet was first seen in the clinic at the age of 2 years 5 months. The
birth had been normal. The patient was breast-fed until 23 months o f age.

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The mother stated that it was very difficult to wean the patient; she cried
so much and went into such temper tantrums that the mother nursed her
until 3 months before her next child was born. Teething, walking, and talking
all developed normally. She had had none of the children’s diseases and had
had no injuries or operations.
She refused to go to bed unless accompanied by either her father or her
mother. She retired at 8 or 9 p. m. and slept until 8 or 9 a. m. Two or three
times during the night she would wake up and scream. Her mother said,
“ She is probably having temper tantrums in her sleep and is dreaming that she
cannot have what she wants.” There was no feeding difficulty— she ate every
thing that was given to her— but there were some indiscretions in diet, such
as tea for lunch. Enuresis occurred occasionally. The child had been known
to masturbate. Her mother said that the child had a “terrific” temper; that
she would lie 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 she
developed one of these tantrums. Sometimes they occurred when the
mother had no idea what the exciting cause might be. They occurred fre
quently when she was playing with other children. Following one of these
tantrums the child had had “peculiar attacks,” getting blue in the face, the
mouth remaining partially open, the body becoming stiffened. These spells
lasted about 10 minutes. During the 2 weeks preceding the clinic visit she
had had seven such attacks.
The policy pursued by the family at that time was one of acquiescence. The
patient was said to be generous “ when she wants to be” ; was jealous ; did
not want others to have things she could not have; did not get along with
other children because she was pugnacious and fought them; was “ always
very bossy and domineering and always makes other children playing with her
do what she wants even if they are twice her size.” She was afraid of the
dark, would not go to bed without a light; was afraid of animals, especially
cats and dogs. A t times she had shown marked affection for her father.
Her father took no part in disciplining her, and her mother had found that
corporal punishment was o f little avail.
The father was Italian and the mother was Irish-American. The mother
said that the father considered her an idiot and had been brutal to her.
She did not know how much he earned. H e was very close with his money
and gave a dollar a day on which to run the house. H e spent little time at
home. The mother felt intellectually superior to the father and was always
conscious of the racial difference. She said that the father hated their older
daughter, Mary, but was devoted to Harriet, whom he fondled and petted.
H e was also quite indifferent to the baby. They lived on a short, paved street
in a three-story brick tenement house. They had a two-room apartment On
the first floor. Father, mother, and Harriet slept in a double bed, and Mary
slept on the davenport. The mother had furnished the rooms with her own
money, and they were fairly comfortable and well kept.
Prior to their marriage the father and mother had lived in Boston as man
and wife. A t the same time, he was keeping company with another woman.
Even at that period he was extremely cruel and abusive to the mother and
was very irritable. He would throw cups at her when things he desired
were missing at the table. H e was arrested in 1918 and was sentenced to
ja il for 3 months. After his release quarrels were frequent, and in selfdefense the mother had scalded and bitten him. Although he was still very
rough, showed temper, and drank a great deal, he had not used physical vio
lence of late. The mother knew that he was not true to her and questioned
his relations with the patient. There was a story of his having infected the
older daughter with gonorrhea when she was 4 years old. H is sexual demands
were excessive and he masturbated frequently.
A t the clinic the patient appeared to be a quiet, demure, neatly dressed little
girl, who sat quietly by her mother until she left to enter the examining
room. The child then went into a violent tantrum, lying on the floor, kicking
her heels, and yelling at the top of her voice. This behavior continued during
the half-hour interval while the mother was talking to the physician, but it
was not followed by one of her spells. The mother verified the history as
given by the social worker and said that the child had been “ cranky since the
day she was born, always crying and whining.” She said, “ I could not do a
thing with her— she has never slept soundly. I always have to lie down with
her and sing her to sleep.” Sometimes the patient stayed up until 10 p. m.

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and she never had a nap. When the patient got jealous of other children
she tried to inflict pain upon them. Whenever her mother paid special attention to other children in the neighborhood or to the patient’s sister, she went
mto a violent temper, bit her sister, pulled her clothes, and tried to bite her
mother. Her mother repeated that she was afraid the patient had learned
to masturbate from her father.
Treatment.— The problems of enuresis and of establishing routine hours of
sleep were attacked first. The mother was instructed to see that the child
was put to bed at 6 o’clock and that she remained in bed at least 12 hours.
She was warned against all the difficulties that would arise in starting out
on this program, but she was told that they* would be only temporary and
slight compared with the trouble that would occur if the child was not taught
to appreciate that tempers could not be used successfully to get her own way.
The routine method as described for enuresis was to be followed, and a chart
was given to the mother for the purpose of keeping a record rather thnn to
interest the child.
A t the end of 2 weeks the mother returned to the clinic, stating that she
had instituted the 12-hour sleeping regime but found it impossible to carry
out the measures suggested for breaking the habit of enuresis.
The situation was particularly difficult because the child cried violently
the tenant downstairs threatened to have the family put out, and other neigh
bors became irritated. The father told the mother that she had no brains—
what could she expect of the child? He said that he thought coming to the
clinic was a waste of time. Under such conditions it was too much to expect
the cooperation necessary for improvement. Jealousy and pugnacity contin
ued, and the patient, on one occasion after her last visit, had had a violent
temper tantrum on the street. The mother stated that to her knowledge the
child had not masturbated since the last visit, and she was encouraged by the
improvement which followed the routine hours of sleep.
Comment.— This case illustrates one of the difficulties of instituting treat
ment that may cause more or less temporary annoyance, not only to the family
but to the neighbors. It is not to be expected that a mother will get up two
or three times^ a night to awaken a child, if she knows that such a disturb
ance of the child’s sleep will be followed by a violent temper tantrum and by
threats and insults from her husband and the neighbors.
It is hoped that the time is not far distant when facilities will be afforded
for taking such children out of the home and training them, temporarily at
least, under more favorable conditions.

• Isabel, aged 2 years 8 m onths; birth and development history nega
tive. She had always enjoyed good health; slept w ell; had well-established
toilet h abits; had a poor appetite and was very finicky about food. Her mother
always had to supervise her feeding, and she refused to eat cereal, eggs or
oatmeal, but was very fond of meat.
The child spent much time sucking her fingers, especially when moody. She
was active and interested in outdoor activities. She enjoyed being with other
children 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 children
other than her younger sister. When the opportunity arose to play with other
children during vacation periods in the summer months, she met every un
pleasant situation by developing a violent temper tantrum. She was domineer
ing and always wanted to be the boss. She was considered a fighter and was
rough and pugnacious toward smaller children. She whined constantly, and
it was frequently difficult to determine just what she wanted. She would lie
on the floor and kick and yell, and was extremely irritable and impatient.
After getting the object for which she had tenaciously fought, she would throw
it away immediately. She was very destructive. Her fear of the dark developed
after the following incident. W hile her father was playing with her she ran
into a dark closet, and her father stood outside the door making a noise like
a pat. She seemed to enjoy it at the time and asked him to continue. Since
this incident, however, she had refused to go to bed unless the door was left
open. In spite of her apparent lack of affection, she made heavy demands upon
her mother’s time and wanted to be constantly by her side. She rarely showed
any 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

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but not cruel. She was ordinarily kind and generous toward the baby in the
household but at times was rough and pushed and slapped her. Her mother
admitted that she did not give much time or affection to the child and said,
“ I am not naturally affectionate, and my husband is more interested in the
children.” The mother was of average intelligence and appeared interested,
but one felt that this interest was rather superficial and that one of her
fundamental characteristics was to take the path of least resistance. For ex
ample, she met the finger-sucking problem by giving the child a bottle.
Comment.— The outstanding features in the foregoing case were the unaffectionate attitude of the mother toward the child and the indifference the child
showed for the parents. The child’s negativistic attitude toward life stood out
very prominently. She was always on the opposite side. In other words, she
belonged to a group of children who, between the ages of 3 and 5, develop what
may be termed “contrasuggestibility.”
This condition in children usually lasts but a short time and passes without
leaving any undesirable effects upon the personality. On the other hand, there
are many individuals in adult life who are chronically negativistic, who are
immediately prompted by any suggestion from an outside source to take the
opposite side of the question presented. Many of these individuals develop
unusual ways. Their habits of living, of dress, and of eating are all such as
openly to defy custom and tradition. In children this negativistic attitude to
ward sleep and general conduct is often difficult to explain, but frequently it
represents an effort to attract attention and to keep themselves in the lime
light and hear themselves discussed. Invariably these negativistic children are
pointed out by the parents as “simply impossible youngsters.”
It seems wise, when this negativistic attitude is first recognized, to minimize
it so far as possible, to see that the child gains nothing by such reactions but
rather t t they work out to his loss. Above all, the apparent peculiarity of the
child should never be discussed in his presence. This is one of the situations in
which the child must be led and not pushed.
This case brings out the importance of allowing children to associate with
others of their own age. One of the most fundamental and important instinc
tive forces is that which is commonly termed the herd instinct. Very early in
life 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 reactions
of those of his own age and is able to get a better understanding and develop
a more sympathetic attitude toward others by virtue of this understanding.
It is, therefore, not surprising to find that the child who has been confined to
his own household 9 or 10 months in the year, making contacts only with
those in the family, experiences great difficulty in understanding and getting
along with others when the opportunity arises. In these days, when the hazard
of automobile accidents in crowded, congested districts cannot be ignored but
must be considered by every interested parent, the nursery and the nursery
school afford the desirable opportunities for youngsters to get together. In the
performance of their simple tasks, in their play life, and in the educational
training received, they will learn much concerning the problems of everyday
life as they are related to the group rather than to the individual.
Although not yet 3 years of age, this child was rapidly developing into a cold,
calculating, unaffectionate individual who utilized pretense of affection toward
others only to gain her own ends. This attitude, of course, only reflected that
of the parents toward the child, and it is not surprising that she utilized such
asocial reactions as temper tantrums and negativism to keep from being oblit
erated from the family horizon.
The treatment in this case dealt primarily with the mother. She manifested
more interest than the foregoing history would indicate that she was capable
o f; and as she was of an intelligence above the average, the situation seemed
quite hopeful. The treatment of such a case must continue over a period of
several months. Much can be expected when this child enters the nursery school
in the fall and makes daily contacts with other children. Much has already
been accomplished by presenting to the mother the program to be followed,
and by changing her attitude toward the patient as much as possible.

Anger is the child’s emotional response to a situation in which
his demands are not satisfied and he is being thwarted in his efforts to
attain some particular end. It is an expression of resentment toward
barriers and restraints set up by his environment. It is evidence of

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dissatisfaction and may be of value in leading to greater effort to
attain the goal, if it does not confuse and dominate him. Anger is
not an emotion to be eradicated by drastic methods but one which the
child should learn to control. Any normal child or adult will be
confronted with many situations in life in which any other emotion
than anger would be entirely inappropriate. Indignation is a con
trolled form of anger and has been the driving force behind many a
movement that has benefited mankind.
The child must learn, as he develops, that uncontrolled anger is
invariably a handicap in that it results in confusion of thought and
action, thus defeating the ends for which he is striving. Rigid dis
cipline which depends upon force and fear for its success may pre
vent for the moment any expression o f anger on the part o f the sub
dued child, but external influences are of little use in teaching the
child control of a normal and often useful emotion.
It is the expression of anger resulting from the constant conflict
between the child and his environment which should cause concern.
This is an indication that for one reason or another the emotional
needs of the child are not finding adequate outlets and that he is not
capable of making the compromises which are essential under such
conditions. Such a child is unhappy, critical, and intolerant, and
his pugnacious tendencies get him into all kinds of social difficulties.
There is no better way o f teaching a child self-control than by
example. Parents who are habitually quick-tempered, who lose con
trol of themselves on the slightest provocation and are always shout
ing at their children, are obviously setting a bad example. Even
if the child, through fear, is submissive in the home, he is likely to
compensate for his pent-up resentment in his contacts with other
children, especially those whom he can dominate through fear and
bullying.
John, 2 y2 years old, was sent to the clinic from the nursery school with the
following statement: “He has a bad temper, is always fighting, strikes and slaps
other children without provocation, and always wants what his brother has and
fights for it.”
In the attempt to determine the cause of this exaggerated pugnacity, rather
contradictory statements were encountered regarding the patient’s older brother,
Henry, aged 4. The home life of the two youngsters was said to be very un
happy and chaotic. The mother and father were always fighting, and both were
said to be impulsive and quick-tempered. The father had been arrested for
assault and battery, and on her first visit to the clinic the mother bore evidences
of his cruelty in the shape of scars.
It appeared that John had always been “mother’s boy” and his older brother,
Henry, had been the father’s favorite. From the nursery school it was learned
that the older brother was very sensitive and extremely quiet, that he was abso
lutely obedient and more polite than other children. A t times he was troubled
with enuresis and stammering. The mother’s story, however, was quite differ
ent. She claimed that Henry was bossy and domineering, always wanted his
own way, was jealous of the younger brother, had a violent temper, and some
times bit other children when he was angry. She further stated that he had an
intense fear of her, that when she “exploded in anger” or threatened to punish
him “his legs actually shook.”
When the mother’s attention was drawn to the discrepancy in the descriptions
of Henry’s personality she said that the picture which she had given the pre
vious week “was only true when he was having ill turns” and that usually he
Was extremely timid and never asserted his own rights, that John would “knock
him down and walk all over him and Henry never made any resistance what
ever.” He was extremely affectionate and liked to be petted and he was afraid
of the dark, where he “saw things and people.”

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In the examining room the child seemed very quiet. He had a marked flush
and breathed through his mouth because of a profuse discharge of mucus from
both nostrils. The cervical glands were enlarged, especially on the left side,
and the adenoids and tonsils were enlarged. The lad was underdeveloped and
nSorlv n o u S S . He was immediately referred to the medical c inic, and the
mother was requested to return to the habit clinic at the end ^
Careful social investigation revealed the fonowmg facts The father a d
mother were “always scrapping,” and on several g a m t o
been arrested for assault and battery. They were living with the ma t f n a i
grandmother because the father did not support or P /o v id e fo r t h e m o th e r .
The grandmother reported that there were two distinct f f j i o n s i n t h e
hnlrt
The vounger child, pugnacious John, was lined up with the momer
G ain st^th e fath lr and timid Henry. Because of the father’s work during
the dav and his pursuit of pleasure at night he spent little time at Lome.
Consequently Henry was left alone pretty much
mother had at all times been the protector of John, who had lea:rned iro
exnerience that he could tease and torment his older brother without fear of
retaliation when his mother was about. Henry undoubtedly had earne
retaliation
Qf valor to submit to tormenting by Lis brother rather
than to raise his mother’s wrath. So day by day the younger lad had become
more domineering and pugnacious while the '¡ M * * * j V ¿ ^ b r o S S T a ^ biting
dued and submissive, only occasionally turning ^upon his b ro th s and Dm g
and scratching in a crude, instinctive way at such times, th is was not mer
speculation b £ was borne out by the fact that John Lad improved
entering the school, where he had less opportunity of mamfestmg his arrogant
doininefring ways without punishment Henry, on the other hand, had re
“ o ^ & ^ f i o ^ m & T p o l n t s brought out in this ease are: 0 4
The” S
of environment on the development of personality and ( 2 ) the
S » r t a £ * of certain types of symptoms in
in atheSdevelopment^of personality, why“ i s t t that two individuais^oming from

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s understand why these two children should have
rv e lo p e d endr“ ly M e S n t V r s S S , one7 characterized by a domineering
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o f S r S u t e i lessors by experience and by the necessity o f adjusting himself to the demands of society.

