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Relation of children's disorders to limiting parental influences : an essay in classification and analysis,… Fogarty, Patrick James 1952

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RELATION OF CHTT^REN'S DISORDERS TO LBgTIMG PARENTAL INFLUENCES An essay in classification.and analysis, concerning a certain.group of children who were referred privately to the Vancouver Child Guidance Clinic between 1948-1951 by PATRICE JAMES FOGARTY. Thesis submitted in Partial Fulfilment of the Requirements for the Degree of MASTER OF SOCIAL WORK in the School of Social Work Accepted as Conforming to the Standard required for the Degree of MASTER OF SOCIAL JDRK School of Social Work 1952 The University of British Columbia ABSTRACT The purpose of this-thesis is to explore the relationships between (a) the be-haviour disorders of a selected group of children who have been referred to the Vancouver Child Guidance Clinic and (b) some of the influences affecting their parents. As an essay in classification and analysis, i t is hoped to point the way to further research in the field vfcicdi will give attention to social work implication. A l l material was gathered from case records made available by the Child Guidance Clinic. The sample is composed of forty-five boys andgirls -aftio were referred by private sources to the clinic between March 1948 and April 1951, and represents approximately one-sixth of a l l private referrals for that period. The sample was so chosen in respect to age, intelligence and home situation, as to be representatives of the majority of a l l children referred privately over that period. The children were classified according to the nature of their behaviour disorders, and an attempt was made to depict some measure of the severity and complexity of each child's disorder. The adequacy of the respective parents was evaluated by the use of a schedule and a rating-scale; and the influences affecting parents were categorized and weighted. Comparison was then made between the children's disorders and the limiting influences affecting their parents. The comparisons of the groups reveal many interesting features but the small size of the sample prevents any purely statistical conclusions. A number of features re-veal themselves, however. In one sub-group of children, relationship was discernible between mothers who were considered inadequate and a certain kind and severity of behaviour disorders in the child. In another sub-group of children, there were indica-tions of confused or disturbed parental identifications at an early age. Above a l l , the study emphasized the high incidence of emotional instability among the parents of these children, which points to the need in Vancouver for an adult or family mental health clinic. TABLE OF CONTENTS Page Chapter I The Vancouver Child. Guidance Clinict Changing Functions • • • • • . . • . • . . . . • • • • • 1 The development of psychiatric clinics for children. The changing function of the Vancouver Child Guidance Clin-i c and the growing importance of treatment for private cases. Assumptions of the study and selection of the sample. Chapter II The Children's Disorders 27 Comparison of the study children to a l l private referrals. Criteria for classification and weighting of the children's disorders. Kind and severity of disorder. Case examples designed to illustrate likeness and differ-ences among the disorders. Chapter III The Parents of the Children . . . . . 62 Gathering and evaluating of Information concerning parents' background, the inter-parental relationship, and the child-parent relationship. Implications of the limiting influences affecting the family situation. Chapter IV The Relation of Limiting Family Influences to ttee Children's Disorders . . . . . . . . . . . . . . . 88 Classification and weighting of the influences limit-ing parental adequacy. Findings of the study and implica-tions for further research, and implications for Child Guidance Clinic work. Appendices: A. Forms in use by the Child Guidance Clinic. B. Children referred privately for years 1948, 1949 and 1950. C. Forms used to gather and evaluate information concerning the parents. D. Bibliography. CHARTS AND TABLES IN THE TEXT Page (a) , Charts Chart I Scatter-Diagram of Age and Intelligence Score of Children Referred Privately to the Child Guidance Clinic from 1948 to 1951. . . 24A Chart II Classification and Severity of the Children's Disturbances 39 Chart HI Classification and Effect of Limiting Influence Affecting the Parents 90 Chart IV" Relation of Children's Disorders to Limiting Parental Influences . . . . . . . . . 109A (b) Tables Table I Frequency Distribution of Children by Age and Sex 28 Table II Frequency Distribution of Parents by Age. . • 65 Table III Parents' Religious Denominations 67 Table IV Distribution of Parents by Grade Attainment . . 68 Table V Limiting Influences in the Family Situation . . 96 Table VI Parental Adequacy 108 Chapter I THE VANCOUVER CHILD GUIDANCE CLINIC: CHANGING FUNCTIONS On this continent, the growth of psychiatric clinics for child-ren can be shown to have developed in three stages*^ The f i r s t of these was the establishment of clinics connected with the mental hospitals or institutions for the feeble-minded. The second development occurred when a multi-discipline approach was taken to the causes and treatment of juvenile delinquency. The final phase came when i t was believed that pre-dominantly normal children could benefit from a psychiatric clinic service. This latter phase, the Child Guidance Clinic movement, i s s t i l l in the process of fruition. It has drawn heavily upon the techniques and knowledge used by the earlier clinics. Late in the nineteenth century, some Massachusetts and New York state mental hospitals began extra-mural outpatient clinics for adults and children. These out-patient clinics were primarily for the purpose of prevention, since, until the year 1920, children of less than twelve years, 1 For a detailed discussion see: Helen L.Witmer, Psychiatric  Clinics for Children, The Commonwealth Fund, New York, 1940, Introduction and Chapter Ij Arthur E.Fink, The Field of Social Work, Henry Holt and Co., New York, 1942, Chapter IV. 2 were seldom admitted to mental hospitals. These clinics were often for the poor, and also were frequently concerned with the feeble-minded, but, at the same time, there was recognition that mental disorders and feeble-mindedness are separate problems. The psychiatrists in charge of these clinics leaned heavily on the belief that mental disorders are caused by organic disorders, Helen Witmer states that the out-patient clinic of the Boston Psychopathic Hospital, directed by Doctor E,E,Southard, an ardent proponent of mental hygiene, was the f i r s t mental hospital to set aside a clinic exclusively for children. One state hospital in Michigan, in 1916 implemented a travelling clinic that would examine children referred by juvenile courts, A second line of development was that stemming from clinics i n -terested in the observation and treatment of juvenile delinquents. In 1909, Dr.William Healy, director of the Juvenile Psychopathic Institute in Chicago, began a five-year study of juvenile offenders. This project, unlike the mental hospital out-patient clinics, was privately financed, Healy followed a liberal philosophy of causation of delinquency and mental disorders, of which Adolph Meyer was the principal exponent. This philoso-phy considers social, psychological and medical factors to be the inter-relating forces affecting the total personality of the individual, and, consequently, that delinquency and crime are largely expressions of de-fective and deranged minds. Thus, the multi-discipline approach in the observation and treatment of juvenile offenders, was used by Healy, His project was staffed by a medical doctor, a psychiatrist, a psychologist 3 and a probation off i c e r who gathered a social history. By the year 1920, the number of extra-mural mental hospital c l i n i c s for children had markedly increased i n many states of the Union. This increase indicated i n some ways that the public of those states, saw a need for greater preventative -measures