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fob

c h il d

g u id a n c e

them down when they crossed her path. She had a very quick, violent temper
and got angry when thwarted. She was extremely jealous of her younger
sister because her father would tell her he loved the baby better. W h e i
scolded or humiliated she put her fingers in her mouth to keep from crying, and
t°
she a ^ a y s indulged in a period of thumb sucking. The
mother had kept the child in the house most of the time on account of her

Sfihiren pugnacity and the difficulty that she caused with the neighborhood
lr 6 Cli* ^
was extremd y active and mischievous, teasing her mother
by pulling at her dress and then running away, pulling down the curtain, and
° ther thi,ngs far whicb the mother was constantly reprimandm f t w m h ai o J " 68- openly rebellious toward any discipline and defied the
any
was made to thwart her. Instead of crying or whining
for what she wanted, she pushed and fought her way until she got it. When
attempts were made by the mother to punish her she ran away, dodging
and ducking into the corners and under the table, and when finally captured
and punished by the mother, she showed no resentment whatever. After she
was completely exhausted she went to the corner, sat down, and began sucking

¡2E
Umb a« d twif ting her curly black hair between the fingers of hef
le m band’ apparently perfectly happy and contented.
he psychologist stated that it was impossible to get any measurement o f
the child s intellectual equipment, as she was too active and unruly. - She con
sented to look at one of the pictures presented to her, but her interest lasted
i r m ent. She «ppeared to be a bright, hyperacaye ch?ld who d?maadld
^
way i ? all times’ exPressed her ideas clearly in sentences, and plaved
with the pencil and paper. She was interested in everything that was going
bite, and kick a

curi0Slty and> when opposed, did not hesitate to scratch)

The patient’s father was a hard-working man earning an adequate salary and
enjoying good health
The mother was also in good health and had a fair
intellectual equipment, having gone through the seventh grade in school
Since coming to this country from the W est Indies she had gone to trade school
and learned dressmaking. She had worked as a housemaid and in a laundry
She was much interested in her children but was not particularly cooperative
so far as the clinic was concerned.
■
Summary.— W e were dealing with a child, not yet 3 years of asre h av in g
a normal mentality and coming from a home that presented no outstlnding de
fects of physical surroundings or social relationships. The most prominent
characteristics m the mental life of the youngster were her curiosity and
tendency to investigate, and a marked hyperactivity and restlessness disnlaved
both at home a n d a t the clinic. Much of the pugnacity which had been at
tributed to the child seemed to be due to her desire for action rather than
to any desire to cause pain to others. Under existing conditions the mothe?
had felt obliged to limit the field of activities to their four-room apartment
which was quite inadequate to meet the demands of the child. It seemed th ?t
much of her mischievousness and naughtiness, so-called, could be attributedto
her desire foreplay life and that it was not associated with any implelsant
emotional reaction
To defy and be rebellious was her method of stimulating
her mother to activity. Her motive was to be chased and to be gtyen th f
opportunity of romping and running. One might well expect that when the
child enters a nursery school in the fall and is given an opportunity to e g r e s s
herself m group g a m es^ p d rhythmic dances accompanied by music m S t of
her difficulties will be adjusted.
most or
it is always important to study carefully the motives for acts rather than
the acts themselves.
£lLmu man

DESTRUCTIVENESS

Much o f the activity o f the preschool child that is termed destruc
tiveness is brought about by the attempt to satisfy curiosity. The
childleam s by handling, pulling, pushing, twisting, throwing, takm g thmgs apart, and exerting his own influence on his surroundings
limited as it may be. During this process o f investigation at a time
when the child s motor coordination is not well established, it is not
surpnsmg that he frequently miscalculates not only his strength

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but also the value o f some o f the material things with which he comes
in contact. The wise parent and the intelligent child S001J
some plan which reduces damage to a minimum. Needless to say, this
plan must be started early and discipline must be enforced. I
must be remembered, however, that the child does not discriminate
between what is valuable and what is not. For that reason the
child should not be surrounded with breakable things^ that are ex
pensive to replace, but should be taught to regard with proper re^
spect the material things with which he comes m contact There
cannot be one standard for the nursery and another for the living
room. I f the child is taught to be careful o f the linoleum on the
kitchen floor he will have respect for the parlor rug. i f h e puts a
value on his heavy china mug he will be likely to handle delicate
^ W ien ever possiblef the child should have some private place for
himself, whether it is a room of his own or merely a corner set aside
for his use. This should be a place m which he can ramble about
without undue restrictions and without fear of d°m g
will bring him into conflict with the adult members of the household.
The continuous nagging and scolding to which many active youngsters are subjected are the cause of much emotional tension on the
part o f the child and continued irritation on the part of the parent.
The constant fear that something is going to happen if Tom and
Mary do not stop whatever they are doing, creates a bad atmosphere
in which to rear a child.
.
. ,.
,, p
Destructiveness may be a way o f getting attention, the result o
jealousy, a method of getting revenge, or a means of settling a
grudge. Under such conditions the child is not
n|hj
motile back o f the conduct; and only after careful study o f the child
and his environment, including the personalities and experiences he
encounters, is it possible to be helpful in solving the problem.
Lydia was a very attractive little girl, 10 years of age, whose medical his
tory^ presented nothing worthy of note. She was in the fourth grade m schoo
“ sh f* was brought to the clinic by her father, who stated that she was “vlcioudy destrucu“ ' an™ 'w Ulfullyy stubborn." H e gave the following detans
^
“ « U X ' S r s S f h a d persisted in going down into the ceUar and
turning on the cold water, permitting it to run into the steam boiler. For this
she was severely scolded, threatened, and spanked, and finally her bare hands
were placed in the hot furnace so that they were badly blistered and had
to be bandaged for several days. Fifteen minutes after the removal of the
hnndases the act for which she had been punished was repeated.
Four days previous to visiting the clinic she scratched the piano with a. pin.
This episode was followed the next day by the mutilation of the top of the
dining-room table with the cover of a tin can. For these two offenses the
fathef scratched her arm and the palm of her right hand with a pm, leaving
ugly-looking wounds which were much in evidence when the child was seen
a tRecentlv1her father had missed several phonograph records and upon being
annealed to the patient admitted taking them to school but did not return
them although her father requested her to do so. She said she had given
the records to her teacher, but the father went to the school and saw both the
teacher and the principal and found that the child had lied. She admitted
this later. She was severely switched about the legs on the way home from
school, but she maintained a sullen silence until the next day, when she told
the housekeeper that she had put the records down through the cracks m the
veranda. 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 accord, she produced the
records, which had been hidden away in her room.
She wrote on the wallpaper, hammered the walls, and destroyed furniture.
She was the oldest of five children whose mother had died 3 years before
T il
He* father
“ I have had 20 housekeepers since then.”
The one in charge then was 63 years old; she was kindly and affectionate
toward the patient, and the child was fond of her. The father was a stern
reserved, quick-tempered man who was trying hard to keep his family together, and in spite of his apparent brutality he wanted to do what was right
A t school the patient was considered bright, well-behaved, and truthful. At
home she was untruthful, disobedient, destructive, selfish, jealous of material
things, unaffectionate, stubborn, and resentful. Her father said, “ She is willing
to undergo any pain to aggravate me.”
s
^
m e.gihiC Lydia appeared to be a happy, cheerful little girl, who frankly
admitted her jealousy of her younger sister. She gleefully told about schooh
day experiences but suddenly became sad and tearful at the m ention of her
mother. She had apparently assumed the responsibility for “all the rest of the
JJJjL
s.ke called them. She was interested in her schoolmates. She wanted
pretty clothes and liked her teachers, the housekeeper, and her father
She
showed no resentment at the severe punishment she had received and offered,
no excuses or explanations for her misconduct. She seemed to be very friendly
and approachable
One felt that a sympathetic relationship had been estab
lished which would do much to get things going right.
was given to understand that punishment was useless, a fact
that he had appreciated for some time. He was asked to get on a more
companionable basis with the children, and one Saturday he demonstrated his
good intentions by bringing three of the children to the clinic en route to the
movies. The father’s report at this second visit was encouraging. Lydia had
been getting along fine” for a week, none of the destructive tendencies being
^he had seemed happier and more cheerful, had talked more
freely, and had been much overjoyed at the prospect of going to the movies
After the picture show the child returned home. Everything seemed to he
progressing well when suddenly, for no apparent reason, she gfthered up sev
eral phonograph records and destroyed them. There seemed to be no particular
CTaotioia a.ttached to this episode, it being apparently the result of an impulsive
idea. She was not punished on this occasion, and everything went along
smoothly for 48 hours, her father being still hopeful that another week might
pass without further manifestation of her destructive tendencies. One e v e £
^ b r o u g h t home a new pair of white shoes for her, a present for which shf
had shown a strong desire for some tim e / She was happy over the gift but
ho a \ h? u r . after 5 * father’s return she cut the upholstery on one of
the best chairs in the living room with a pair of scissors. This information
was reported to the clinic by the father over the telephone. He admitted that
he had reached the limit of his patience and said that some plan must be
made to take the child from the home.
y
ust De
ro.ArQran.gT « eni were. ajade with a child-study home in Boston to take this child
for an indefinite period; but although the father had demanded that such a
plan be made, he let the matter drop at that point
sucn a
Nothing else was heard about the case until 6 weeks later, when the Society
P£e3rn£10K
Cruelty to Children was notified that the neighbors had
been much disturbed the previous night by screams coming from the home of
the pa&ent. Upon Investigation they fonnd'that the father
whSptofi
° ? t^e
buys severely- They threatened to break in, and the father
tkat the boy had been damaging the furniture in much the same
way as Lydia had done. The father admitted that he had a violent temper
l0St C° “ tro1 of it- If: was generally agreed by those interested
that the children ought to be placed out, but the father would not consent
H ? r r er’ a plan w as agreed upon and carried out whereby the children
o S y 'temporary

the Summer months-

Such a plan was, of course,

Comments—-This child was not under the personal observation of the author
enough to enable him to formulate any definite ideas of the underlying
cause of the child s destructiveness. There were, however, several pertinent
he fo n n w J he i n St°fiy Jhat gave an inkling of the line of treatment that must
be foUowed. The first and most important was the child’s devotion to her
mother, 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 deprived of her

S S K S s& 2 &

m§^ s s iS i
$ £ fo ^ S e S
5
voluntary vicious acts of destructiveness m some
deep-seated C e n t a l conflict with which the child was blindly struggling.

WiB82&=3&23S&8g
dUriI1

as S2 £g frightened™ he had recently been by one
B e ate weU. There was no

history of enuresis or masturbation

particularly satisfactory.

he had had se\eral convulsions, t _
^ i l e ^ f w fs T

l ^

l o

The laSt one which had occurred
rS o r ie a as being definitely epileptoid in

eharacter and^ ^ ^ e d _30 minutes.
ftl
with other children. He was
The patient•
t into many fights and was constantly teasing those
unduly pugnacious,
^
,
seemed to enjoy playing with animals, but
usually ended Dy using vaiiuu»
stubborn His mother ^ ‘ ed A a t w h e n h e »
did just the opposite. She f e i y n a t sne coum

thing he always
^
if
the water

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S e ? occasions S T a d started automobiles on the street.

For these reasons

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S

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t r e S

f t S * . S S S F S S * . In b«s eye. and

w ou ld 1enter a ^ y ' T S f S p r i n g

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bouses without bnoebing, and openly

H A B IT CLINICS FOR C H ILD GUIDANCE

appropriated what he desired. A t the nursery school he was considered a
difficult child to teach, seemed unable to follow directions, and had no sense
of rhythm or order. He did very poor work and would not obey— was con
sidered a general nuisance. O f late he had been calling his teacher bad namoa
whenever she asked him to do anything.
The family occupied a four-room apartment situated on a busy thorough-,
fare. The house was well furnished and homelike, well ventilated and neatly
kept. Family relationships were unusually pleasant Both the father and
the mother were much interested in the children and were eager to cooperate
in any way possible. The discipline had been left very largely to the mother,
who looked upon the patient’s behavior as something inevitable and thought
that it was too much to expect results from the clinic.
Summary. The patient, nearly 5 years of age, had been having convulsions
at rather infrequent intervals for 4 years. It was evident from his general
reactions to the problems of everyday life and his behavior in school that he
was not endowed with a normal intellectual equipment or that if he had such
an endowment at birth, its development had been retarded by the convulsions.
In spite of the fact that the home situation was at least average and the
parents were cooperative, it was perhaps useless to hope that satisfactory
results would be obtained so long as treatment was carried on in the home,
where the mother was inclined to take the stand that “what is to be will be.”
There was every reason to believe that this child would be much benefited by
institutional life during the developmental period, for not only was the young
ster’s mental development somewhat retarded but the whole situation was com
plicated by the convulsive phenomena and the emotional instability. Under these
conditions a very special environment, such as can be obtained only in the best
institutions, was needed so that the limited abilities of the child could be
developed to their fullest extent.

DELINQUENCY

The self-regarding sentiment o f most individuals is to a very large
extent dependent upon the opinion that other people have o f them.
It is only after an individual has achieved success and established
himself firmly in science, business, or a profession that he has suffi
cient confidence in his own achievements to ignore the opinions of
others to any marked degree.
During the early years o f a child’s life, when imitation and sugges
tion play a leading part, it is particularly important that he should
not absorb from those about him ideas in regard to his own qualities
which might react disadvantageous^ on his conduct. The child who
is continually led to believe that his word cannot be depended upon
or that he has no regard for other people’s property and other peo
ple s rights, is quite apt to accept this suggestion as representing the
truth and to make no effort to avoid doing what he feels is expected
o f him. On the other hand, suggestions that he has certain capabili
ties and that a certain moral standard is expected of him may do
much to stimulate his efforts in the direction o f a line o f conduct
which will furnish in itself the satisfaction to assure its continuance.
It is too much to expect that the child who is being reared in an en
vironment where truth and honesty are held lightly will develop o f
his own accord standards acceptable to society. No one expresses any
particular amazement over the fact that a child brought up in a
German family learns to speak German or that the French child
learns to speak French, but we sometime fail to appreciate the fact
that conduct as well as speech is to a very large extent an imitative
phenomenon.
One mother brought her child to the clinic, stating quite frankly
that the child, aged 3 years, used the same swear words that her hus78985°— 39------5

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band used and that he manifested the same arrogant, defiant atti
tude toward her that he saw in his father. There is nothing obscure
between cause and effect in this particular case. Another woman
brought in her youngster, quite perturbed because the child had
bought candy with a nickel which had been given her for carfare
to visit the dentist. Only a week before, however, this same mother
had told the child that she was going on an automobile ride and then
had taken her to the dentist. One finds that a child is quite capable
at a very early age of differentiating fact from fancy and that one
o f the first important needs in the development of honesty and integ
rity is conduct on the part o f those with whom the child comes in
daily contact which he can safely imitate.
However, the problem is not by any means one o f suggestion and
imitation entirely, and frequently very complicated situations arise
which do not permit such a simple interpretation. A little girl was
sent to the clinic by the court because o f stealing. Investigation
showed that the motive in this particular case was intense jealousy
o f her chum, whose family could afford to give her many o f the
little niceties which young girls crave but which the patient could
not have. This feeling o f jealousy had persisted over a period o f
years, and it was not until she was given charge of the cloakroom
at school, a privilege assigned to her because o f her apparent honesty,
that the jealousy made itself manifest in stealing.
Delinquent behavior—that is, the type o f activity which is eventu
ally going to bring the child into conflict with society—should receive
the same consideration and thorough investigation as any other symp
tom o f maladjustment. The only approach to the problem that will
bear fruitful results is interpretation of the child’s difficulty in terms
o f his past experience, his present environmental situation, the per
sonalities surrounding him, and his own intellectual, physical, and
emotional make-up.
A ll children who steal cannot be treated in the same way. The
child who goes into the department store and steals something which
he desires although he has in his pocket a sufficient supply of money
to attain the thing desired in a socially accepted way is quite a d if
ferent problem from the child who steals money to buy candy for dis
tribution among his contemporaries in the hope that he will thus
be allowed to participate in their activities.
Stealing in young children often has its origin in what Dr. Healy
terms “ grudge formation” 5 and in sex conflicts. Such cases call for
most careful, intensive study, frequently over long periods o f time.
They require patience and kindness on the part of the parents, and
before they are satisfactorily adjusted they may tax the skill and
ingenuity o f the specialist.
The problem o f lying also must be regarded from various angles.
The lying associated with stealing is invariably o f a protective nature
and is quite different in its psychological implications from the
problem o f the child who lies in an effort to bolster up his self-esteem.
Truancy may result from varied motives, some closely tied up with
the personality make-up o f the child and others entirely dependent
upon environmental situations. It is not a sufficient deviation from
8 Healy, William, M. D .: The Individual Delinquent, p. 376.
Boston, 1915.

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Little, Brown & Co.,

H A B IT CLINICS FOR C H ILD GUIDANCE

normal conduct to be considered too serious in itself. It is only when
truancy represents an effort to escape from an undesirable environ
ment that it should cause concern, and then the environment rather
than the symptom requires treatment. It is the spirit o f “ wander
lust in most youngsters that prompts them to investigate whatever
is strange and new. To most youngsters this means nothing more
than investigating a new alley, making friends around the corner,
or gomg to the park; with the more venturesome it leads at times
to the motion-picture shows or wherever there seems to be anything
exciting gomg on. Unfortunately most o f these early truants are
, after the first offense, and the punishment in no way inhibits their desire for future adventure or satisfies the curiosity
stimulated by their first experience. It is only when the moment to
return home is at hand that they recall the last experience. This
very often prompts them to remain away from home on account of
youngster
o f remaining out at night with
the other boys, who would leave him one by one, said he was always
afra!d to return home “to face the music.” His mother said that
he had been beaten very hard but that it did no good. Beatings do
not solve these problems.
The discovery o f the child’s motive—that is, what he hopes to
accomplish by his misconduct—is a prerequisite for any intelligent
plan o f treatment. The importance o f this is brought out in the fol
lowing cases:
a< p d l ° . ; , birth
devel°pmental history quite normal. She was the
? rl
cí 1H ren: She was brought to the clinic by her mother because
she told silly lies without any reason, stayed out at night without permission
and stole small amounts of money. The child had had measles and w h o o S
cough, but none o f the other children’s diseases; had no history of iniuries
or operations; slept and ate well, occasionally talking in her sleep but not so
^ndeS ° d- Sh® wet
bed at S e q u e n t S te r v a ls
T h f mother
s ~ld . ^ at J-b e
was selfish and always wanted her own way. She was not
affectionate and showed no attachment for her father or mother
She was
extremely jealous o f 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 and
mother stated that she did the punishing with a strap as the
f f l t w w * w disciplined the child. The patient was apparently afraid of her
bu^ ot. o f
moí:her; The mother said that the child got along well in
SCTn,01 f
g<?* good marks’ but subsequent investigation did not bear this out
The foUowmg comments on the other children in this family weie of Inter
• . Geor^ ’ aged 3 5’ was said t0 be disagreeable, troublesome, and a trial
ta bis
When 8, he was arrested for brekking into the Srls^ h S h
t^ ° . ? ther boys and destroying microscope lenses. He was put on
r bat on- and bis conduct since had been unsatisfactory. Four years later '
he was again arrested for breaking into and entering a grocery s t o r e b u t the I
case was dismissed. He was always lazy at school, whteh h 7 le f t at tee aae !
o L ík
rT ated,ly pIayed truant After leaving school L worked as In .
errand boy for 6 weeks at a stationery store and made $7 a week
He wa?
looking for work at the time o f the clinic visit and spent most r f his tim e ™
X ei tree!
? e WaS scorBful and deflaat toward his fateer and L fu s e d ^ o »
t0 nb^^?b" Joseph, aged 10, was still attending school. He had alwavs been
Sossed

H e was areested S

and after that he had become irritable when '

vbysi,M or mentBl make-nf

of »«te.

^be clinic the patient appeared to be quiet and subdued. She was rather
lTIfiL d?v®loPed and well nourished and was fairly attractive. She manifested
little interest in her surroundings. When questioned regarding her S -

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quencies she answered quickly but apparently without frankness, judging from
the data previously obtained. She accounted for the time spent away from
home as being spent with her girl friends and with the other children on the
street. She said she never asked permission to go out because her mother al
ways refused it. When she was out, she said, she was afraid to go home.
She appreciated the seriousness of her present situation and her attitude toward
her difficulties seemed quite normal. She admitted quite fr^ k^ J a t^
^
not like housework, but said she was willing to do it since she must. She was
looking forward to learning cooking in school the next yeai. She adm t
taking8 money that she found about the house, stating that the amounts varied
from 10 to 45 cents and that she always denied having taken the money be
cause she wished to avoid the punishment that always followed. She said she
enjoyed most being on the street or with her friends and liked to be away
from home. She read little and did not care for the movies.
The following briefly summarizes the home situation. .^he
to be a hard-working woman who bore the marks of her toil and hardships. She
had never had good health and was obviously discouraged over the discord
among the members of the family and the poorness of the t e n e m e ^ m which
they had to live. She had always had considerable worry and anxiety over the
three older children. Her husband kept her constantly upset because of his
marked irritability and fits of temper, which disturbed the family most of the
time. He was apparently disgusted with the lack of success they
ha(*
raisins the family, and there were many scenes between him and the oldest
boy
The husband’s reactions were always worse when he had been drinking.
Ttfe patient seemed to be his favorite child and had considerable influence over
him when he was having one of his “ spells.” The mother tried to adjust t
this chaotic situation, but the alcoholism of her husband and the constant
auarreling of the children made her very unhappy. The home situation was
auite intolerable. The family occupied a five-room flat in a poor neighborhood
on a S i s y crowded street. The tenement was damp and cold, and in spite
nf thp mother’s efforts to improve it it was not attractive.
During the first clinic visit little was accomplished except to get the h /s^ ry
and an interview with the child. The mother was requested to return to the
next clinic but it was several weeks before she appeared again. The report
was very1Cdiscouraging. The child continued to disregard her parents wishes,
Daving no attention whatever to her mother. She always avoided telling her
mother where she was going and where she had been, even i f her conduct had
been such as to justify praise. Her school work was not satisfactory, and it
was expected that she would have to repeat her grade or else take summerSCOn 1the°rsecond visit sufficient time was taken to discuss the problem in some
de?ail ^ t h both Ihe mother and the child. It appeared that the mother’s re
strictions on the girl had been rather severe. Her anxiety over the patient s
whereabouts and her distrust of her ability to take care of herself made t e
mother feel that the only safe place for her was in the house. The
was such that the mother felt unable to give the youngster any allowance and
she invariably refused her when she asked for money. The mother was frank
in admitting that on occasions her irritability toward the other members of the
l i o u s e S was spent on Nora, and that she rarely if ever ]t £ d ? & S e t o
devote to her except for matters of discipline. An effort was made to present
to Nora some of the difficulties of the mother’s position and the importance of
her assuming certain responsibilities in helping out in the household and causing
S
Z S r Is Uttle anxiety as possible. It .tas agreed beWeen them that ft e
Datient should have an allowance of 10 cents a week and that she would ask her
mother’s permission before she went out to visit other girls or to play in the
St The mother did not return until about a month later, notwithstanding the fact
that she had been urged to make weekly visits to the clinic. She said that the
patient was doing better, and that she was not running away as she formerly
had but that she was still very unreliable about keeping her promises, irritable
with the other children, doing poorly in school, and of little assistance m the
household
The mother said it was difficult for her to get to the clinic more
than once a month because her household duties made heavy demandsi upon
her time. The whole situation was gone over again in detail, and an effort was
made to have both the mother and the patient make some concessions.
The following 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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run away any more, and she did not tell silly lies” so often. She reported that
Nora was still very quarrelsome and hard to get along with. Her school work
was poor and her deportment mark low. At this visit, the patient got a little
friendly and confidential for the first time. She said that although she did not
like her teacher and hated the thought of going to school during the summer,
she was very anxious to stay in the sixth grade so that she could be with her
brother. The child was apparently in a very unhappy frame of mind, resenting
authority and feeling that she was not having the opportunity that other children
had. Her attitude seemed to be that she had to take whatever she got out of life
in spite of what others thought. The mother seemed to feel absolutely hopeless.
She had lost her courage to go on, was unable to see anything bright in the
future of the patient, and did not hesitate to let the patient know how discouraged
and unhappy she was about the outlook.
The patient did not return to the clinic for several months, and then she
came alone. She stated that she was getting along well in school, that things
were improving at home, and that she was getting more confidence in her
mother. But the mother’s report, as gathered by the social worker, was that
of a harsh, pessimistic critic who saw nothing but the unfavorable side of the
situation.^ She had just received a school report which indicated Nora’s ab
solute failure. Her deportment, writing, and geography were poor, and the
mother laid great stress on these failures. Nora said, by way of apology, that
besides these poor marks she had received four marks indicating exceptionally
good work— a fact that the mother admitted. When the patient was asked
in her mother’s presence if she was helping in the household, the mother spoke
up, saying, “Believe me, she don’t do much. She lies and steals money. I
don’t dare take her in anyone’s house for fear she might take something.”
The mother still refused to give the child money for any purpose, in spite of
the promise she had made at the clinic. The patient said that she never had
a chance to go to the movies, that she got candy from other children but never
had any of her own— “only what I take. The girls I play with sometimes have
candy and sometimes give it to me.”
She thought that a little girl of her
age should have 10 or 15 cents a week.
The child was given a long talk on the value of honesty, playing the game
fair, and helping her mother. The mother was interviewed at length about
the absolute necessity of changing her attitude toward the child. The im
portance of making the child believe that something was expected o f her was
called to the mother’s attention. It was pointed out that nothing could be
accomplished if she persisted in impressing the child with her delinquencies,
especially if this was done in front of other people. The fact that she had
unsuccessfully followed her own methods with the older children was pointed
out to her with extreme frankness, and an effort was made to show her that
nothing could be lost if she followed the plan outlined by the clinic.
Notwithstanding the fact that the situation seemed extremely hopeless i f
the child was to remain in that environment, it seemed worth while to con
tinue the efforts in this case. Something about the patient— her honesty and
frankness at the clinic as compared with her reported actions at home and
her insight and appreciation of the importance of overcoming her delinquen
cies— gave encouragement in spite of the wretched environmental conditions
in which she was living and the poor cooperation of the mother.
The latest reports from the school had been encouraging. The patient was
in the seventh grade, got along much better than the year before, got a
mark of “one” in effort and “ two” in conduct, and had not been sent to the
office for disciplinary reasons during the entire year. The patient was frank
and free in her talks with the doctor and had lost much of the stubbornness
which characterized her first visit to the clinic. Her mother had put her
on an allowance of 10 cents a week and had recently given her 30 cents to go
to a festival. There was no trouble at home about taking money, and the
patient seemed to be making a fairly good adjustment. She had passed all
her examinations in school and was looking for a summer job instead of having
to make up school work.
Although this improvement had been in evidence for a period o f only 3
months and might not continue without occasional relapses, the case was par
ticularly interesting as an indication of what could be done in spite of
wretched environmental conditions and lack of cooperation.
Besides the
rather infrequent visits to the clinic during which the problem had been dis
cussed with both parents and patient, successful efforts had been made to get

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the girl interested in a girls’ club and in taking books from the library, both
of which activities gave her much-needed interests other than street life.
Olive, aged 6 years 4 months, third of four children— the other children
being 8 years, 7 years, and 11 months old, respectively ; birth and development
normal except that talking was delayed until she was 26 months of age and
that she had always lisped. Except for an orthopedic operation on account of
a shoulder deformity, the child had always enjoyed good health. Prior to this
operation she was very restless at night and frequently walked in her sleep,
but since the operation her sleep had been restful and quiet. She had a good
appetite 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 extremely
affectionate and sensitive and was inclined to be jealous when she saw others
being petted. She got along well at home— at least her mother said the child
was easy to manage. She enjoyed her play life and spent much time by her
self. Her mother denied that the child had any propensity for stealing (in
spite of a history to that effect obtained from outside sources) but admitted
having lost money which she had left about the house. She said she could
not suspect the children as she had always trusted them. The child was in the
first grade. In spite of her history and the poor impression she made during
the first contact because o f her unattractive manner and unkempt appearance,
she graded normal on the psychometric test.
The parents were separated, but the father occasionally came to the house
to see the children. The mother seemed quite devoted to the children, and
although the living quarters were poor— they consisted of a four-room apart
ment on the third floor o f an extremely dilapidated building— and the home
was untidy and cluttered, she attempted to do more than give them purely
custodial care. She made an effort to amuse them, occasionally taking them
to the motion pictures and for walks.
Olive was referred to the clinic by a settlement worker because of her per
sistent stealing and the conditions under which the thefts were carried out.
From the settlement she had taken two hats and an umbrella. She was fre
quently found going through the children’s clothes, rifling their pockets. She
admitted these thefts only under conditions in which it was apparent that
she must be caught. Even when called to account for having stolen an article,
she would make attempts to take things from the person reprimanding her.
It did not matter whether the articles were of particular value or whether they
would naturally interest a child of her age. From the school she had taken
beads a rubber ball, a teacher’s key, fruit, and numerous other articles. When
confronted by one in authority with thè charge of thieving, she invariably
denied the thefts but always confessed later. There seemed to be no outstand
ing problems except the stealing and lying.
M e home situation was one of filth and immorality. The father had ap
parently spent much of his time with other women prior to leaving home. He
claimed that the mother was irresponsible in the care of the children and the
household, 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 of
having a violent temper, saying that he frequently went into a rage and that
there 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.
’ .
Obviously little or nothing could be expected by the clinic in the way of co
operation by the parents. The only hope of helping the child lay in those
with whom she came in contact outside the home. The assistance of her teacher
was solicited, and her cooperation did much toward any improvement that was
made The teacher stated that the patient was a dear little g irl; she seemed to
be much attached to her. The child got along well with the other children in
school but it was very difficult to make her concentrate. She did not seem
to have any interest in school, was poor in all her subjects, and probably would
not be promoted. At school her speech defect was a great handicap. She was
considered very childish for her age.
,
,
A t the clinic she entered the examining room in a shy and diffident manner
but did not appear frightened or resentful. A t first she merely smiled at the
examiner’s questions. Soon, however, she became more responsive and, with
a marked defect in her speech, began to repeat letters and numbers for the doctor.

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She volunteered a little information about her home life— the fact that she
had two brothers, that her father took her to the movies, and that she went to
the 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 pleasant
one. She said she liked to play ball and skip rope but did not like dolls because
they break; she liked the dances at the movies and said she could dance; she
told of seeing Charlie Chaplin, told the doctor what she had had for different
meals during the last 24 hours, named a number of common objects in the
room, and gradually became more interested in her surroundings.
A week later the patient returned to the clinic. She was much more friendly
but still a little shy. She made an effort to carry on a few speech exercises,
imitating the doctor. When asked with whom she played she said, “No one.”
When asked why, she said, “Nobody likes me.” Then she discussed the subject
more spontaneously, saying that she didn’t see why they didn’t like her— no
one liked her except her father and mother and the baby. Girls didn’t like
h er; they knocked her down. She insisted that she was the only one the other
children did not like. She said she didn’t like anybody but her family. There
seemed to be real emotion attached to the idea that nobody liked her. She
tried to hold back the tears, but it was difficult. She talked more frankly
about her thefts and tried to justify herself by the fact that she did not
like those from whom she took things.
A t 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 told
that a careful record was to be kept of the days on which she did not take
things and that she was to bring the record to the doctor the following week.
The teacher was seen, and arrangements were made to keep a chart on which
a star would indicate each day that the patient’s conduct had been satisfac
tory. This was carefully explained to the patient. She started off in a happier
frame of mind than she had thus far exhibited.
Just a week later the following report was received from the school: “Olive
has 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 rather
suspicious way. There is no record of her having taken anything that did
not belong to her at school all week.” A t the clinic, however, she found two
pennies in the toilet, which she returned with some reluctance. She seemed
quite happy while at the clinic and said she enjoyed making the visits.
The following week the report was excellent. The patient Was much pleased
at the interest the teacher had taken in her and was apparently making a
persistent effort to get the coveted stars to bring to the clinic. A t the settle
ment house which she visited frequently, however, she was found several times
in the act of taking things that did not belong to her. Her reaction on being
questioned about taking these things seemed one of remorse— she cried and
seemed very much upset.
There was something very inaccessible about this child. She chattered away
and answered questions very readily, but it was difficult to get close to her
innermost life. The last report received from the school was excellent. “Olive
has not taken anything for a long time.” She came into the clinic cheerful,
happy, and cieanly dressed. . She had genuine pride in the fact that she had
such a good report, and again it was felt that in spite of wretched environmental
conditions much had been accomplished toward helping this child to overcome
two very asocial reactions and to get much more happiness out of life.
Paul, a lad 13 years of age, was brought to the clinic by his stepmother, an
unusually bright, intellectual woman, extremely fond of and interested in her
stepson. For the last 5 years he had been developing certain delinquencies
that had caused the family much concern. He began by taking money from
the family and doing such things as mailing letters without putting on
postage and short-changing when sent on errands. He would tell lies to get
out of difficult situations. He would not, however, persist in the lies but would
confess what he had done and then break down and cry.
About 3 weeks before coming to the clinic his stepmother lost $5. About
the same time the patient came home and said that he had got a job in a
store. He gave the name of the store, the man he worked for, and the streets

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where he had to deliver goods. He elaborated to the extent of telling what
the storekeeper and the customer said to him. He said that he was treated
well and was given crackers at the store. A t the end of the week he brought
home $5 and turned it over to his mother. Investigation revealed the fact that
the lad was not employed and that the money was the same that he had
stolen. Immediately after this episode, he made further attempts to take m oney;
that is, he was found searching in places where money was usually kept.
This lad was in the eighth grade and was getting on well in school. The
psychometric test showed that he had normal mental equipment. He had
never worked. The father was generous to the children; he gave them a
dime on Saturday with which to buy candy. Paul was interested in playing
football and baseball and in skating and sledding, and got along well with
other boys. He said everyone was kind to him. He admitted that he cried
easily but knew no reason for doing so. He appeared to be an unusually
cheerful, active boy who, in the examining room, was frank and honest. He
made no effort to attribute his delinquencies to others. He said he seldom went
to movies and never went with a gang.
A study of this case showed that the motive was the desire of the boy to
emulate his father and play the part of a grown-up in helping to provide for
the family. It was what Kirkpatrick has called “passive enjoyment rather
than active effort,” but the motive was obviously not a malicious one, and
intelligent cooperation on the part of the parents made it quite easy to straighten
out this lad’s point of view. The social-service department of the clinic was
very active in this case. The lad’s interests were broadened, and arrangements
were made for him to spend the coming summer on a farm. The last notes
stated that he had been completely freed from his former delinquencies, that
he had been getting on well in school, and that the family had been relieved of
the worry and anxiety that were naturally associated with his former difficulties.