to relieve some of the strain on mental hospitals. The juvenile delinquency project by Healy i n 1909, and the second program undertaken i n 1915 by the establishment of the Ohio Bureau of Juvenile Research, created widespread public interest and enthu-siasm for the treatment approach to personality and behaviour d i f f i c u l t i e s . In part, as a result of this interest, the National Committee for Mental Hygiene, through i t s Division on Prevention of Juvenile Delinquency, was instrumental i n 1921, i n persuading the Commonwealth,Fund to finance a five year program (1922 to 1927) of demonstration child guidance c l i n i c s . The Demonstration Child-guidance-clinics phase i n the develop-ment of psychiatric c l i n i c s for children, brought together the experience and techniques embodied i n the former mental-hospital c l i n i c s and also i n the delinquency c l i n i c s . Some of these were: diagnosis for prevention, direct treatment, travelling c l i n i c s , and multi-discipline approach. As the Demonstration units gained experience they i n turn provided a store of knowledge for later psychiatric c l i n i c s for children. The f i r s t group1of these Demonstration c l i n i c s WSB set up i n 1922, for the purpose of showing the juvenile courts and child-caring agencies what psychiatry, psychology and social work, had to offer i n the direct treatment of problem children. The plan had two purposes i n 4 addition to that of diagnosing and treating childrens' problems: to provide for research concerning childrens' problems and to provide val-uable training experience for personnel* In a l l , five hundred clinics were set up, serving forty thousand children. Most of these clinics were distributed throughout the central and eastern states. One was established in Canada, at Toronto, Ontario. Since 1927, mental health clinics for children appear to have incorporated in their techniques the findings of the Demonstration Clinics.' Those evaluating the Demonstration Clinics were of the opinion that though the f i r s t child guidance units had been concerned mainly with referrals from the juvenile court, such clinics had much to offer children of normal intelligence with difficulties of relatively short duration. Therefore i t was recommended that child guidance clinics should not be limited to any one diagnostic group such as delinquents or pre-psychotics. The findings also concluded that the total treatment plan of a child guidance unit was dependent not only on community resources, but also on the readiness and understanding of other disciplines such as teaching and medicine, and es-pecially of parents, to make use of and to cooperate with the guidance c l i n i c s o 2 1 Witmer, Helen L., Psychiatric Clinics for Children. The Commonwealth Fund, New York, 1940, pp. 53-56. 2 Ibid., pp. 4 9 - 5 5 . 5 Child Guidance Clinics in British Columbia In Canada, the number of psychiatric clinics for children has . gradually increased since the Toronto Demonstration Unit was established through the Canadian branch of the National Committee for Mental Hygiene. Today, a l l provinces except New Brunswick and Prince Edward Island have some form of psychiatric clinic for children, and these two provinces are seeking personnel to set up clinics. Many of the clinics in Canada began as parts of extra-mural or out-patient treatment programs of mental hospi-tals, where such programs had been established for ex-patients and their families, and-for diagnosis and prevention. Other clinics were associated with educational facilities, and a few were operated i n connection with juvenile courts or social agencies. Ontario has examples of a l l these types of clinics, but the rest of the provinces with psychiatric clinics for children have mainly established units that are extra-mural projects of provincial mental hospitals. The Province of British Columbia has two psychiatric clinics devoted exclusively to children. The Provincial Child Guidance Clinic i s the most important and now consists of a stationary clinic-team in Vancou-\ ver, a travelling team for interior points of the province, a team for the correctional establishments in the Greater Vancouver Area, and a partial clinic-team for Victoria and Vancouver Island. A psychiatric clinical service, limited to referrals from the Vancouver school system, i s afforded 6 by the Mental Hygiene Division of the Metropolitan Health Committee.-' | The Provincial Child Guidance Clinic, hereafter referred to as the Clinic, was opened in 1932 in Vancouver after a request was made by the Provincial Psychiatrist to the National Committee for Mental Hygiene for help in a program of prevention of mental illness. The Committee was instrumental in obtaining the services of the f i r s t psychiatric social worker. Nevertheless, the Clinic, since its inception, has been closely linked with the Provincial Mental Hospital, and the Annual Report of the Clinic s t i l l appears embodied within the Annual Report of the Mental Hos-pitals of the Province of British Columbia. For the f i r s t few years of its existence, the Clinic provided mainly a diagnostic service for social agencies of the Greater Vancouver area. By 1938, the Annual Report of Mental Hospitals for British Columbia, stated that considerable treatment was being given at the Clinic, and by 1947, the Report announced that, i n addition to diagnosis and treatment, other functions of the Clinic were training. education and research. Under present circumstances, a diagnostic service, in i t s f u l l -est sense, consists of: "application" and acceptance of the referral; an "intake interview" or interviews - which leads to the compilation of a "social history"j and a f u l l "clinical examination" and "conference". There are some differences between "diagnostic service" for the Clinic's private case referrals, and "diagnostic service" for other referrals -1 The history and function of this clinic i s described in detail in: Roberts, Mental Health Clinical Services. Master of Social Work Thesis, University of British Columbia, 1949. 7 such as those from social agencies or correctional institutions. For example, the age range i s more flexible for a social agency or institu-tional referral, whereas private referrals normally must be less than nineteen years of age, A social agency may request a specific service such as an intelligence rating, while a private case would ordinarily receive a f u l l clinic examination. Nevertheless, "application", "intake" and formulation of a "social history", and a f u l l "clinical examination" and,"conference", are basically the same for private referrals and other referrals, la "application", tlte referral source contacts the'Clinic in some manner, generally by telephone - and requests some form of help i n regard to a child's alleged problem. Ordinarily to be accepted for "diagnostic service" by the Clinic, the child must be between two years and eighteen years of age, and have an alleged problem apparently manifest-ing evidences of abnormal social, emotional or intellectual adjustment. If a private referral application i s accepted by the social worker who is on duty to screen such contacts, the referral source i s informed of an approximate date when a social worker will contact the child's parents or guardians, in order to make a preliminary investigation of the problem during an "intake interview(s)'1, and perhaps begin gathering the informal tion required in a "social history". If the application i s not from a private source, the referring agency or institution i s generally respon-sible for compiling the "social history". During the "intake interview", the social worker accepts rather than explores the parent's or child's feelings, and initiates a clarifying a and working, not an intensive "casework relationship", while making a tentative investigation and diagnosis of the situation from a case-work viewpoint.