Quentin, aged 11 years, was brought to the clinic of the psychopathic hospital
by his mother upon the recommendation of the principal of his school. He
was under the jurisdiction of the court for entering a hotel by one of the side
windows and taking $10 from a desk. He denied the theft when discovered
hiding in a closet, but finally gave the money up when the policeman arrived.
H e had stolen many car tickets from the family. There had been a long history
of delinquencies.
The patient was a keen, bright lad, with normal intellectual equipment. He
discussed his trouble frankly and was anxious to overcome his “bad habits.”
He was kind, affectionate, generous, made friends easily, was interested in all
sorts of games and sports, mixed well with other children, and never held
grudges. He lacked interest in his studies and up to the time o f coming to
the clinic had never responded to discipline. He had been scolded, deprived
of privileges, and whipped, without results. He had no fear of policemen nor
of going to court.
Through the social-service department of the clinic this lad joined a boys'
club, and supervision was carried on from the out-patient clinic. Results were
extremely 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 get
crazy, but it is because I want sleds and things. My brother used to do all
these things. Now he is big and he gets me to do them.” Frequently parents
try to attribute the delinquencies of their children to some sickness or accident,
and sometimes the children themselves are prone to accept the suggestion as
an excuse for doing those things which they enjoy.

Gordon, the older of two children, was referred by his mother to the clinic
at the age of 4 years and 9 months for disobedience, masturbation, and quarrel
ing. H e was also described as stubborn and very destructive.
Birth was by Cesarean section. Developmental history was normal except
that the patient had been given a bottle until he was 2 years of age, having
refused to drink milk from a cup. At 4 years he had had whooping cough,

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followed by influenza, pneumonia, and an abscessed ear. He had been circum
cised. Tonsils and adenoids were removed when he was 2 years of age. His
eating habits were always a problem. He refused to eat unless fed, told a
story, or offered a reward. He had enuresis until he was 4. Occasionally he
bit his nails. He had masturbated since infancy, apparently without realizing
it. The patient presented the picture of an undisciplined child, very stubborn
and negativistic. He was prone to show off, and was very destructive of furni
ture and toys. He would throw objects about without any consideration of
the possibility of injuring another child.
The home situation was physically good, but was undesirable from the point
of view of meeting the patient’s personality needs. Maternal relatives in the
home dominated the situation, and the mother’s attachment and dependence on
them showed her own emotional immaturity. The psychological examination
revealed the patient to be of normal intelligence. The case was carried in the
clinic for 7 months, but service was interrupted by the mother’s inability to
attend because of illness. The mother lost interest and the case was closed
while the boy was still unimproved. The psychiatrist considered the mother’s
own adjustment very poor. He observed that she seemed unable to profit by
advice 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 problems were all intensified. Gordon had no idea of obedience
and presented many types of habit difficulties. He was extremely jealous of
his younger sister; he had begun to have nocturnal enuresis; he had developed
the habit of biting his finger and toe n ails; and he chewed his pajamas, blouse
collars, and so forth. He took money wherever he could get it and used it for
the purchase of guns. His mother threw away the guns, because of her fear
that the patient would grow up like “Abe” F------- , a man who had been involved
in a bank-robbery case and who was well known to the patient’s family.
Gordon was very inattentive and a daydreamer; in fact his mother had at
times feared he was deaf. His lack of concentration made his teacher in the
second grade consider him the “worst child in the class.” His first-grade
teacher, having had a much smaller class, had had no difficulty with him.
Much of his behavior was thought to be a demand for attention.
A new psychological examination gave the patient a rating of good, average
intelligence. A hearing test showed a loss of hearing in both ears, but this
was not considered sufficient to account for his lack of response.
Home conditions had been somewhat improved, as relatives no longer lived
with the fa m ily; but the mother was still very dependent on the relatives.
She also rebuffed the patient and favored his sister. She had not wanted a
boy. The father worked long hours, saw the children seldom, and thought
that the problem was the mother.
The problem of stealing was treated by arranging for an allowance to the
boy from the parents to take the place of former gifts from the grandfather.
Attempts to give the mother a more objective point of view and a knowledge
of mental-hygiene principles were not very successful because of her own
emotional immaturity. In spite of this, however, the patient’s behavior showed
some improvement. Arrangements were made for “attitude therapy” for the
mother. It was also recommended that the father attempt to give the patient
more of his time.
Mildred was 6 years and 8 months of age when first seen at the habit clinic.
She had been referred by a school teacher because of lying, stealing, truancy,
and swearing. She also had temper tantrums.
Mildred was born of an illegitimate union, and nothing was known of her
parents. She had been adopted shortly after birth by Irish parents of a low
intellectual, economic, and social level. A t the time of the clinic visit the
adoptive mother was over 60 years old and the father about 44. The reason for
the adoption was the mother’s desire to compensate for her inability to have
children of her own, since she was past the child-bearing age at the time of
her marriage. Besides the patient and the adoptive parents, a maternal aunt
was in the home.
The patient’s early development was normal and she was in good health.
She had had no diseases, operations, or accidents. She had good eating habits

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but was a restless sleeper. She had the habit of hiding in bed such stolen
articles as scissors, nails, and pencils. She had been masturbating since she
was 2 years old.
' 1
,/M ^
This child lied about everything. She had stolen candy from the five-and-tencent store, and she frequently took things from about the house and hid them.
She had started to swear at about the time that she was referred to the clinic.
Her temper tantrums dated back to the age of 17 months.
They were
resorted to when she could not have her own way. When having such a
tantrum, she would scream, kick, pick up anything handy, and threaten her
mother with it.
She usually played with younger children, and whenever she become angry
with them she would hit them with the first weapon she could find. On several
occasions she had hit a neighbor’s child on the head with a hammer.
She was hyperactive, stubborn, willful, and quite unaffectionate. She com
pletely dominated her parents, who no longer made any effort to discipline
It seemed unlikely that the patient would improve in this environment, as
she had complete control of the situation and her parents were too ineffectual
and ignorant to profit much from attempts at reeducation. Mildred was ac
cordingly placed for observation in the study home of a child-placing agency
with the possibility of long-time placement in a foster home. The clinic, how
ever, was unable to convince the parents of the advisability of such a place
ment, and the patient returned home.
Intensive therapy was then carried on by the social-service department. For
several weeks the patient showed improved behavior and the mother ap
peared to make an earnest effort to help carry out the clinic’s recommenda
tions. The maternal aunt refused to cooperate, however, and the home situa
tion became worse when the patient realized that she was the cause of friction
between her mother and her aunt. The case was closed after 7 months, as it
seemed useless for the clinic to try further treatment until the home situation
should be improved by the aunt’s departure from the household or by a change
in her attitude.

Truancy, which is a common problem among urban children, may
be motivated either by the desire to escape from an unhappy situation
or by curiosity about the unknown and longing for something new.
As with much undesirable behavior, however, once a pattern is es
tablished it seems to become self-perpetuating; and although the
original motive may be forgotten, the habit has become so strong that
no new motive is necessary.
Sam was a colored boy, 6 years and 10 months of age when first seen at the
clinic. There was nothing unusual in his birth or developmental history.
The patient went to bed, when he was at home, at about 9 o’clock and slept
until 8. Often he did not come home until after midnight. H e sometimes
had nocturnal enuresis. H is appetite was excellent and he would eat anything.
He was quarrelsome, hyperactive, and stubborn. H e could not be trusted
and he tried to be very independent. He ran away whenever he had a chance
and often did not come back until late at night. H is family picked him up
in police stations and on the streets. According to his mother he had “busi
ness ability.” He sold newspapers, ran errands, and shined shoes. H e either
gave the money to his mother or bought food with it. The patient was curious
and liked to look at books, but he had a reading disability. He was very
imaginative 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 intelligence quotient of 99.
The family occupied a six-room apartment on the first floor of a tenement
house. The apartment had a bathroom and three bedrooms. The furnishings
were adequate. Sam slept in a room with two brothers, sharing a bed with
one of them.
fi
,, .
. .
The problem as presented by the father and mother was that of truancy
and difficult behavior. Sam had been a truant off and on ever since he had
left kindergarten. He would wander away with the other neighborhood chil
dren. The family moved away from the neighborhood and the first Sunday
in their new home Sam wandered back to the old district. He might go as
far as 5 miles in his wanderings, sometimes riding on the back of a streetcar.

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A week before his first visit to the clinic he had left home about 2 p. m. and
had been found by the police at 3 a. m. after an 8-hour search. He picked up
a dime to a dollar a day from his various activities, such as dancing, singing,
or getting papers and selling them. He would often bring home rolls which
he had bought. At other times he would bring home money. H e was in and
out 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; I
work in a barn; I mind the horses and keep people from taking them aw ay;
I work in a show— pick up papers so I can get in for nothing. Sometimes I
clean automobiles; for a dollar I do the wheels and the windows and clean
the seats and everything.”
It was suggested that the patient be placed out in the country in order to
determine the importance of environment in his conduct. He was placed in a
suburb by a child-placing agency and he got along very well. His problems
have been minimized and there is no evidence of truancy at present.

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R ETR E AT A S A M ETHOD OF M EETING FAILURE

Unlike children who develop a resentful, rebellious attitude toward
restraint are those who respond by retreat. These children do not
battle in an endeavor to break down the barriers but are inclined to
retreat in the face o f obstacles, to become submissive rather than
rebellious. The mental characteristic known as plasticity seems to
play an unduly important part in their make-up. They offer no
resistance to factors in the environment which play upon them.
These children as a rule are timid, shy, and cautious. They find
little satisfaction in the activities of their more venturesome com
panions. Thus, while one child is thrilled by the experience of play
ing truant from home or school, another finds his satisfaction in
the overprotective atmosphere provided by an oversolicitous mother.
One lad finds life crowded with so many interesting and exciting
episodes that he spends but little time thinking what it is all about.
To another child life is dull, barren, and boresome. He runs away
from it, and only in his daydreaming does he get enough satisfaction
to justify his existence. These children are self-centered, critical,
jealous; they have limited interests and few friends. They get but
little satisfaction from the ordinary, everyday activities of life.
They turn their headlights in upon themselves rather than out upon
the world. They are inclined to be extremely dependent on one or
two people but are quite withdrawn from the world at large.
Many of these children in early life are looked upon as being re
sourceful, capable o f entertaining themselves and providing their
own amusements. This in itself is o f value if it is not just part of
the activity of an asocial child.
These children invariably suffer from a sense o f inferiority. They
do not enjoy any feeling o f security about life, and in comparing
themselves with other children they are vaguely conscious of their
own inadequacies so that they seek to avoid competition when failure
seems inevitable. The importance o f preventing the child from de
veloping what is commonly known as an inferiority complex is ap
parent to all who are concerned about his happiness and efficiency.
The child is so dependent upon the opinions o f others, especially
those from whom he seeks approbation, that adults cannot be too
careful about helping him to build up his self-esteem. A father
who thoughtlessly tries to stimulate his boy to greater effort by con
stant teasing may be quite unaware that this humiliates the child and
does something to his pride that will not easily be eradicated.
When the standards set for the child, whether in conduct or in
school work, are so high that failure is the rule rather than the excep
tion, the child is losing the one great motivating force to further
effort—success. Children who are unfavorably compared with others
in the home or neighborhood develop a sense of inferiority very easily,
especially when the comparison is unfair because of their inherent
deficiencies in mental equipment or physical strength. Habits like
enuresis and masturbation, when managed unwisely by the parents,
70

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may also cause the children, to feel that they are different, leading
them eventually to build their lives around their liabilities instead
o f around their assets.
(Df course, mental and physical handicaps necessarily impose certain limitations upon a child, but even when these are present every
effort should be made to see that the child has an opportunity to develop to the fullest extent of his capacity. The child who is conscious
o f doing this will not feel inferior.
When the child, no matter what the reason, develops this feeling
o f inferiority, many things may happen. As has been shown, some
children bolster up their self-esteem by aggressive measures such as
stealing, truancy, ^and defiance toward authority. Others assume
the protective attitude o f always being right while evervbody else
is wrong. But the group we are concerned with at tlie moment
succumb to their feelings and take the passive course which appears
to them to be easier. Shyness is a mode o f behavior that serves as a
retreat for individuals of all ages, but the emotional experience leading to this behavior is often obscure. In the following case shyness
was associated with stammering and both conditions seemed to bear
a definite causal relation to an unhappy home situation to which
the child had been unable to make a satisfactory adjustment.
Adele, a Negro girl, 4 years and 9 months old, was referred to the clinic
because of shyness.
Birth and development were normal.
She had had chiekenpox, measles
whooping cough, mumps, and sore throats. Her habits were regular.
Adele was a shy, quiet, unassertive child who did not appear to be interested
m her environment. She asked few questions, being content to sit back and
watch what was going on. When speaking, her voice was scarcely above a
whisper. Although quite able to take care of her own wants, she was never
very active or noisy and spoke only when necessary. Her shyness had been
apparent at so early an age that her mother thought it must have been inhented. A t times the child stammered considerably, according to the mother
although the school and the clinic saw no indications of this. In kinder!
garten the patient did good work, but she talked little and never made advances
to the other children of her own accord. Aside from kindergarten she had
little or no contacts, for the mother treated her as a “hothouse flower” and
considered her too delicate to play outdoors except in very pleasant weather.
When tested at the clinic the child showed normal intelligence: her in
telligence quotient was 105. As usual, she was shy and bashful
There was considerable friction at home. The father was cruei and abusive
hl? .,Y lfe
was interested in other women. He paid no attention to
the children. The mother had no social outlets. There were, moreover re
ligious differences between the parents. All this resulted in manv bitter
quarrels in the presence of the children.
Careful study of this case showed that after one of the parents’ quarrels the
childs stammering increased noticeably and her withdrawal became more
apparent. The mother was urged to allow the child to play outdoors without
too much supervision from herself and to encourage the child’s social contacts
Arrangements were made to have the mother and the children attend a camo'
The harm of overprotection and the results of marital difficulties as thev
re.fLte£ t0 the chlld s Problem were discussed. The mother tried to eooDerate
with the clinic as far as she could, and the child developed more independence.