*'" The social worker assists i n clarifying the situation, mak-ing sure that i t i s not more appropriate for another agency. He finds out what the applicant has done about his problem and what he wants to do, or wants the Clinic to do about i t . Then the social worker gives the client, through interpretation of the agency's services, some idea of the probable role that client and agency w i l l take i n the future i n planning and working toward some help with the problem* This information and intuitive apprai-sal of the l i f e situation of the client and his family i s enlarged through subsequent interviews and finally summarized into a social history. As previously mentioned, the Clinic social workers prepare social histories for private referrals only. Other social agencies and inst i tu-tions generally prepare their own histories i n accordance with the Clinic's form. The social history i s a ski l l ful blend of factual material and a careful evaluation of attitudes and feelings centered around the client and his problem, including the social setting of the family and pertinent information about the physical, cultural and psychological aspects of the family unit and the client. A f u l l c l inical examination consists of a physical examination, a psychological examination and a psychiatric examination, by the Clinical 1 For a f u l l discussion of the nature of a "casework relationship see Gordon Hamilton, Theory and Practice of Social Case Work. New York, Columbia University Press, 2nd Revised Edition, 1951, pp. 57-60. 2 A copy of the "social history" outline currently i n use at the Clinic is appended i n Appendix A (1). 9 team which is composed of psychiatrist, a psychologist, a public-health nurse and a social worker. The team generally completes the fu l l examina-;-tion in one day. The psychiatrist and a public health nurse undertake a complete physical examination to ascertain the extent of any organic basis for the child's problem, and they record their findings on a standardized 1 2 form. The nurse also makes and records playroom observations. The clinical psychologist i s responsible for the psychological examination. A battery of standardized tests i s used to evaluate the child's innate and achieved abilities and special aptitudes, and to obtain some measure of his attitude to others and his personality structure. The findings of this examination are summarized on a systematized form,-^ The psychiatrist is mainly responsible for the psychiatric exam-ination by reason of his special training and understanding of the inter-relationship between the physical and mental aspects of the patient. He i s aided by the social worker's evaluation of the child and parents, which is written in the social history. The psychiatrist bases his appraisal of the child and the family relationships upon what is revealed to him during a private interview with the child, and a later interview with the parents. The psychiatrist may or may not make a written report of his findings. In the conference held at the completion of the previously men-tioned procedures, the members of the c l inical team meet with other inter-•1. See Appendix A (2) 2. See Appendix A (3) 3. See Appendix A (4) 10 ested and responsible agency representatives or persons. The clinical team and the others sum up their findings at this conference and give opinions as to suitable future treatment plans for dealing with the case. This process is termed a diagnostic service. If the child in question has been referred by a private source, treatment i s carried on as required by members of the Clinic staff j i f a social agency has referred the child -they usually carry on the treatment. If the case i s other than a private case, the prescribed treat- ment i s most often carried on by the concerned agency or institution. If the case is a private referral, the treatment plan may require the use of the special skills of any or a l l of the members of the Clinical team. This may involve some change in the child's or the family's environment, or may involve a change in the personality of the child and/or the parents. Dur-ing the treatment process a shift i n emphasis may seem advisable since no diagnosis i s considered a static evaluation. Further conferences may be called from time to time to bring together the entire Clinical team think-ing on what has developed, and to give direction to future plans. The other Clinic services of training and education, and re- search are more recent and are perhaps of lesser importance. Those persons who receive training and education can be considered as being intrinsic or extrinsic to the Clinic. The intrinsic members'are unqualified or junior practitioners of the several Clinical disciplines, who are serving a f i e l d placement or interneship. They follow a regime of supervised clinical experiences and later may become members of the qualified staff. Those persons extrinsic to the Clinic who are accorded a training service are, 11 for the most part, undergraduate nurses and social workers who are re-ceiving some "in service training",, There i s often no set pattern of instruction accorded this group. They may receive a number of orienta-tion lectures, a teaching clinic or series of clinics, or may possibly just observe some phase of the Clinic's function. The Child Guidance Clinic also serves to promote and interpret mental hygiene information to the community, to lay groups, and to other professional groups. Through the Audio-Visual Department, under the auth-ority of the Director of Provincial Mental Health Services, films are. dis-pensed through the Clinic to Vancouver schools and to other interested community groups, in addition to being used in the Clinic's own education program. Also, the staff members of the Clinic interpret the function of the Clinic and the objectives of mental hygiene through formal and informal personal discussions or lectures. The research function of the Clinic, in its present form, i s perhaps less well defined, and i s somewhat ancillary and incidental to the previously mentioned functions. Statistics that appear i n the Annual Re-port regarding most of the Clinic's objectives, are kept by the public health nurse. Clinic staff members, in their own time, sometimes do sur-veys and write papers on special features that are of interest to them. From time to time, university students use clinical material for papers and thesis projects. But, despite the wealth of information available and the possibility of obtaining the team approach to a problem, there i s no com-prehensive and coordinated program of research carried on at present by the Vancouver Child Guidance Clinic. 12 Purpose and Assumptions of Study Normally, scientific research into a problem, goes through at least three major phases - the correct formulation of the problem, the exploration of the problem and framing of an hypothesis, and finally, the planned research designed to test the hypothesis. The assumed correct approach to the problem of human behaviour - the recognition of i t s uncon-scious springs and the profound influence of early inter-personal relations between infant and parents -belongs, of course, to psycho-analysts such as Freud. If this study can be said to f i t within the formal framework of scientific research, i t belongs i n phase two - that of exploration of the problem and framing of a hypothesis. Primarily, this study is an essay in case-work method. The sub-ject matter i s relatively well known - that of the relation of childrens1 disorders to the limiting influences in the home situation. But, an attempt is made in this paper to go beyond describing the particular manifestations of childrens 1 problems and the particular pathological features in the home situation thought to be associated to these problems. A method has been employed of classifying the kind and severity of the childrens' disorders, and a method has been devised for studying, evaluating and classifying limiting influences affecting the parents. It i s hoped that some relationships will appear to be significant, and that this study will delineate areas i n which a multi-discipline re-search approach by a Clinic team could be effectively used. But, because of the relatively small number of children studied, there will be no formal attempt to correlate the cause of the problem, with the effects manifested. 