In the following case shyness was associated with general timidity.
Pauline was referred to the clinic at the age of 5 years and 9 months because
of her extreme shyness. She was also described as oversensitive and timid and
given to crying easily.
This child’s birth had been difficult (breech presentation) but her develonment was normal. She had been in good health until her fourth year and then
within 1 year she had measles, whooping cough, and mastoiditis. She re
covered from all these infections. She wore arch supports to correct flat feet,

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but suffered from no other defects. Her eating, sleeping, and toilet habits
were normal.
Her mother described her as being very shy and as having a tendency to be
unduly anxious and worried over minor matters. When she was with other
people she was likely to hang her head and seem embarrassed, especially in
large groups and in school.
J
These traits were demonstrated at the clinic. In the clinic playroom the child
stayed close to her mother and was very reluctant to join the other children.
She was overconscientious about the order of the toys, chairs, and other
equipment in the room.
The parents were intelligent and the home atmosphere was harmonious in
spite of fiTinnnini strain. There were two other children, who seemed entirely
normal. A sister of the patient had died during the preceding winter and
this experience had a serious effect on her. She was sensitive to her mother’s
grief over this loss and would try to comfort her. A t the same time she was
apparently having reactions of her own to this experience as well as to the
family financial difficulties. Her mother observed that she seemed to be
“ walking in a trance.”
,
„
, .
In the psychological examination this child proved to be of good intelligence,
having an intelligence quotient of 113.
In the absence of either physical or mental handicap, treatment was directed
toward increased socialization of the child and a change in the family methods
of discipline. The mother cooperated well with the clinic. She not only
allowed the child to play more freely with other children, but she restrained
herself in the use of peremptory commands and in her constant emphasis on
cleanliness and manners. In the more relaxed atmosphere the child soon lost
some of her tenseness and no longer found it necessary to hide behind a wall
of shyness.

The death o f some member o f the family is often the source o f
behavior difficulty in a child—not that death in itself is a cause o f
behavior problems but that members of the family are often unwise
in their explanation o f it or in the display o f their own emotions and
attitudes.
The following case is interesting in its presentation of an unusually
complex method used by a 4-year-old child to escape the mental
anguish associated with the death of his grandmother. It also in
dicates that even at this early age the child meets his problem quite
differently in relation to different individuals. The symptoms in
this case were such as to cause real anxiety, for the child’s regression
from reality into a world o f fantasy seemed complete at times.
However, responses o f this type to difficult life situations are not
particularly uncommon in children. Although every effort should
be made to so organize the child’s mental outlook on life that he
may become more objective and deal more efficiently with reality, the
implications o f such symptoms during the preschool years are quite
different and of less significance in relation to actual mental disease
than would be the case in 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 complicated
situation.
The family history disclosed tuberculosis on both sides of the
family. The general background was poor and unstable. The maternal rela
tives and the patient’s immediate fam ily were dependent upon public aid.
The home atmosphere was far from serene. The father was in poor health
and took only a passive part in family life. The mother was erratic and
inconsistent in her discipline and showed definite favoritism toward the boy’s
younger sister and an antagonistic attitude toward the boy. The home was
shared by an aunt and an uncle, the latter adding to the difficulties by calling
the boy a “ sissy” and constantly teasing him in this way.
Further study of the case showed that the boy had been much attached
to his grandmother, with whom he had spent much time. , At the time of her
death he had stayed with the family upstairs and had cried bitterly for her,

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saying, My grandma s gone.” He was told by his mother that grandma had
gone to New York. Two months later, however, he told his mother that his
grandmother was dead, that she “went down a big hole.” He continued to talk
incessantly of his grandmother. Whenever he had a pencil he would write
letters to her, often saying that he heard his “grandma calling him” ; and when
punished, he would say, “ I’ll go to grandma.” He called for her in his sleep.
His mother at times found him gazing at his grandmother’s picture and holding
imaginary conversations with her. When his mother interrupted him he would
be very angry with her, saying he hated her, telling her to get out and stav
out, and even trying to strike her.
*
The mother claimed that his attitude had changed completely since the
grandmother s death. Whereas, formerly, she had had no fault to find with
him, he now cried for the least little thing, had become bold, and was unkind
and disagreeable to her.
From the account given by the mother one felt that the child presented cer
tain symptoms quite malignant from a mental point of view and that he was
in need of careful study and supervision.
The boy was normal physically but had many personality defects in his
make-up. He was very jealous of his little sister and selfish with her, prob
ably because his mother openly favored her. He held a bitter, antagonistic
feeling toward his mother and said that he hated her. She interpreted everv•A? k.e dld as being “fresh and bold” and expressed herself as too disgusted
with him ever to bother to praise him. His uncle’s teasing made him feel
inferior, and he resented being called “sissy.” He preferred to play with dolls
and games about the house, and it was not surprising to find that he had
always been kept close to his family and was not allowed to play with other
children. He was afraid of the dark and cried out in the night that pigeons
were biting him. His mother admitted that she had at times frightened him
m order to make him obey. He wet his clothes and had temper tantrums.
In the treatment of this case there were several factors to be dealt with
The most important was the mother, who had to be reeducated in her attitude
toward the patient and in her methods o f discipline. The father had to be
made to realize his responsibilities and the child had to be educated to meet
his problems in a more satisfactory manner.
1S ieiii:reai m?nt c°Psisted of frequent visits to the clinic and long talks
d° Ct0r‘ Ti e, . mo<* er’s attitude was changed; masturbation was
stopped by means of diversion and the substitution of other interests- the
child was desensitized to the dark through education and through h is’ love
of approbation; enuresis was stopped by the institution of routine measuresthe boy was allowed to play outdoors with other children; and he was no
longer teased or called “ sissy.” W ithin a few months the child made a per
fectly satisfactory adjustment to his home and to his play activities
Subset o ei S e mVeStlgatl° n Sh° Wed that he continued to make a very good adjustment
Comment.— The foregoing case is not particularly different from other cases
cited, except for the reaction o f the patient to the death of his grandmother
^ 1Sn P^ayma^es
met the situation in a fairly satisfactory wav
He
would talk about making trips with them to New York to see his grandmother
apparently refusing to think of her as being gone in the sense that she would
never return, and undoubtedly lessening the sting by handling the situation
as a child might be expected to do. W ith his mother he apparently faced the
question openiy and frankly, and his antagonism toward her indicates that he
,k ? r to be responsible in some way for the grandmother’s death. H e stated
S aL o ^ gT dmi ? S erx,WaS “in a holf in the ground.” This was his conception
of death, the child having none of the conceptions of the hereafter which
those of his age usually entertain and which help them to face such sorrowful
situations during their early years. When alone, however, he withdrew more
completely from the realities surrounding the situation and carried on imaginary
conversations. I f these symptoms had been presented in a child 10 or 15*years
older, they would have appeared to be rather definite psychotic symptoms, but in
i ^ t r e m e l y difficult to separate the products of daydreams and unfilled wishes from symptoms tlmt hftVG graver significance.

There is no cause for alarm if children have playmates o f an
imaginary character or if they hold conversations with their dolls
or other toys. Not infrequently their own personalities split up tern-

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porarily so that they are dealing apparently with two or three distinct
individuals at the same time, asking and answering questions, prais
ing one and punishing the other. It is these more imaginative chil
dren who make up the dreamers o f later life, some o f them achieving
success because o f these dreams, other falling by the wayside, unable
to cope with their more materialistic brothers.
There is cause for concern only when these definite retreats are
used by the child to meet some definite problem which has made
unusual demands upon his powers of adjustment. Here it indicates,
perhaps, a type o f reaction which later in life may be developed
and utilized to the disadvantage o f himself and all others concerned.
Isolated fears are often found to be due to threats thoughtlessly
made by parents or other people who are concerned with the problem
o f breaking some undesirable habit acquired by a child. This may
be seen in the case o f Gladys.
Gladys was 3 years and 1 month old when she was first brought to the
clinic by her mother because of fears.
Birth was 3 weeks premature but normal. Her development was normal
and her health history, except for pneumonia in infancy and several severe
colds, was good. She was still wetting the bed at night and was receiving con
siderable attention during mealtime and bedtime. She slept well except after
an attack of fear, during which she would stand up in bed and cry for her
mother. She often had “muscular spasms,” which came during the night, wak
ing her out of her sleep. At such times she would scream violently, clutch
at her mother convulsively, and become limp after a few minutes. The phy
sician who examined her reported that these were not convulsions.
Being the only girl and considerably younger than her two brothers, Gladys
was always the recipient of much attention from the family. She was, more
over, a much-wanted child, her parents having longed to have a girl for some
time preceding her birth. An atmosphere was built up in which “ everybody
always shushed for Gladys.” She became self-confident, happy, friendly, and
affectionate, with no fear of people.
/ ‘
Her chief fear seemed to be of the wind. As a small child she had been
in the habit of getting up in bed during the night and her mother had tried
to stop this by threatening that the wind would blow over her and she would
get sick if she did not stay under the covers. She began to think of the wind
as a terrifying monster leaning over her, and she would become especially
frightened when she heard the autumn wind blowing through the trees. Thun
derstorms were terrifying to her. She was very much afraid of the vacuum
cleaner and always stayed on a chair when her mother used it.
During one of her “muscular spasms” the patient began looking around in her
bedroom as if fearing some horrible specter. She gave her parents the impres
sion that her acute fear was due to the imagined approach of some dreadful
monster whom 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
would come and grab her hand away from her head. Although at that time
she stopped pulling her hair, she began to have a continuous fear of this
monster.

Another group of cases in which fear plays a very important part
during the early part of the individual’s life and is often carried
into late adolescence and sometimes never completely eradicated, in
cludes those cases in which some form o f sex activity has played a
part. Frequently sex problems are created in this way by the par
ents. One little girl who was battling the problem o f masturbation
happened to live near one o f the State hospitals for the insane, and
it was firmly impressed upon her that i f she continued the habit she
would eventually end there. She was taken around the institution

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in order that the threat might be more firmly imprinted upon her
mind. The child was told that everybody would soon know what
she was doing—that they could tell by her expression and by the
way she acted. Other children are threatened with operations under
the same conditions. It is not unusual to find parents mutilating the
fingers of young children, either by burning them or by pricking
them, because of this habit.
It is hardly necessary to say how acutely sensitized the young, im
mature mind becomes to the habit of sex when such drastic measures
are taken by interested but injudicious parents. Many of the inade
quacies o f adult personalities undoubtedly had their origin in feel
ings o f inferiority that were stimulated during childhood. A p
parently everything is done to make these children feel that they are
different, and it is not surprising that they become shy, timid, and
self-centered. Finding themselves in association with others who
are quite intolerable to them, they seek solitude and build up in
fantasy a dream world in which they can reside unmolested.
The situation o f the child who flees from reality and finds consola
tion for his feelings o f inferiority in a world of fantasy is well
illustrated by the following case:
Harry had not quite reached 10 years of age when he was first seen at the
clinic. He was described by his grandmother as being a lonesome, friendless
child. She stated that her earliest recollection of the boy was that of hearing
him tell her about an imaginary “friend boy” and that up to the time of his
coming to the clinic his chief companions were various insects and imaginary
children. He did not get on well with other children in school and was regarded
as queer. He was very fond of old people and very sympathetic with them,
being “very much upset,” for example, over seeing an old lady crying in church.
He was very responsive to music, singing church litanies to himself and im
provising songs about fairies.
In spite of the fact that this lad had a good intellectual equipment, with an
intelligence quotient of 121, his adjustment to school had been rather poor.
The boy was very restless during his sleep, talking as if he were fighting
with someone, shouting, and tossing about, and occasionally laughing. His
general health was good. He lived with his paternal grandparents, who had
adopted him and his sister at the time of the death of their parents. The
home, although small (a three-room apartment) was comfortable but obviously
lacking in space for play. The problem presented was mainly one of with
drawal, daydreaming, and running away from life as it actually exists. The
boy had an unusually acute imagination, was very keen in his observations,
and could occupy himself with his fantasies for hours at a time. He would
carry on imaginary conversations with a grasshopper, philosophize over the
different cloud formations and what they might mean, and discuss with himself
the observations that he had made upon the different kinds of trees and other
living things.
He appeared to be on intimate terms with fairies and he
symbolized them by taking a couple of match sticks wrapped in silver paper
and describing them as the fairy king and queen to whom he would sing.
According to his grandmother these imaginary figures became so real to hi™
that he would leave them with great reluctance, saying he was afraid to go
away lest they be unhappy. He also had imaginary children as playmates.
During his psychological examination at the clinic he talked to himself a
great deal, seemed to be thinking aloud, often about things that were irrelevant
to the examination. His manner to the examiner was, however, responsive
and friendly.
After helping his grandparents to build up a more objective sort of existence
for this child by getting him promoted to the fourth grade where he belonged
and by helping him make contacts with children in a “play group” who were
more congenial than those of his immediate neighborhood, the clinic was able
to close the case at the end of 11 months with the report that the child was
making a satisfactory adjustment.
78985°— 39------6

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OF TH E CHILD’S S E X LIFE

Parents who at some time have received help from the clinic in
the handling o f a specific problem often come to regard the clinic
as an educational center to which they may turn for advice and sug
gestions on various subjects connected with child training. They
may wish guidance in choosing toys and play equipment or sugges
tions for children’s books, or advice regarding a child’s speech de
velopment, or help in considering a summer camp. No less fre
quently, however, they want help in handling some aspect o f their
child’s sex education.
The question how reproduction occurs is one that every child with
average curiosity will ask sooner or later unless some experience has
made him unduly self-conscious and prematurely reticent. By the
time a child is four, he has probably asked about the origin of babies
many times. The answer given by the parents depends largely on
their own sex adjustment and their attitude toward the subject. The
clinic can be of great help, however, in giving parents an opportunity
to think out and talk over some o f the concepts which they wish to
give the child.
The whole task o f sex education can be made easier for parents
if they are encouraged to keep these two thoughts in mind: First,
that they must be absolutely honest as far as they go at any one
time so that they will not be obliged to retract some o f their state
ments later; and second, that they are telling the child about the
normal, natural process of reproduction and not about sexual inter
course. The young child has no curiosity about adult emotional rela
tionships or the actual process o f conception. He is, however, vitally
concerned and intensely curious about his origin, and the facts are
so simple and understandable if presented frankly and unemotion
ally that the child can be completely satisfied. I f parents will answer
the question o f the preschool child about reproduction without mak
ing him feel that he has introduced an unclean subject which only
naughty children speak of, something will have been accomplished.
It is a real achievement it the parent can make the child feel that
he has brought up one of the most interesting topics in the world
and if he can show the child, so far as his age and intelligence will
permit, why it is interesting.
The knowledge o f reproduction is in itself not so important as the
attitude and emotional response which such an approach will foster
in the child. In this connection the clinic can be o f great help in
giving parents an opportunity to rehearse—at least in their own
minds—what their own attitude and emotional response will be. It
is not enough for the clinic workers to tell a timid and inhibited
parent that he must state the facts truthfully, for in that case the
clinic worker is actually being as evasive as many parents. The
76

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workers should, be as frank as they advise parents to be. For many
parents the experience of hearing another person speak o f the sex
organs by name, simply and correctly? is o f the greatest benefit in
helping them to overcome self-consciousness in approaching the
subject.
6
Clinic groups that find it impossible or impractical to give this
type o f help to individual parents may accomplish similar results
arranging to have part of a parents’ conference or one o f a series
o f lectures for parents devoted to this subject. The clinic may pro
vide the speaker or leader from its own staff, or may sponsor presen
tation by an outside person.
Reproduction is a topic to be neither featured nor ignored. Not
all problems will be eliminated even when reproduction and sex
are wisely presented to children, but the problems will be easier to
manage, and parents will be in a far better position to help if they
have been accepted by the child as guides and counselors. It is forindeed, that some of the taboos regarding sex are being
lifted and that older children are no longer entirely dependent upon
the parent and the home for honest information regarding these
vital matters. The preschool child, however, must still depend on
parents and parents must therefore assume the responsibility of
seeing that the child embarks upon life with a wholesome outlook
and an intelligent understanding of the process o f reproduction.
In addition to helping parents in the matter o f sex education,
the clinic offers help in handling the various habits and attitudes
arising m connection with the child’s sex development. Common
among these is the habit o f masturbation.
Mothers o f problem children frequently say that the habit o f mas
turbation began at such an early date in the life o f the child that it
la.
^
tell when it did start. One child said that he had
handled himself ever since birth. Such statements bear witness
to the fact that the child may become aware at an early age that
he can arouse pleasurable sensations by manipulating the genitals
and other erogenous zones. This awareness is usually brought about
by some external stimulation such as may be caused when the child
is given a bath, when uncleanliness gives rise to various irritations
when the child makes a rather minute investigation o f his own
body, and all too frequently when older children become curious
about sex and make investigation o f smaller children. In certain
cases sexual precocity has been deliberately stimulated by irre
sponsible nursemaids.
It is not desired to convey the impression that masturbation be
gins so early in the great majority o f children. When it does begin
m these immature years it invariably lasts a short time. It may
recur between the ages o f 10 and 14. In fact it is so common durmg this period that a transitory period o f masturbation about the
age o f puberty is generally considered quite normal.
The masturbatory act is usually carried on by irritating the ex
ternal genitals with the hand, but children occasionally use sticks
pencils, and other small objects for this purpose. The act is often
complicated by other manipulations which apparently add to the
pleasure. Thumb sucking, rectal irritation, and rubbing the navel

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are most common, and any one of these acts may be performed alone
to the satisfaction o f the child.
.
i-i
Visits to the toilet are frequently events o f great mterest to chil
dren, and it is not unusual to find that masturbation occurs only at
these times. Not only their own visits to the toilet but those of
the adult members o f the household are o f interest. One. little girl
was brought to the clinic on account of her interest m
®
nude. She was accustomed to secrete herself behind the bed or m
the closet or to peep through the keyhole and put many other in
genious schemes into operation to see any of the adult members of
Other children are unduly sensitive about being in the presence
o f any member of the family while disrobing, and at a very early
age they are what we commonly term “ prudish regarding the prob6 Most o f these youngsters, from a therapeutic point of view, fall
into two groups: (1) Those who cling very tenaciously to these
pleasures and m fact to all the pleasures o f their lives, and ( )
those who give them up with little reluctance. Members of the
latter group need little or nothing more than to have their ener
gizing forces sublimated along some more desirable path, and stress
should be laid on the development o f some new interest rather than
on the undesirable habit. The treatment must be outlined to cover
not a few days or a week but a period of several weeks. The par
ents’ fears and anxieties over the outcome of the habit must be
allayed so that they can carry out the treatment without undue emo
tion. All that is usually required m such cases is to attract the
child’s attention with a picture or a game when he is m the act of
performing the undesirable habit. .Other methods that require in
genuity may be used, such, as directing the child s attention to some
situation, even though it is only of passing mterest, ^
ciently unique to hold his attention for the moment. The habit of
itself, gradually subsides. This habit m young children is not so
serious as in older children with whom masturbation occurs only
in seclusion, for in the early years the asocial quality of the act is
not yet appreciated. Parents may be .assured that no undue anxi
ety regarding these cases is justified if the child is directed with
^The^calS* that present the most difficult problem for treatment are
those o f children who turn to masturbation only when they are m
unhappy or despondent moods. They find m this habit a source of
comfort, and a comfort which is always at hand. As they grow older
they may continue to indulge in the habit much as children turn to
thumb sucking, especially as a means o f inducing sleep. They may
not experience any particular sex urge at the time, but they are
bothered by a general, indescribable feeling o f unrest, both physical
and mental, which they find can be subdued if a sufficiently strong sex
feeling can be stimulated.
.
The most practical method o f treatment is as follows:
(1) Careful physical examination to determine whether there are
any definite sources o f irritation.
(2) Absolute cleanliness.

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(3) Knowledge o f those with whom the child is making intimate
contacts.
(4) Knowing the child well enough to be able to understand his
moods fairly well and appreciating the fact that masturbation is
frequently sought as a retreat from unhappiness.
(5) Allaying the fears and anxieties o f the parents and helping
them to realize that dangers to the physical and mental well-being
o f the child are more apt to come from injudicious treatment than
from the habit itself.
In any attempt to dispense with an undesirable habit something
must be substituted for what is being taken away. Not only must
approval replace disapproval, pleasure replace pain, and reward
replace punishment, but some very definite and tangible method o f
sublimating energy must be presented to the child and presented
in such a way that it can be utilized.
Considerable experience has shown that mechanical appliances
which are used for restraining children are o f little value unless the
child is at an age when he can fully appreciate why the restraint is
being used and can develop a state o f mind in which he is quite
willing to cooperate instead o f resenting the treatment. I f restraint
is used forcibly the situation resolves itself into an open battle be
tween the child and the parents in which both are doomed to lose;
for invariably the child clings to the undesirable habit in spite of
these drastic measures.
The following case is presented in considerable detail because it
brings out several important points regarding the early development
o f sex interest in children and because it is further complicated by
convulsions o f an epileptoid character, which was the symptom that
brought the patient under observation.
Frances, a 9-year-old girl, was brought to the clinic by a social worker for
two definite reasons:
(1) Because of convulsions which resembled epilepsy
and ( 2 ) because of her precocious sex interest and sex delinquencies, which
had begun when she was between 5 and 6 years of age. The episode that
brought the child to the attention of the referring agency was that the child’s
teacher found an obscene picture in her possession.
Physical findings were negative, except for a positive tuberculin test and
the “spells” which resembled petit-mal attacks. The gynecological examination
that was made on account of the social history indicated a certain amount of
irritation of the genital organs.
The child was well developed and well
nourished.
The child’s intelligence quotient was found to be 111. Mental findings graded
the child 1 year above her chronological age, which gave her an intelligence
quotient of 111 on the Stanford scale. All the tests given were responded
to at about the same1level except that for rote memory, which was particularly
good, and that for practical judgment, which was below her mental age. She
was much interested and entered eagerly into the spirit of the tests. She was
in the third grade at school and was capable of doing work above the average.
The teacher considered the child very bright but stated that at times she
appeared extremely absent-minded.
The parents reported that the child had “immoral habits,” that she never
sought girl friends but was always in the company of boys, and that she had
immoral relations with them.
No information was obtained regarding the grandparents of the patient, but
her father appeared to be a fine, self-respecting man, who was making, every
effort to do all he could for the welfare of his family. The child’s mother had
died 4 years previous to the time of the clinic visit. She had been epileptic
and hypersexual to a marked degree. She died at a psychopathic hospital in
a toxic psychosis. The child’s father had married a second time and the step-

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mother seemed to be kindly and affectionate toward the child and interested
in her welfare. In matters of discipline concerning the younger children, she
received but little support and encouragement from the three older married
sisters in the family.
The child had been living at home with her father, stepmother, and brother
John, aged 13. The latter was said to be a quiet boy but it was learned
that he indulged in petty stealing and had been arrested twice. There were
three older married sisters who continually interested themselves in the
father’s household, much against the wishes of their stepmother and prob
ably to the disadvantage of the home. The father stated that none of his
children seemed normal. He had always had difficulty in bringing them up.
They were delinquent, misbehaved, and had bad reputations. On the whole
there seemed to be nothing obvious in the immediate household to account for
the delinquent tendencies of the children.
For the last 3 years Frances had interested herself in boys, although accord
ing to her own story she did not exclude girls as companions in her erotic
indulgences. From the history it appeared that the patient had been more
of an influence on the environment than the environment had been upon
her. The father stated that since the child was 3 years of age she had shown
an abnormal interest in sexual things and had been quite aware of her own
sex feelings and how to stimulate them. When returning from the moving
pictures she appeared to remember nothing but the sensual aspect of the pic
ture.
On several occasions the patient had been found in the cellar of
an unoccupied house, with three or four boys of her own age. She told her
father what had happened and showed no sense of shame in speaking of the
active part she played in these episodes.
In the doctor’s office she answered all questions frankly and showed herself
an extremely precocious individual with an intimate knowledge of sex affairs
which could have had its basis only in personal experience. She made no effort
to minimize her part in these events and voluntarily expressed a desire to over
come these hypersexual tendencies. She discussed the entire situation without
embarrassment, went into the minutest details, and discussed her innermost
thoughts and dreams in an interesting and enlightening way. She appreciated
the effort that she must make in order to overcome the cravings and desires
responsible for her past difficulties. She was also anxious to develop other
interests to substitute for her erotic daydreams. A t no time did she blame
others for her trouble, and she stated that she was extremely anxious to over
come her undesirable habits in order to make it easier for her stepmother, to
whom she was apparently very much attached.
This case presented two definite problems for solution: (1) The convulsive
tendency and (2) the precocious sex interest and sex delinquencies. Physical
findings in the case were essentially negative. Mental findings indicated that
the child had more than ordinary intelligence. Her teacher considered her
bright.
The delinquent behavior might have been considered accidental in
origin and as being continued because of hypersexual cravings. Home condi
tions were not ideal, yet they were not sufficiently difficult to account entirely
for the strain of delinquency found in this family. Associations were neither
better nor worse than those found in many districts. Nothing in the mental
make-up of the child or in the environmental conditions stood out distinctly as
the exciting factor of her difficulties.
The effect of such a series of experiences upon the development of character
and 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 well
be considered as environmental or accidental. The effect of such an experience
depends upon circumstances and conditions that are beyond the control of the
child, and the solution is quite as dependent upon accident as was the origin
of the primary experience.
The fact that this child was of rather high-grade mental equipment and some
what precocious in her interests other than her sex interests was indeed for
tunate, for the experience could be very well assimilated and digested by the
child, minimized by the parents, and perhaps turned to some good purpose.
On the other hand, the habit might be repressed so completely as to lose its own
identity entirely, only to appear in some quite pathological condition or some
definite asocial act— as apparently occurred with this patient in her hysterical
episodes. Again, the experience might be rather imperfectly repressed; and
continually and persistently forcing its way into consciousness, might produce

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disintegration of the personality such as is manifested in many of the psy
choneuroses of the neurasthenic and anxiety types.
From a physiological point of view it is not difficult to conceive of such early
sex experiences as sensitizing the individual to subsequent emotional experi
ences of a sexual nature and producing a hypersexual individual whose sexual
outlet may be prostitution, homosexuality, or other perversions. Notwithstanding
the fact that this tremendous physiological sexual drive may exist, it is not
unlikely that such an experience would produce a psychological repugnance to
sex, the two forces combating each other and resulting in conflicts that torment
and incapacitate.
W hile the child is passing through these experiences she needs all the help
and understanding that she can get from those having the case in charge
To wait 20 years and then begin philosophizing about the effect of such early
sexual experience and its relation to the nervous breakdown of an adult is perhaps easier than to get a clear, concise picture of just what is taking place when
the child is passing ^through the experiences. But there is no comparison in real
value between gaining information while the forces are operating and guessing
w^a^ actuaUy happened, how the mental mechanism worked, and what
effects the experience had on the development of the individual.

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PER SO N ALITY CHANGES FOLLOWING ILLNESS AND
IN JU R Y

Parents are frequently inclined to blame an illness, an operation,
or an accident for some change in the behavior of the child, when
a careful examination and thorough investigation of all the facts sur
rounding the problem would indicate that the illness or accident has
been to blame only in so altering the relationship of the child to his
environment as to allow these personality problems to develop.
It is only natural that parents are deeply concerned when a child
is ill, especially if the condition is at all serious. Their anxiety over
the welfare o f the child is often out of all proportion to what the
situation really warrants. Whether the child has been cared for at
home or in a hospital, the period of illness and convalescence is one
during which the entire household revolves around the child. The
other children are instructed to give in at all times to the ailing mem
ber. His every want is anticipated, and his demands, however
numerous and varied, are satisfied at the earliest possible moment.
He is in a position to commandeer everything in his environment and,
needless to say, it is not an unattractive situation in which he finds
himself.
For the first time, so far as he can remember, he is the center of
attraction and attention. He never before appreciated just how im
portant he really was. Before this illness he had had to give and
take with the rest of the family. He had his responsibilities and he
was expected to “ carry on” like the other children in the family. He
took his shares of punishment and accepted it, but now everything
has changed to his advantage. It is therefore not surprising that the
child who finds himself in this situation should get an exaggerated
idea o f his own importance and that after he has enjoyed these
indulgences on the part of the oversolicitous parents he should cling
rather tenaciously to his new position, being reluctant to give up the
symptoms which created it.
A typical example is that of James, whose mother said, “James is very rest
less, cries easily, twitches his arms and body muscles, is very irritable, flies into
tempers, and cannot sleep nights.” This change appeared after his return from
a hospital where he had been treated following an accident. H e became^ very
surly, always looked ugly, seldom smiled, and appeared unhappy and discon
tented. He had become so different since the accident that the boys started
to call him “Empty-head.” The problem confronting the mother was whether
she should follow the advice of her lawyer and sue for damages. Fortunately,
however, her primary interest was in the recovery of the lad. Inquiry revealed
that since the accident the routine of the household had revolved around the
patient. Every whim was gratified regarding his food; other children were
notified that they must accede to his every w ish ; all the toys were his to accept
or to reject; and the lad found himself in the limelight.
After a careful physical and neurological examination had been made, it was
planned to change the regime of the household. The mother was to revert to
the old plan of making the child give and take and battle for what he could get
with the rest of the children. In just 1 month his mother reported that he was

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happy and contented and played with the other boys, had lost his surliness, was
getting along well in school, and showed no evidence of the personality change
whieh was so apparent when he first came under observation.

Many o f these problems might have been avoided had the parents
appreciated just what all this attention might mean to the child.
The most important part o f most illnesses is the convalescing period.
A t this time the parents must use the best judgment to avoid not only
prolonging the illness but creating attitudes on the part o f the child
toward the illness which cause trouble later. Quarrelsomeness,
jealousy, selfishness, disobedience, sullenness, tempers, and many other
undesirable personality traits may have their origin during the con
valescent period.
.
Although many o f these personality changes have a definite psy
chological basis, it has been recognized within the last 10 years that
many cases of marked personality change are the result of encepha
litis. These changes may manifest themselves in a deep apathy or
a marked hyperactivity characterized by irritability, destructiveness,
and not infrequently by violent temper. Occasionally delusions and
hallucinatory experiences are also associated with them. Such
changes are usually preceded by a fairly typical history of encepha
litis, which should ordinarily not be confused with other diseases.
There are, however, a number o f cases in which the attack was so
mild that the diagnosis o f encephalitis was not made but which were
nevertheless followed by marked change in personality.
i
This point should be kept in mind in making a diagnosis and plan
ning treatment. Obviously the ordinary clinic measures carried out
on a psychological level or any reconstruction o f the environment do
not materially alter the conduct of these children. The treatment to
a very large extent is one o f reeducation under adequate supervision.
Another situation that may arise with reference to personality
changes and their relation to accidents is brought about when parents
take the opportunity o f blaming illness and accidents for undesirable
behavior. Thus, the mother of an 8-year-old child gave a history o f
the child’s lying, stealing, being cruel, and other asocial conduct as
beginning after a coasting accident which took place about a year
before the time of her coming to the clinic. A subsequent social
investigation revealed, however, that this child had been a serious
problem at home, at school, and on the street for several years; that
he was well known to the police and the truant officers; and that
although the accident itself and the attention which the child re
ceived may have exaggerated the situation, it could in no way be
regarded as the cause.
#
,
.
Undoubtedly certain peculiar personality traits are developed by
children who suffer from such chronic diseases as^ diabetes and car
diac conditions which have limited their activities and prevented
them from participating in a normal way with children o f their
own age and by children who have been the victims of illnesses like
infantile paralysis which leave physical handicaps. Usually, how
ever, those children who are handicapped by infantile paralysis in
early life are remarkably free from personality changes. This may
be due to the fact that the limitations imposed by the illness are
present at such an early age that the child learns to live with the
difficulty from the very beginning. Furthermore, the handicap is

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o f such a nature that his contemporaries make certain allowances
for it. The cardiac and diabetic children, however, have no such
obvious defect. _ Children with heart conditions become overwhelmed
by their inability to compete with other children after they have
recovered from the disability and so may develop a feeling o f in
feriority. But the diabetic child is more likely to become critical,
irritable, resentful, and defiant unless wisely managed fr o m the
beginning o f his illness. These personality traits are not character
istic o f the respective illnesses, but they are observed with sufficient
frequency to be worthy o f comment.
It should always be remembered that every family has its own
history and its own associations which color its attitude in a new
situation. Prolonged and exaggerated solicitude over a child who
is ill with measles may seem quite out o f proportion to the cause
until one learns that an older child lost his hearing following an at
tack o f measles. It is important to get a complete history in order
to interpret these situations correctly and arrive at a practical thera
peutic approach.
The following case, discussed in some detail, is o f interest in this
connection.
Randolph was referred to the clinic at the age of 3 years because of a
personality change first noticed on his return from the hospital, where he
had been confined with diphtheria. He was quarrelsome and had frequent
temper tantrums, during which he threw himself on the floor and kicked
and screamed for long periods. A t night he refused to go to bed unless
accompanied by his mother, and occasionally he had night terrors. In addition,
he was capricious about food and had developed the habit of soiling himself
daily.
This boy’s birth and early development were uneventful except for a mild
attack of scurvy when he was a year old, and the attack of diphtheria already
mentioned.
The father had suffered a nervous break-down a year before. Although he
was occasionally irritable he was, on the whole, a generous and considerate
father and an excellent provider. The mother was well meaning, but highly
neurotic and unstable and she had many superstitious interpretations of the
simplest incidents. An older boy had died of diphtheria and she had not fully
recovered from her sorrow, a fact which had considerable bearing on her
present condition. Besides a younger brother there was in the household the
maternal grandmother, who interfered greatly with the discipline. According
to the mother the grandmother “would turn the house upside down to please
the children, as she hated to hear them cry.”
Prior to the boy’s illness his mother had noticed nothing peculiar in his
behavior, but following his return she had observed a decided change. He was
sullen, irritable, seclusive, and unreasonable. He expected more than his share
of attention and went into a tantrum when it was not forthcoming. H e went
to the window every night before retiring and, looking upward, bade good
night to God and his older brother— a practice which his mother considered
uncanny and unexplainable. He had not been permitted to play with the
other children in the neighborhood because of his peculiarities and because
none of them were his age. The mother complained that it was impossible
to have the child remain in the bedroom alone before going to sleep— he begged
her to remain with him to make sure there were no wolves outside the door.
He entertained this constant fear of having wolves enter the room.
On his first visit to the clinic the boy refused to leave his mother or to
permit her to enter the examining room without him. When she left he flung
himself upon the floor and remained there in a rigid state until her return.
She then picked him up and allowed him to bury his head in her bosom,
simulating a nursing child. He later began to pout and talk in a babylike
fashion but refused to converse with the examiner.
The intellectual equipment of this boy was about average.
He had an
intelligence quotient o f 98.