13 In addition, i t i s hoped that the experimental method employed in gather-ing and evaluating the information about the children and their parents, will make some small contribution to casework-diagnosis and casework-evaluation. A survey of the sources of referrals to the Clinic for the past two decades suggests that a steadily increasing number of children i s being referred to the Clinic for psychiatric treatment, by doctors, parents and other private sources. Particularly in the past ten years, the proportion of the number of children of low intellectual capacity has decreased marked-ly among Clinic referrals. There i s now a higher proportion of children of normal intelligence, and a higher proportion who are living with their natural parents. During the Clinic's f i r s t decade of operation, from 1932 until 1942, i t mainly provided a diagnostic service for children referred by social agencies. Correctional institutions and courts referred a smaller number of children; and private sources such as parents, doctors, teachers, etc., were responsible for only a very small number. In the years from 1942 to 1951, there has been an increasing proportion of children referred by private sources (hereafter sometimes referred to as "private referrals"). By 1948, social agencies were responsible for only 61.09$ of a l l referrals to the Clinic. 1 In the following year, the proportion had dropped to 55.00$, and, according to the Annual Report, private referrals, particularly by private physicians, parents and relatives, had increased so markedly 1 Annual Report of the Mental Hospitals. 1948. p.B.B.24. 14 that the Clinic was tunable to accept a l l of the referrals from social agencies.1 Private referrals accounted for almost 12% of a l l referrals in 1948, and approximately the same proportion in 1949J i n 1950 the private referrals amounted to about 10#, but, since the total of a l l re*> ferrals was much greater, there was an actual increase i n numbers of pri -vate referrals. 2 Nevertheless, i t i s apparent that other sources s t i l l refer the largest proportion of cases. Social agencies which refer the bulk of cases to the Clinic are private agencies such as the Vancouver Children's Aid, and public agencies such as the Provincial Social Welfare Branch. Public schools seldom refer children directly to the Clinic. However, correctional es-tablishments for delinquent or defective children do refer directly. Medi-cal and health program referrals include those by the Children's Hospital, Vancouver, those by public health nurses, and those by an assortment of health agencies. Other sources of note are the adult, and family and juvenile courts. There is insufficient statistical information available to justify stating that there i s a definite trend towards more private re-ferrals and fewer referrals from social agencies; but i t does seem evi-dent that a decreasing proportion of a l l referrals to the Clinic concerns children of low intellectual capacity. In any fiscal year from 1932 until 1947, at least one-half of a l l children examined at the Clinic were rated 1 Annual Report of the Mental Hospitals. 1949. p. V.47. 2 Annual Report of the Mental Hospitals. 1950. p.H.H.31. 15 as having less than average intelligence, that i s , a " ful l score" of less than 90. During the f iscal years 1948, 1949 and 1950, less than one-third of a l l the children examined, were listed as having less than 90 of an intelligence quotient. For private referrals, the proportion of mentally retarded children was far less, and further attention w i l l be given to this feature during the i n i t i a l remarks pertaining to the children in the sample. The children who are subjects of this study are from a particular group of children referred to the Clinic, The reasons for attempting to -relate children's problems to limiting influences i n the home environment, rest upon a priori assumptions. It i s f irst assumed that these children and, perhaps, their parents, have problems, because of the fact that the Clinic accepted the cases for examination. Secondly, i t is assumed that although the children's problems and their home situations differ from case to case, some casework classification of the problems and of the limiting influences i n the home environment would be possible. Whether or not cause can be related to results, i s the end product of the study. The reason that the home environment alone, rather than a broader concept of the child's environment, w i l l receive the focus of attention, i s partly deter-mined by the selection of the case, and partly determined by the main forces thought to affect these children. For a variety of reasons, this study i s limited to children between the ages of six and twelve years of age. It i s limited to child-ren of legally married parents, with at least one parent residing i n the home setting from the birth of the child unti l the date of referral to the Clinic. Adopted children, foster children or children who have lived apart from both parents for a considerable length of time other than for 16 hospitalization or brief holidays, are excluded from the sample© One premise of this study i s that an outstanding characteristic of the modern metropolitan family is i t s anonymity and i t s Lack of neigh-bourhood and kinship t i e s . 1 The increasing industrialization and urbaniza-tion of our modern western society has resulted in a depersonalization and mobility of family members. The complexity of modern living has increased the number of pressures exerted upon an individual family, while at the same time, the group and kinship ties have diminished, leaving the family to meet these pressures alone. It i s not the purpose of this study to examine or evaluate the changing function of the family. It i s sufficient to note that the rearing of children until they reach school age remains largely the responsibility of the natural parents. What then, are the features of the family situation deemed important for optimum physical, emotional, social and intellectual growth of children? The child, in a l l stages of growth from birth to age six, i s assumed to have three basic needs: the need for adequate physical care and conditions to maintain good health; the need for new intellectual and social experiences within his capabilities; and above a l l , the need to be loved and to feel secure. In reality these needs are inseparable and continually reacting on one another. For example, pain caused by hunger 1 This argument is developed by an anthropologist and a sociologist i n these recent examples: Margaret Mead, "What i s happening to the American Family", Journ. Soc. Casework. Nov. 1947, pp. 323-330; Earn-est W.Burgess and Henry J,Locke, The Family. New York, American Book Co., 1945, PP. 523-554. 2 Towle, Charlotte, Common Human Needs, Washington, United States Gov. Printing Office, 1945, pp. 37-45. 17 motivates a child to cry; he soon learns that crying often results" i n being fed; i f he is not fed sufficiently, not only will his health be impaired, but also, because of the failure of his mother to provide suffi-cient food, the child may feel that he i s not loved. The extent to wlich the above needs are met by parents will depend in turn on many subtle and interrelated circumstances, beliefs, attitudes and patterns of behaviour. In order to facilitate study, this milieu of forces acting and interacting upon the parents and the child, has been arbitrarily divided into three areas: the f i r s t consists of those forces originating primarily in the parents1 own familial back-grounds; the second area consists of forces stemming mainly from inter-parental relationships; and the final area consists of forces thought to originate i n the child-parent relationship i t s e l f . Ideally, both parents should have become emotionally, socially and economically well adjusted before marriage. Ideally also, they should have been free from serious health disabilities. For satisfactory emo-tional adjustment each parent would have to have achieved relatively com-plete emancipation from his or her respective parents. While reciprocal affection and mutual interest between young adults and their parents would be some evidence of satisfactory emotional adjustment, such mutual inter-dependence should be a positive feature and not a limiting or morbid element. One indication of optimum social adjustment would