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This is a ease which superficially would impress one as having all the essen
tials of an early mental aberration, were one to base one’s conclusions entirely
on the mother’s interpretations and findings without further analysis of the
situation. Indications which the mother accepted as being highly ominous were
really 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 which
will be mentioned shortly.
The mother, grief-stricken over the death of her older son (who had died while
the patient was convalescing), attempted to compensate for her loss by in
dulging the patient to an unlimited degree. Everything began to center abound
him. He was the one attraction in the house and all the members of the
household exhibited their joy at his recovery. The child saw himself in this
prominent and not unpleasant position and it was not long before he took
full advantage of it by making numerous demands which the family readily
granted.
A t one time the family had employed a maid who had nightly threatened the
child with a wolf story before he went to bed. She used this story in an at
tempt to hurry him to bed and always warned him to remain in the room
lest he be captured by the wolf. This bit of information revealed the origin
of his fear of wolves.
Later it had been the grandmother’s privilege to prepare the patient for
bed.- She would undress him, hear his prayers, and, before putting him to
bed, take him to the window and have him bid good night to his deceased brother,
who, she explained, was watching over him with God. When the development
o f this particular practice was explained to the mother she no longer looked
upon it as being a mysterious procedure but realized that it was simply what
his grandmother had taught him..
Much of the success of the treatment in this case rested on the mother’s
acceptance of modern methods of dealing with the child’s problem and the
destruction of many of the superstitions which had previously handicapped
her. 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 o f wolves. He no
longer was to assume the role of invalid but was to take his place in the
household on an equal footing with his younger brother.
The child made three visits to the clinic. On his last visit his mother
reported that he went to bed unaccompanied, that he no longer talked about
wolves, and that he had earned his complete quota of stars on the chart. TTis
marked aversion for milk had been overcome and he drank it unprotestingly
with every meal. The fam ily was leaving for a summer resort where it was
hoped he would be given a wider opportunity for contacts with children of
his own age.

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CONVULSIONS, TICS, M AN N ERISM S

When one considers that more than half of all individuals suffer
ing from chronic convulsive disorders in adult life, the so-called
epileptics, had their first convulsion prior to the fourth year of life,
the importance of convulsions in children becomes apparent. This
does not mean that the isolated convulsion which sometimes ushers
in an acute infectious disease in children need be taken too seriously
or cause parents undue anxiety. Any child, however, who has a
series of convulsions or is prone to react to infections, falls, and emo
tional stresses and strains by having a convulsion is in need o f the
best medical attention.
A study was made of a group o f children under 4 years of age who
had been patients in hospitals and had suffered from convulsions asso
ciated with acute infections, spasmophilia, gastrointestinal upsets,
rickets, and whooping cough. These cases were carefully followed
up to discover their subsequent history. A surprisingly large number
o f these children eventually died o f convulsions and many of those
who were still living continued to have convulsions or were mentally
deficient. The implication o f this study is that convulsions in
children should no longer be looked upon as a mere incident in their
medical history nor as something that happens to every child, like
an increase in temperature or a gastrointestinal upset. The convul
sion itself must rather be considered as a certain criterion o f the in
herent instability o f the nervous system. Some children are so in
herently stable that the convulsions associated with actual irritation
o f the nervous system (such as is seen in encephalitis) may subside
and leave no ill effects. This indicates that there is no well-defined
limit to the amount of brain irritation that may occur without leaving
ill effects. It appears that some nervous systems are capable of with
standing a rather severe disturbance such as would naturally be pro
duced by an acute inflammatory condition o f the brain. Others will
succumb to a mild infection or a slight trauma, leaving behind an
increased instability which responds more or less periodically to the
minor vicissitudes o f life and manifests itself in convulsions.
From the standpoint o f preventive medicine it does not matter
whether these early convulsions are of psychogenic or of biochemical
origin. There seems to be little doubt in the minds of those most
interested in the subject o f epilepsy that each convulsion paves the
way for the succeeding one, and that the path becomes deeper and
the line of demarcation sharper and more easily traversed by the
excess of liberated nervous energy. For this reason it is tremendously
important for the future welfare of the child that a careful investiga
tion be made, by both clinical examination and laboratory tests, to
determine the exciting factor in the production of these infantile
convulsions.
It is important for the pediatrician and the psychiatrist to work
hand in hand. The former usually sees the child over a short period
o f time, but it is an extremely important time when the undesirable
forces, whether they are psychogenic or chemical, are operating. The

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latter, on the other hand, sees the child over a longer period of time,
but invariably at a period somewhat removed from that in which the
exciting factors actually operate. Until a better working knowledge
is obtained of the baffling phenomenon called epilepsy, it is especially
important for the psychiatrist and the pediatrician to cooperate and
to have a clear knowledge of each other’s technique. In almost every
case of a convulsive disorder it is necessary to look for both a pre
disposing and an exciting factor.
There is no group o f cases today more worthy o f the attention ox
those best qualified in the practice of medicine than those o f early
infantile convulsions. It has been said that “the child, for the first
5 years o f life, is an organism so tender, so easily broken, so easily
damaged, that it needs all the care that first-class intelligence can
give it.”
Susan, a poorly nourished and underdeveloped girl, 6 years o f age, was
brought to the clinic by her mother for a series of problems of which fainting
spells were the most important.
„
There was no history of epilepsy or mental or nervous diseases in the family.
The child’s birth and early development had been norm al; she had had the
ordinary diseases of childhood. There was no history of convulsions, but the
mother stated that the child, since she was 8 months of age, had had spells
during which she had momentarily lost consciousness. These fainting spells,
so called by the mother, usually took place when the child found herself in any
difficult situation. When threatened with punishment she would fall to the floor
in an apparent faint. She would hold her breath and get blue m the face.
The mother would then pick her up, fondle her and put her on the bed, and
the episode would be over. A t other times these “fainting spells” would follow
one of her temper tantrums. She would lie on the floor, kick, and yell) holding
her breath for varying periods and apparently losing consciousness. She might,
however, have one of the temper tantrums without the fainting spell.
The mother stated that the child was very affectionate but domineering. She
always wanted “to be the boss,” whether at home or at play, and usually got
her own way. She was extremely stubborn and when refused she responded
in the manner already described. She was said to be friendly and generous.
She was jealous to the extent that she demanded at least as much attention
as was given to the other children in the family. The mother repeatedly stated,
“ The child must have her own way. The only way to manage her is to give
in to her.”
. ,
Comment.— The foregoing history, in association with the negative physical
examination, stamped these “fainting spells” as belonging to a psychogenic
group of reactions. It seemed quite obvious that the child was utilizing this
method, to gain her own way. It is always difficult in a case of this kind to
divorce the physiological aspects from the purely psychological. For example,
the effect on the oxygenation of the blood of holding the breath mighty in itself
produce unconsciousness. This case was stamped as being psychogenic by the
fact that the treatment, which dealt entirely with teaching the mother how to
deal with the child during one of these “fainting spells” or temper tantrums,
completely relieved the symptoms. At the time of the last visit the child had
not had a spell for over 2 years, although she occasionally met an unpleasant
situation with the cruder method of tantrums.

The case of Theodore may also be mentioned. The child, aged 2 years and 5
months, was brought to the clinic on account of severe temper tantrums, which
only recently had terminated in convulsions. When one considered the complete
disintegration of the mental life of this patient as indicated by violent temper,
insomnia associated with night terrors, enuresis, pugnacity, extreme jealousy,
selfishness, destructiveness, and masturbation, it was not very difficult to explain
the convulsions as one of the numerous manifestations of an inherently unstable
nervous system. This manifestation at times might follow the sexual excitement
o f masturbaton or the extreme emotion attached to a temper tantrum, and at
other times it might be the manifestation of more definitely physiological causes,

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such as would be associated with excessive fatigue, lack of sleep, or marked
indiscretions in diet. The treatment had to be directed not toward the convul
sions but rather toward rehabilitating the individual as a whole.
Billy, aged 4 years, was brought to the clinic because he was extremely stub
born and difficult to manage and was seemingly quite insensitive to the praise
or blame of those in his environment.
In this case the first convulsion occurred at the age of 13 months and was
associated with an acute infection of the influenza type. Since that time the
child had had nine convulsions, occurring at intervals approximately 6 months
apart. These convulsions had invariably been associated with some acute
illness. One spell was associated with an acute febrile condition which lasted
several days. One occurred after circumcision. Several others were in asso
ciation with definite gastrointestinal upsets at the hospital. The convulsions in
this case never occurred with any emotional experience, but always at such
times and under such conditions that it was difficult to determine the exciting
cause.
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 mental
retardation is common. Mental deficiency of this type should not be looked
upon as congenital or due to defective germ plasm. It must be assumed that
the 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 that
does not by any means indicate that he would have been mentally deficient if
he had not had the convulsions. Many of the physical abnormalities seen in
children, such as monoplegias and hemiplegias, are not congenital but appear
during the first 2 years of life, following convulsion. This is a practical as well
as an interesting point to be kept in mind when considering the general subject
of heredity.
The treatment in such a case, so far as the convulsions are concerned, is
obviously not one of psychotherapy. A special regime should be instituted
in which the amount of physical and mental stress should be definitely limited.
Diet is of paramount importance and one should avoid all the more indigestible
articles of food and the methods of preparing food which render it less digest
ible. Tea, coffee, and other stimulating as well as irritating articles of diet
should be eliminated. Constipation is invariably found in these cases and
should be guarded against. It is best combated by a carefully selected diet,
which should include much fruit, green vegetables, and bread made of whole
wheat. After such a case has been carefully studied to eliminate every possible
physical cause, and the proper regime has been instituted, it may also be
necessary to use some drug. The treatment of such cases should always be
directed by a physician.

There are many and varied physical manifestations indicating
disturbance o f the nervous system in children, and from the begin
ning all such symptoms should be considered as having a physical
basis and should be referred to a physician. Chorea is one o f the most
common examples o f what an infection may do to the nervous system,
especially in a child who is inherently unstable. Chorea is usually
associated with rheumatism, and the symptoms are undoubtedly due
to a mild form o f meningitis. Motor unrest and mental irritability
invariably precede the characteristic, involuntary movements which
involve the arms, legs, and frequently facial muscles. These move
ments may become very violent at times and the child will throw
himself aoout in a manner that may do him bodily harm. Although
it is now generally recognized that chorea is due to an infection,
fatigue and excitement markedly exaggerate the symptoms.
Habit spasms sometimes present a picture that is closely allied to
chorea, but the muscular involvement is less extensive, usually affecting
only one group of muscles of either the upper or the lower extremity.

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The spasm may take the form of blinking the eyes, wrinkling the
forehead, and making a pulling movement of the facial muscles, espe
cially the nose, which result in peculiar grimaces. Spasms of spitting,
coughing, and peculiar types of breathing are also observed frequently.
When these involuntary movements have been present o v e r a period
of months or years, they frequently resist treatment and an absolute
cure is not always possible. This accounts for the fact that many
adults are still afflicted with habit spasms that were acquired during
early life. There is undoubtedly a predisposition on the part of some
children which permits the ordinary stresses and strains of everyday
life to throw the coordinating mechanisms of the brain out of adjust
ment. The first evidence of this instability may be precipitated by
fright, grief, intense anger, or physical fatigue. These habit spasms
are not infrequently seen in children when there is a history of pro
longed mental exertion, as for example, the child who is subjected
to a school program plus outside activities such as music and dancing
lessons that make up an intellectual and physical load beyond his
ability to carry. These symptoms are but the first evidence that the
child is working too hard.
One must keep in mind, however, that in dealing with these prob
lems it is not the symptoms but the child who needs treatment, and
every effort should be made to determine the emotional stresses to
which he is being subjected. Such an investigation leads in various
directions. The discipline in the home may be too rigid; an ambi
tious parent may be pushing the child too hard; the child may be suf
fering from extreme anxiety in his personal relationships with his
teacher or over failure in his work. Often teasing and bullying by
his contemporaries supply the answer to the problem. Besides these
more obvious situations, fears and anxieties of which the child is
not aware may be operating below the level of consciousness. The
symptoms are of such a nature that parents are sometimes worried
and irritated and are prone to put considerable pressure on the child
to make a greater effort to overcome what they consider an unattrac
tive habit. They do not realize that the more conscious the child be
comes of his difficulty the more likely it is to be exaggerated, so that
scolding, and punishment are not only useless but harmful.
Under a physician’s direction the child should be removed from the
irritations of his environment. He should have complete rest, and
general routine measures for building up physical health, such as
proper food, sleep, and elimination should be put in force. After the
acute symptoms have subsided, it may be necessary to make important
changes in the child’s daily routine.
The early manifestations of these involuntary muscle spasms are
often detected in a clinic when the child is brought in for some other
reason. It is during the early and incipient stages of these emotional
upsets that valuable preventive work can be done. These problems in
themselves are not serious medical problems, but certain attitudes that
develop around the problem have important implications. The child
may become very self-centered, shy, and diffident, showing marked
feeling's of inferiority which lead him to refrain from entering into
activities with other children and prevent him, from developing a
normal, healthy outlook upon life. Early recognition and treatment
are therefore imperative.

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TH E CRIPPLED CHILD

The White House Conference on Child Health and Protection in
1930 called attention to the fact that “ there are more than 10,000,000
children in the United States who are ‘handicapped’—-in the sense
in which the term is here used—i. e., children who are blind and par
tially seeing, deaf and hard o f hearing, crippled, who are mentally
deficient or disordered, who are suffering from tuberculosis, cardiac
or parasitic diseases.” 6 This is a very conservative statement, yet it
indicates the magnitude of the problem and is a challenge to those
responsible for rehabilitating, so far as possible, the physically and
mentally handicapped child. The problem is further complicated
when consideration is given to the interdependence o f the physical,
intellectual, and emotional aspects o f life and the extent to which the
individual’s personality, his general outlook on life, and his capacity
for happiness and efficiency may be materially and permanently
affected by the wisdom with which handicaps are treated in early
life.
The effect o f physical disease, injuries, and accidents on the per
sonality of the individual has already been discussed (pp. 82-85) .
The chronically ill and the permanently physically handicapped have
some general problems that are not unlike those found in persons
suffering from acute conditions, though it must always be taken into
consideration that a particular handicap may exert a specific effect
upon the personality make-up o f a particular individual. The fact
that one’s mood or feeling o f well-being is affected by the condition
o f the bodily organs—that is, the functioning of the liver, the gastro
intestinal tract, the thyroid gland, and so forth—is so well understood
that it needs no further discussion. It is not so commonly under
stood, however, that emotional responses toward life, such as worry,
grief, or anger, affect the functioning of the bodily organs; that high
blood pressure, indigestion, diarrhea, pains, or hyperacidity may Ibe
the result o f a love affair, a disastrous speculation, or the loss o f a job;
and that cause and effect can be demonstrated, whether from the
point o f view that feeling tone is affected by physical ailments or
vice versa. The whole problem may become very much involved,
but for practical purposes it is important to keep in mind that the
patient’s mental attitude toward his illness or his physical handicap
is o f paramount importance—so important, in fact, that this attitude
in itself may account for so-called personality changes and for much
o f the resulting incapacity.
During the last 2 decades the attitude toward the crippled child
has gradually changed. Society, families, and individuals have been
in the past rather prone to view these unfortunate individuals sym
pathetically yet pessimistically, accepting them as responsibilities for
home and institutional care who were entitled to kindly consideration
« White House Conference, 1930: Addresses and Abstracts of Committee Reports, p. 292.
Century Co., New York, 1931.
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adequate custodial supervision when facilities were available.
With the development of improved surgical techniques, deformities
and resulting handicaps have been greatly reduced. This has meant
that certain children who were suffering from a form of physical
handicap previously considered permanent have had complete correc
tion of that deformity. Other children whose deformities could not
be corrected have had normal function restored through treatment
so that the deformity is no longer a handicap. W ith better insight
into the incapacitating aspects of the mental attitude toward the
handicapped, efforts have been made to consider the individual as a
whole and to find some life occupation in which his deformity would
be minimized and his assets given the fullest opportunity for expres
sion. This attitude on the part of society toward the crippled child
has opened many new channels through which the handicapped in
dividual has been able to find adequate outlets for his potential physi
cal achievements and his emotional and intellectual satisfactions.
.Parents, having been awakened to this new social optimism in regard
to the handicapped child, have felt less sensitive about these un
fortunate members of the family and as a group are seeking all
available assistance as soon as they recognize the problem. Under
such conditions we have a right to anticipate earlier recognition of
the child s needs, better medical care, help and guidance in the selec
tion of a vocation, improved mental attitudes on the part of the
A i .lcaPPe^ child, and in general an increase in his happiness and
efficiency.
The most important therapeutic contribution that can be given to
the crippled child is the assurance that there is a place for him in
™ he has a contribution to make to justify his existence, and
that effort on his part is worth while. Only in this way can the will
to attain the maximum degree of independence be established within
the child When this is accomplished the handicapped individual no
longer indulges in introspection and self-pity but turns his attention
to the outside world, where he can now find guidance and direction in
preparing himself for a life of usefulness. It must be kept in mind
that the attitudes which the crippled child assumes toward his handi
cap will invariably be but a reflection of attitudes shown by those
with whom he comes in contact during his early years. The parent
who is constantly reminding the child that he cannot do this or that
because of his limitations or the dangers involved will contribute
little toward helping him build up the attitude of confidence which is
essential if he is to utilize his assets to the fullest extent. On the
other hanch it the child is reared in an environment where his physi
cal limitations are relegated to the background, where he is being
constantly presented with opportunities and tasks that are well
withm his ability, and where his attention is focused toward in
tellectual interests, he soon learns that there are many ways and
many opportunities by which he may compensate for his particular
handicap. Every handicapped child should be not only permitted
but encouraged to do everything he can possibly do for himself, and
the assistance that he receives should be limited only to those tasks
which are definitely beyond his ability. Only in this way will he
attain that sense of normality and independence which is essential
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to his ultimate success. The child who has acquired a healthy atti
tude toward his handicap and a sense of independence will embark
upon the task of fitting himself for life with confidence and courage.
The next important step perhaps is that of selecting a voca
tion. Here again guidance and training are important, and the
problem o f determining the work which is best suited to his particular
abilities and in which his handicap will be least in evidence needs
careful consideration. The wise counselor will realize that the work
should be selected with the idea of giving the individual not only the
opportunity of doing his particular task efficiently but also the
maximum amount o f emotional satisfaction.
,
»
Especially careful consideration should be given to the type of
vocation selected for the handicapped child. One naturally selects
a field of training that offers opportunity for subsequent employ
ment. Insofar as it is humanly possible, this particular group of in
dividuals must be safeguarded from failure. They are invariably
sensitive and are inclined to compare themselves, to their own dis
advantage, with those unimpaired by handicaps; and they are prone
to think in terms of what they might have achieved were it not tor
their handicap. It is, therefore, important that they attain success
regardless of what the job may be. This is essential if confidence is
to be acquired and if they are to become self-sustaining m the held
o f industry. It is obviously more difficult for the handicapped to
throw aside training in one activity and start over in something
new. No effort is too great nor time too precious to spend m helping
the handicapped child to overcome those difficulties and surmount
those obstacles which obstruct the path to a happy, useful, productive
life. Every handicapped child must be considered as an individual
needing special consideration. These children should not be looked
upon as cases to be dealt with in any routine, mechanical way, as one
might deal with a piece of defective machinery.. They are human
beings struggling to make a place for themselves in an environment
in which they will meet keen competition, under conditions which,
to say the least, call for all the help that science and human con
sideration have to offer.
. .
„
One need not look far afield to find shining examples of the vic
tory which modern surgery, wise counseling, and vocational guid
ance, associated with confidence and courage, have won for the
handicapped child. Many of these individuals have reached peaks
in their achievements, not in spite of their handicaps but because o
them. Many o f these young people have been stimulated to greater
effort, have acquired a finer sense o f values, have been aroused to
loftier ambitions, and have been generally stimulated m the right
direction by virtue of their handicap.
y
.
It is impossible to lay down specific rules and give definite 1 formation on how to direct the activities o f any individual handi
capped child. Keen appreciation of the desired objectives and ot
the fact that the case involves a human being and not just a de
formity will do much to help the handicapped child develop to his
highest degree o f usefulness from a physical and a n economic point
o f view. It will also create in him attitudes toward himself and the
world that will give him assurance of his own worth, a feeling ot
independence, ana a sense o f security about life in general.

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M EN TAL D E FIC IE N C Y

Although the problem o f mental deficiency is not one of primary
concern to the habit clinic, it is an important problem of childhood
and one that is directly related to behavior problems. Imbeciles and
idiots are obviously cases for institutional care, but high-grade de
fectives must often be cared for in the community. The social mal
adjustments o f the latter group are due not to the mental defect as
such but rather to the accompanying mental instability. Since the
advent o f so-called intelligence or psychometric tests, the large num
ber of mental defectives in the population has become more apparent,
and it is realized that but a limited number can possibly be cared for
in institutions. As a group they are, moreover, neither bad nor
vicious, and they may serve a very useful purpose in the industrial
world.
Mental tests are of real value in determining within reasonable
limits the intellectual load which any child is capable of carrying.
The results of such tests should receive serious consideration, how
ever, only when the tests have been both given and interpreted by
one who is expertly trained.
In testing the preschool child there are several points to keep in
m ind:
( 1) Considerable time is required to establish friendly relation
ships with the child.
(2) In addition to having the child in a cooperative state of mind,
it is frequently essential to get the intelligent cooperation of the
mother. The child who embarks upon a psychological examination
after having just overheard his mother say, “ He is stubborn and
won’t do a thing unless I am right with him,” has been given every
incentive to do nothing whether the mother is present or not.
(3) It is absolutely essential to have a clinical psychologist who
has sufficient imagination and flexibility and has had sufficient ex
perience to elicit the child’s maximum efforts and to evaluate the re
sults. He must keep in mind that these children have not had the
standardized training of the school. Children o f preschool age who
come to the clinic are often shy and reticent, afraid o f new surround
ings, indifferent, or inattentive. They may come from homes where
little training or stimulation has been offered them. There may be
language difficulties. Giving mental tests by any rule of thumb is
therefore even less practical with the preschool child than it is with
older children. I f they are so applied, a shy, diffident, unstable child
o f superior intelligence may appear backward or even defective.
(4) In spite of the advances that have been made in tests to meas
ure the intelligence o f preschool children, there are still relatively
few that are standardized. Nonlanguage tests are practically essen
tial, and in checking test results a certain amount of leeway must
be given the examiner, thus allowing for the child’s interests and
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activities at home and for his fund of general information. I f it
appears worth while to make a psychological examination of a child,
as full a sample as possible should be made of all his abilities and
disabilities.
The advantages of these examinations may be summed up briefly
as follow s:
( 1) Unfortunate and deficient home training is shown by these
examinations at an age when those trends of mental development
which are stunted can be stimulated. In many cases this implies
the possibility o f preventing special disabilities and intensifying
special abilities. The child who shows underdevelopment in idea
tional or verbal fields can be given special story-telling advantages—
can be read to more. The child with inferior manual ability can be
given more and better opportunities for manual work.
( 2) Children who have unusual precocity of a specialized type
(for music, color, and so forth) or o f a general sort may have this
precocity appreciated and developed.
(3) Children examined before starting public-school work can be
put into special classes to see how much of the retardation is real
and how much apparent, thus avoiding the undesirable sequelae o f
early school failure, the clogging of normal primary grades, and the
stunting o f a precocious mentality.
(4) It is essential for successful therapy with neurotic children
that their intelligence be known. Obviously the feeble-minded and
the precocious cannot be given the same treatment.
A careful psychological examination should be considered an im
portant and essential part of every attempt to understand a child
and his particular problem. It is important to keep in mind that the
clinic has not only an obligation to the defective child but also a
responsibility to the family in which that child lives. It is invariably
necessary to point out to parents that the home and the lives of the
normal people in that home cannot be built around the feeble-minded
child. JParents of mentally defective children are not inclined to
accept the diagnosis regardless o f how thoroughly the case has been
studied; or if they accept the diagnosis they are prone to seek every
available source of help. This state o f mind often leads to con
stant pursuit of a cure for something that is incurable. The emo
tionally overwrought parents feel that there must be an operation, a
drug, or some bit o f medical magic that will create or restore what
never existed. This tragic and pathetic situation, however, is not
alleviated by offering false hope. A ll too frequently parents devote
their time and practically all their available money to building the
home around the abnormal child. This deprives the normal children
in the home o f the opportunities to which they are entitled and at
the same time creates in them jealousy, resentment, and other unde
sirable personality traits which prevent happy family relationships.
It is the duty of the clinic to see that physically and mentally
healthy children with potentialities for worth-while achievements are
not neglected because of the undue sentimentality o f the parents for
the mentally defective child. Whatever can be done for the defective
child must be done by adequate methods o f education and training.
Direction as to how this training may be best obtained can be given
by the clinic or other sources that are available in the community.

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Extensive surgical and medical procedures are rarely called for after
the child has had a careful physical examination and the necessary
laboratory tests. In order to help these distraught parents to meet
their problem in an intellectual rather than an emotional way and to
safeguard the interests of the home, the clinic must present the prob
lem to them with absolute frankness, regardless of how difficult such
frankness may be.
The following case, although not belonging to the preschool group,
is an example o f what may happen to the mentally defective child
who is also the victim of unintelligent parents and a sordid, immoral,
poverty-stricken environment.
A girl 13 years of age was seen in jail while being held for trial because she
had pushed a little boy 4 years old into the water, causing his death. The
family background in this case was particularly bad; poverty, ignorance and
vice each played a part. For a long time the girl had been recognized as a
menace to the community, and efforts had been made by the Society for the
Prevention of Cruelty to Children to have her cared for in an institution. The
mother, however, resented any interference from outside, and the case was al
lowed to drift along, one unhappy incident following another until this final
tragedy, which demanded the attention of the law.
It was said that 2 years before, while bathing, this girl had held a youngster’s
head under water until the youngster was nearly drowned. A year before she
liad voluntarily had sexual relations with a man. At frequent intervals less
serious incidents had been brought to the attention of the family and various
social organizations.
In the psychological examination she graded at a mental age of 9V2 years.
Her emotional reaction during the examination, however, was a fair criterion
of her irresponsibility.
When first visited in the jail she was very much concerned over the fact
that she was being detained and could not go to the beach with her aunt
bhe showed little or no concern about the death of her playmate or about
what would eventually happen to her. She did, however, manifest some anxiety
over what the deceased lad’s older sister would do to her, as the sister had
threatened her before she had been sent to jail.
At the time of the next visit she was very much upset because she was not
allowed to have the papers in order to read about herself and what had
happened. It was almost impossible to hold her attention on any subject
She
would constantly revert to the fact that “she wanted to read about herself and
see what it said and the other prisoners who had the papers wouldn’t permit
her to see them.
The lack of normal emotional response and the absence of
concern regarding the youngster whose death she had caused are characteristic
of many of the higher-grade mentally deficient individuals, and it is this insensitiveness to praise and blame and lack of ability to learn from previous exPe.^ e“ ce ykich
them a menace to society and require some type of institutional training for an indefinite period. Many of these individuals, however, eventually become stabilized through institutional care and are able to
make satisfactory adjustments in the community in later life.
This case was disposed of by commitment to an institution.

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CONCLUSION

The material as presented indicates two things: First that there is
still much to be learned about the art o f training children and that
we are still in search of more adequate ways o f overcoming undesir
able habits and straightening out twisted personalities; and second,
that there is an orderly, systematic, scientific approach to these pioblems which will produce increasingly satisfactory results as oui
knowledge advances.
. .
.
„ » i _
, i •
Habits of eating, sleeping, and elimination are o f fundamental im
portance in the development of the child s early life, and it is around
these normal functions that many more serious difficulties occur in
litter I110
• /v
*
■Vv
' It has been pointed out that there are inherent differences in the
way children are constituted mentally as well as physically. I-herefore, it is not reasonable to expect all children to meet the same ti pe
of life situation in exactly the same way. In fact, it has-been shown
and demonstrated by case material that their responses may be ,.y
diverse. One child fights while another flees; one basks m the warmth
of attention and affection while another is made self-conscious and
uncomfortable by the same experience; Johnny worries over any
minor deviation from the family moral code irhdi
in his success in outwitting his parents, his teacher, or
P invptati*
The point is that each child is in need of personal stu d y and imrest gation, and no general scheme for handling problems of behavior
likelv to be of any great value.
, „
•
The attitudes of parents which may result from th® o f !J ^
adequate training and unhappy experiences m life
to be among the most detrimental influences to the child during .
formative years, and much that is of value in clinical and educationa
efforts results from helping parents with their
lems as they are reflected m their attitudes toward the children.
One must continually remind those dealing with parents that it is
not sufficient to point out the faults in their attitudes and techniques.
Theyrnust also.Se made to understand why they persist m carrying
a
»
attitudes in spite o f the fact that they W b ^ i R e n t e d
with failure over a period of years. The point is that parents .ue
quite unconscious o f the fact that they are reacting on an emotional
rather than on an intellectual level.
.
,
It is therefore, important that the existing emotional attitude
toward the child should not be exaggerated by the parents visd to
the clinic. It requires nice judgment to impress the paraits wit
the necessity o f giving serious consideration to the mental health
the child in order to avoid difficult problems later on while at the
same time giving them understanding and confidence to replace
worry and anxiety.
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The responsibility for the mental health o f the child must rest in
the hands o f parents, teachers, nurses, and the family physician.
The same cooperative spirit in the management of the child’s be
havior as is evident in dealing with physical health and education
will contribute much to the future happiness and efficiency o f a large
army o f children who would otherwise embark upon life handicapped
by habits, attitudes, and personality traits which result in delin
quency, peculiar social behavior, antagonistic attitudes toward par
ents and society, and in an introspective, analytical approach to life
where self is always so much in the foreground that it prevents the
individual from getting the proper perspective of his environment
as a whole. These distortions in outlook, when they are not caused
by mental disease, are invariably the product o f what the child has
acquired from his early training and experience. Insofar as possible,
it is the duty and responsibility o f parents to see that the early career
o f the child is so guided and planned that he will avoid the shoals
upon which many are wrecked.

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Full text of Habit Clinics for Child Guidance, Bureau Publication No. 135

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