be a lack of sibling rivalry i n the parental home. The school experience and other group experience of the parents should also have been devoid of marked 18 discord. In addition, interest and participation in some form of group activity during the post school years i s felt requisite to optimum social adjustmente Economical adjustment would require that the father, prior to marriage, had a record of fairly stable employment, unless circumstances beyond his control had thwarted employment, A stable employment record by the mother prior to marriage would be considered a distinct advantage, but absence of employment would also have to be weighed against opportun-it y and age, etc. Nevertheless both parents should have illustrated that they appreciated but did not overemphasize the value of money, and that they were able to plan and live within the confines of their income. What constitutes a serious health disability would be defined, in the f i r s t place, by a medical opinion. If such an opinion were lacking, a serious health disability would be thought of as a physical or mental condition which would markedly limit the person's social and economic ad-justment. Concerning inter-parental relationships, i t would be expected that there had been a reasonable period of courtship, that the predominant motivation for marriage had been affection, and that the marriage had been planned. For good inter-parental relationship the marriage partners would necessarily agree, to a large extent, on such matters as handling family finances, common interests and activities, the sharing of household tasks and on the disciplining of the children. General agreement does not mean dominance by one parent and a passive acceptance by the other, but, rather, a mutually determined decision. 19 Coming more closely to child-parent relationships, i t would be expected that both parents had desired to have children and had plan-ned for the children. The birth i t s e l f should not have been an unduly painful shock physically for either mother or child, Gptimum care after birth could be considered in relation to the previously mentioned basic needs of the child. The mother should have wanted to breast-feed the child. But, whether breast-fed or bottle-fed, the child should have been fed adequately and in a warm affectionate manner. Following the birth of the child the father should actively enter into i t s care i n an increasing degree. During the first few years i t would be essential that there be harmony and affection between the parents; and they should have a store of affection sufficient for each other and the child without detracting affection from either. As the child develops, he should be accorded new experiences within the limits of his capabilities. Weaning and the introduction of new foods should be a gradual process i n accordance with the child's de-sires. Walking and talking should be given encouragement and interest, but the child should not be made to feel he i s a failure i f he is not ready to take steps or to say words at the chronological age at which the so-called average child accomplishes these acts. Toilet training should also be patient, i n accordance with the child's physical and mental development, and should be devoid of special concern. The parents should be concerned and devoted enough to spend time answering the child's questions and should answer questions on a l l subjects in an open and straightforward manner. They should understand that there 20 are individual differences i n the physical and emotional growth of each child, and should accept and respect any difference i n their child. In event of sickness or a severe disappointment, the parents should realize the child's increased need for affection and approval. If symptoms of maladjustment appear in any or a l l of the child's interrelated areas of growth, the parents should be secure enough and concerned enough to take intelligent action in seeking help from such community resources as are available. The Selection of Cases In keeping with the purpose of this study, only private referrals from certain years were included. The selection was limited to children between six and twelve years of age, and of average intelligence. They were children who had lived since birth with at least one of their natural parents, and a l l were residing in the Greater Vancouver area. The availability of material was a major factor i n selecting the cases for this study. For private cases, a l l records are written by the Clinic staff, whereas for other cases, records may be written by an assort-ment of professional and non-professional persons. Records for private cases are kept at the Clinic, but records for other cases may be kept by the referring agencies. At the Clinic, the records, such as the social history, the medical information sheet, and the psychological tests, are in standardized form. Therefore the information for private cases i s not only more accessible and probably more accurate than that for other cases, but i t i s also in more comparable form. 21 The cases are limited to families living in the Greater Vancouver area to further maximize the number of common factors* While there can be no assurance of economic, cultural or social homogeneity, there are some common factors. The area i s urban, trade unions have had some measure of success regarding minimum wages, and inspected sanitation and building construction has had some effect on minimum housing conditions. In addi-tion social facilities such as churches, schools, public playgrounds and parks afford something of a common religious, educational and recreational opportunity. Limitation of this study to private cases referred between April 1, 1948, and March 31, 1951 was for two main reasons. Primarily, i t was during these three years, that the increase i n private cases became appar-ent. In addition, the Annual Report of the Clinic reveals that prior to 1948 the Clinic operated with serious shortages of professional staff; therefore, i t i s argued that with an increase in staff since 1948, a higher and more consistent standard of professional service has been permitted, which would include a higher standard of case recording by a l l disciplines of the Clinic team. Since this study i s largely based upon recorded infor-mation, the accuracy of case recording i s important. Another criterion of selection was that the cases chosen for this study were those where the children's intelligence score f e l l between the intervals 90 to 110, If intelligence scores of a l l the children tested at the Clinic since 1942, or i n any individual year since that time, were represented in a smoothed histogram, i t would be found that the mode invar-22: iably f e l l within the interval from 90 to 110. A histogram of the i n -telligence score of a l l the Clinic children would differ from the accepted histogram for the general children population only in so far as there would be more skewness to the l e f t . This indicates that the Clinic has a higher proportion of mentally retarded children than the general population; which i s to be expected. If the interval 90 - 110 of a theoretical histogram of a l l Clinic intelligence scores were considered, this interval would exhibit a marked central tendency, with a minimum of dispersion. Therefore, i t i s argued from the viewpoint of intelligence, that not only does this interval contain the major number of Clinic cases, but that i t s form corresponds to the form of a like interval from the general population. Further, children whose in-telligence scores f a l l above or below the limits 90 to 110, are felt to present special problems because of mental retardation or exceptional brillianceo The final criterion for selection of cases i s that these children are between the ages of six years and twelve years at date of referral, and that they have lived from birth onward with at least one of their natural parents. As the study i s concerned with the relationships, i f any, that may exist between the child's problem and the home situation, foster-children or adopted children having previous varied experiences are excluded. By limiting the age range from six to twelve years, these child-ren would necessarily be going to elementary school. The school would af-ford another source of information about the child. On the other hand, the children would not have been so long in a school setting that the latter 23 institution could be considered the major force in their development. From a social point of view, i t i s in this period of a child's l i f e that he leaves the relative security of the family and faces the demands of the school and of increased group participation. He is requir-ed in the school setting to perceive more quickly and to remember his perceptions, while.in play he i s expected to accept and identify himself with the group. Whether these pressures can be looked upon as causes or catalysts affecting inherent privations in the child's social and psycho-logical development, will be the subject of further discussion as the case material unfolds. From the emotional viewpoint, the six to twelve year period i s considered one of relative emotional stability. The turbulent oedipal phase i s thought to have been resolved, and the child can now make satis-fying object relationships with the world about him and i s readily able to identify with the parent of his or her own sex. Preliminary Appraisal of the Children The cases falling within these parameters were selected from the Clinic daily intake book, A separate card bearing the identifying information was made out for each child. Eight children, consisting of three girls and five boys, were selected from the fiscal year 1948; twenty children were selected from fiscal year 1949 which included four girls and sixteen boys; and twenty-seven children including ten girls and seventeen boys were selected from fiscal year 1950, 24 AH children referred te the Child Guidance Clinic by private sources between April 1st, 1948, and March 31st, 1951, are cross-classi-fied by age and intelligence score in Chart I. On the same chart, the study sample itself is enclosed by a solid line. From the chart the cen-tral position of the study sample i s apparent. In a l l , a total of 55 children of normal intelligence, *>f age six years to eleven years 11 months inclusive, who resided in the Greater Vancouver area, comprise the sample used f«sr this situdly. The total of a l l private referrals from the Greater Vancouver area who were examined at the Clinic during the same period was 300. To verify that each of these 55 children f e l l within the para-meters of the sample, the files were drawn and examined for these children. It was found that 13 of the selected children did not meet the various c r i -teria, so the corrected sample i s comprised of 42 children. Five were not yet six years of age and two were over twelve years of age, two resided out-side of Greater Vancouver, two were adopted children, one had too high an intelligence quotient to be included in the sample while another had too low an intelligence quotient. The next step was to organize the clinical information about each case, and to analyze this information. In the main the information consisted of written material to be found in the case records, and verbal information gleaned from members of the clinical team. Written case mater-i a l f a l l s fairly logically into two categories: that which i s written by the team members during the diagnostic and evaluatory process, and that which is written after the f i r s t clinic conference during the treatment 24a CHART X S C A T T E R - D I A G R A M O F A G E A N D I N T E L L I G E N C E SCORE OF CHILDREN FROM VANCOUVER WHO WERE REFERRED PRIVATELY TO THE CHILD-GUIDANCE-CllNIC FROM A P R I L 1 9 4 - 8 — M A R C H 1 9 5 1 * AGE CLASS - INTERVAL OF INTELLIGENCE- SCORES TOTAL I N Y E A R S 0 _ -25 2 6 - 5 0 5 / - 7 0 7 1 - 9 0 9 / - / 1 0 iU-IZO 1 2 | -1. / - / 2 . 2. // /// M // 1/ / 15 3. f HI m mi /// m /// 26 4 . / in Mill mn /// Ml 28 5. /// m llll mm mi mm 3 4 6. // in mil 77—~— m mi / / //// 27 7. // mn MM mini mn //// _. 3 9 a /// 11/ im in // 16 9 - i III mm mi mi 22 10 . / ll/> mm/ / n / 8 11. i mi mm 15 12. / u 11 //// /II/ 13 13. // / 1 i/// 14. / // / I 6 . 1 5 _ u // 8 16 /// if / 6 1 7 < // / / 4 1 8 // // // HI ' in/~ 13 T O T A L 1 1 6 4 3 6 2 8 7 4 r so 3 0 0 * D I A G R A M S E A C H Y E A R A P P E A R / N A P P E N D I X 8-* • * S A M P L E BOUNDARIES MARKED By R E C T A N G L E . 25 process. The diagnostic and evaluatory process includes: the applica-tion and intake notes; the social history by the social worker; the playroom observation notes by the nurse; the psychologist's evaluation and notes; the psychiatrist's notes concerning both the medical and psychiatric aspects; and the clinic conference notes which draw upon the knowledge and understanding of the entire team, and summarize what the treatment plan i s , and how, and who, will carry i t out. The case recording by a l l or any members of the team after the f i r s t conference, i s generally in. relation to the goal or goals set out in the treatment plan. The focus may change, and further conferences may prescribe a change in treatment plan as new diagnostic material is reveal-ed. The pertinent information concerning the case, together with future suggestions, i s abbreviated into the closing summary, which, of course, is the final entry in the case record. Verbal information was used to supplement the written case re-cording. A l l of these cases were of relatively recent referral, and eleven of the forty-two concerned, were s t i l l active at the time of selection. Therefore, by seeking the opinion of clinical members who were working with the cases, added information was obtained. Nevertheless, omissions in the written recording could not be entirely f i l l e d i n by interviewing the team member, because very often the staff member concerned, was no longer with the Clinic. Having discussed the parameters of the sample, the task in hand, i s classifying the kind of disorder(s) afflicting these children and indi-cating some measure of the severity of their disturbanceso The pattern of 26 presentation proposed is to devote the second chapter to classification of the children's disorders. Subsequent chapters wil l focus attention on the parents of these children, and relate the children's disorders to the limiting influences affecting the parents. Chapter IT THE CHILDREN'S DISORDERS Important as i t i s to this study, i t i s not a simple task to make a systematic classification of the children's disorders, or of the limiting influences affecting their parents. Indeed, the major problem confronted in this study i s one of classification. But, before proceeding with this, some information i s needed about the subjects of the study. Who referred these children to the Clinic? And how do these children com-pare with a l l children referred privately to the Clinic between 1948 and 1951? Fourteen of the forty-two children were referred to the Clinic by persons associated with the school program. Of these, teachers sug-gested for seven cases that the parents get in contact with the Clinic, while for the other seven, referrals were initiated by some members of the school health program. In twelve cases, a Mfriend M who knew of the Clinic service, suggested the referral to the parents. Nine children came as result of medical opinion expressed by private physicians, and seven children were referred by members of the family. The mothers were princi-pally responsible for referring the latter groupj and mothers also were generally those who contacted the Clinic upon the suggestion of teacher, friend or doctor. 28 The parameters governing the selection of cases restrict this group of children as to age and intelligence, and require that each child has lived continuously with one natural parent* But some comparisons can be made between this sample and the parent population of a l l children re-ferred by private sources during the specified period. In addition, some observation about the characteristics of the sample itsel f , are thought to be pertinent. The median age of a l l children referred privately to the Clinic between April 1st, 1948, and March 31st, 1951, was computed to be 8 years, 6 months; the median age for the forty-two children in the study was found to be 8 years, 7 months. The modal age of total group i s between 5 years and 6 years. From an appraisal of Table I which shows the age and sex dis-tribution of the children of the study, i t can be seen that there i s a bimodal effect in the age distribution. One concentration appears in the interval w 6 - 7 years", the second appears in the interval "10 - 11 years". Therefore, i t i s quite probable that the children in the study are repre-sentative of the parent population with respect to both median and modal age. The second concentration in this study age array i s no doubt due to chance errors of sampling. Table I Children Sex and Age Distribution Class Interval of Age Years Boys Girls Total 6 - 7 9 4 13 7 - 8 3 1 4 8 - 9 4 1 5 9 - 1 0 2 2 4 1 0 - 1 1 8 2 10 11 * 12 4 2 6 Total 30 12 42 t , 29 A comparison of the sex ratios of the parent population and the children in the study, however, reveals a possible significant dif-ference. The ratio of boys to girls in the total group i s roughly 3:2 (183 boys to 117 girls), while from Table I i t can be seen that the ratio of boys to girls in this study i s 5:2 (3© boys to 12 girls). Therefore, while normally more boys than girls are brought to the Clinic - this sample seems especially heavily weighed with boys. Since one criterion of selection was that the children must have a f u l l intelligence score of between 90 and 110, there is l i t t l e point in making any comparisons concerning this factor. The intelligence scores of the children in the study were evenly dispersed throughout the range. Gen-erally, the psychologist responsible for the testing recorded a definite score, but with many qualifying remarks. The impression gained was that each child was rated in a range of intelligence, rather than with an absol-ute score. Further comparisons between the total number of children refer-red by private sources for the stipulated years, and the children in the study, can be made regarding siblings i n the home. The median number of children in the families of both groups was two. Almost one-half of the children (16 boys and k girls) were eld-est children; "only children, (6 boys and 3 girls) accounted i n equal numbers for almost a l l of the remainder. Only three boys and one g i r l were "middle" children. In summary, these children were often referred to the Clinic by 30 their mothers, acting upon suggestions of persons in the school setting, or friends who knew of the service. These children were representative of a l l children referred by private sources during the sample years with respect to agej but the group of children in the study contained a higher ratio of boys than did the total group. Finally, these children often came from families composed of two or three children, and i f there were more than two children, the child with the problem was seldom the "middle" child. Behaviour Criteria When this study was undertaken, i t was hoped that the psychia-trist who made the examination of the child, and who would later give guidance to the Clinical Team during the treatment process, would have recorded a tentative appraisal or formal diagnosis of the child's disorder. However, while a formal psychiatric diagnosis i s the rule with cases other than private referrals, this was found to be the exception with private Clinic cases. Therefore, i t was necessary to make some case-work classi-fication of the disorders of these children. Social case-workers have many sources of knowledge and under-standing with which to facilitate a classification of human personalities, and personality' disorders. Generally speaking, case-workers receive in their training a fragmentary knowledge of the client as a biological or-ganism, and have some understanding of physical illnesses. They have a more specialized knowledge of the client from a psycho-social standpoint -which i s predicated upon understanding the emotional development of the 31 child. An integral part of the social case-worker's knowledge about, and understanding of, emotional development, i s his ability to evaluate the client's capacity to form face-to-face relations, and the client's ability to use these relationships. The disciplined use that the professional social case-worker makes of this face-to-face relationship in order to activate intellectual and emotional processes, and to provide a favourable climate for the client's self-growth - i s termed a casework relationship. As the three major sources of information utilized in this study, - the intake notes and social history, the conference notes of the Clinical examination, and the subsequent inter-views by those staff members'taking part i n the treatment - were most often recorded by a social caseworker, an understanding of this frame of refer-ence i s essential for classification purposes. The classification of the children's disorders used i n this study i s the general classification proposed by Gordon Hamilton of "primary behav- iour disorders", "the psychoneurotic child". a n d "the severely disturbed  child." 1 This classification i s oriented to the generally accepted person-ality developmental phases of the child, as forwarded by the proponents of Freudian psychology. It i s postulated that there are broad phases in per-sonality development of the child, from birth to adulthood. The classifi-cation proposed here endeavours to relate arrest i n total development to 2 the manifest disorder. And, while there will be no attempt to outline 1 Gordon Hamilton, Psychotherapy in Child Guidance. New York, Columbia U. Press, 1947, Po340. 2 Ibid., pp. 19-44. 32 various theories of personality development, or to substantiate the above theory, i t i s thought necessary that a few summary remarks be in -cluded concerning the characteristics of the early developmental phase of the child, and their relation to the two main categories of disorders -the "primary behaviour disorders" and "the psychoneurotic child". The child at birth is self-centred, requiring instant gratifica-tion of his bodily needs, and he seems unable in the first few months to distinguish between himself and the outside environment. He can be des-cribed as somewhat narcissistic, and he operates upon the "pleasure princi-ple"* In addition, the devoted attention he receives tends often to make him feel omnipotent* If the child's early experiences with his parents and the rest of his environment i s satisfying and stimulating, he will normally, in the process of differentiating between himself and his environment, ar-rive at the realization that he i s dependent upon his parents for bodily needs and affection, and will want to be like his parents. Narcissistic tendencies, feelings of omnipotence and the desire for instant satisfac-tion will be gradually discarded as the child develops capacity for object love and identifies himself with his parents. The process of developing capacity to form relationships with others for the development of an ego-ideal and for the acquisition of a proper super-ego, i s dependent upon the child giving up those satisfactions and defences of the "primary self". The motivating force in the transition from interest i n the self and the need for instant 'gratification, to interest in other persons and the ability to delay satisfaction, i s warm and consistent parental affection. Sometimes the child lacks adequate affection and turns back to 33 his own body for pleasure, e.g., thumb-sucking and masturbation. The child then continues to have a poorly defined ego and l i t t l e super-ego awareness, hence i s motivated towards immediate satisfaction of instinct-ual or id urges. If this behaviour manifestation becomes habitual and continues until an inappropriate age for such behaviour, this i s termed a "habit disorder" and i s included in the more general classification of "primary behaviour disorders". Often the child at an age of between one and two years approxi-mately, i s s t i l l somewhat confused in the process of differentiation be-tween himself and the outside environment, and i n addition i s understand-ably interested in his body and i t s functions. If his toilet training or table manners (or both) is rigid or inconsistent, the child becomes further confused. This is also the phase i n which the child realizes new forms of expression in bodily movements such as stamping, hitting and even in biting. Therefore, i n the face of unaffectionate or inconsistent handling, he often gives vent to his feelings by temper tantrums, soiling, food fussiness or other outbursts of aggression. This behaviour manifestation i s termed a "conduct disorder" and makes up the rest of the general classification "primary behaviour disorder"• There are three outstanding behaviour manifestations of children grouped under primary behaviour disorders, which afford general criteria for the purpose of classification. These are: (a) inability to form close person or object relationships; (b) aggression or impulsive action in the form of active attack, or as a stubborn defence against pressures of 34 the environment; (c) and lack of capacity for anxiety or guilt. 1 The children of this group often exhibit l i t t l e capacity for affection because they have not received any; thus they have established l i t t l e or no iden-tification and are motivated towards none. They feel that no one cares for them and therefore they do not feel guilty in seeking satisfaction for them-selves by any means. In contrast, a more severely disturbed child such as a schizophrenic will react with panic to frustration of his attempts to maintain and clarify his identity, and a psychoneurotic child will react often with anxiety and apprehension over aggressive actions. Additional characteristics of children suffering from primary behaviour disorders are testing behaviour, shallowness in phantasy material, and defect in conceptual thinking particularly in relation to timeQ Because of lack of identification, language development i s impaired, and there i s often a semantic defect. However, manifestation of any or a l l , of the pre-viously mentioned characteristics, need not guarantee accuracy of classifi-cation. More severe disturbances such as psychopathic personality, schi-zoid personality or psychoneurotic disorders may produce comparable sympto-mology. Therefore, in the absence of an expert psychiatric opinion, the classification proposed is quite general in composition. The classification "psychoneurotic children" is also very gener-al and possibly includes many admixtures. Gordon Hamilton states "... Whereas the primary behaviour disorder i s a direct reactive disturbance to 1 These characteristics are discussed in detail i n Jewish Board of Guardians, Primary Behaviour Disorders in Children ... Two Case Studies, New York, Family Welfare Assoc. of America, 1945, p.59 35 the environment, the psychoneurotic child is no longer purely reactive, but already has to some extent, an intraphysic conflict of greater or less intensity, depth, and complexity." Anxiety comes with this repression of the impulse leading to symptom formation.1 Common neurotic manifesta-tions include obsessions such as intense cleanliness, phobias - wherein fear of the dark or of real or imaginary objects is pronounced, nightmares, nightmares, nocturnal enuresis, and compulsive acts - as perhaps stealing. Generally these symptoms are believed to originate during the "phallic phase" of personality development (when the child realizes his own sexuality and begins to develop homosexual relationships and heterosexual relationships) from castration fears, or from feelings surrounding the 2 oedipal situation. Some psycho-analysts believe that in a neurosis the ego sides at f i r s t with reality when the id tries to enforce the gratifi-cation of a desire irreconcilable with the demands of reality. That i s , the ego withdraws from that particular urge and represses i t . When the urge grows strong and succeeds in circumventing repression, the neurotic manifestation returns in the second stage of the disorder to the confines of the ego. Then, in a disguised shape, e.g., phobia or compulsive acts, the urge forces the ego into a partial avoidance of that sector of reality with which the original impulse was irreconcilable. In the neurosis, the id i s partly restored to its rightful position by means of the neurotic symptom; in a phychosis, a new reality is forthcoming, partially substi-tuting for what has been lost. 1 Gordon Hamilton, Psychotherapy in Child Guidance, p.71. 2 Kate Friedlander, The Psycho-Analytical Approach to Juvenile  Delinquency. Chap.6, "The Oedipus Conflict", London, Routledge and Kegan Paul Ltd., 1947. 36 Neurotic acts are essentially problem solving behaviour,, These acts make use of symbolization and mechanisms of ego defence in such a way that the resulting behaviour appears to have l i t t l e or no connection with the causative force. Nevertheless, there are three fairly common criteria of neurotic disorders. The fir s t criterion concerns causation, and i t i s generally held that the i n i t i a l arrest occurs later i n the child's develop-ment than do those disturbances classified as primary behaviour disorders, (the latter fixations are thought to occur during the "oral" or the "anal sadistic" phases, while the former arrest is thought to occur in the "phallic" phase). The second criterion i s that the neurotic child usually has a ready capacity to form object and person relationships, but the use of these relationships suggests that the i n i t i a l identification was distort-ed or confused. Finally, the neurotic child i s not often so markedly aggressive towards the outside environment as are children of the primary behaviour disorder group, and, in addition, the neurotic child more often displays marked anxiety. Aggression can appear superficially as a strength in order to protect the child's tremendous fear of being destroyed as a person - in which the arrest i s mainly in the oedipal phase of development. Again, ag-gression can appear as a fundamental human drive, or reaction to a depriva-tion - in which the arrest would seem to l i e in the pre-oedipal phase of development. Absence of anxiety or guilt does not necessarily mean that the disturbance is not rooted in neurotic elements. A superficial indifference can appear as a strength and a protection to the child, but, often, beneath 37 this facade, i s a real concern. Nevertheless, i f there i s a lack of ability to form a relationship, coupled with intense aggression and anxiety that approaches panic when these children are allowed to carry out their drives, then i t might be suspected that the child has a severe disturbance such as schizophrenia.^ In this case, the ego would have recognized the dangers of being overwhelmed by these drives, and have feared complete disintegration. The third broad classification group has been termed "severely disturbed children." This group includes those children who manifest physical ailments that are without any organic cause; those children who manifest frank withdrawal and bizarre behaviour; and those children who manifest the more severe psychoneurotic symptoms. In absence of a psychiatric opinion, no attempt will be made to categorize these children 1 disorders more narrowly, other than to comment on the gross symptomology so as to justify their classification as "severely disturbed children." Classification of the Children's Disorders In addition to the previously mentioned qualitative criteria of the children's disorders, three quantitative criteria were used i n classi-fying each child's disturbance. These quantitative criteria were: the multiplicity of symptoms; the degree of inappropriateness of the symptoms and the persistence of the symptoms under treatment. That i s , the qualita 1 Anna Freud, War and Children. New York, Medical War Books, 1943, P. 5S. 38 tive criteria attempted to define what kind of a disorder i t was, and the quantitative criteria tried to indicate some measure of the severity of the disorder„ In Chart II this i s pictured graphically by stroke marks in the appropriate categories,, A l l the children in the study are listed i n Chart II by f i c t i -tious names, and by age and intelligence scores, together with a descrip-tion of their symptomology. They are arranged so that the children who manifest severe "primary behaviour disorders" are in the centre of that array. In the other classification groups, there was an attempt to ar-range the children according to ascending order of the severity of their disturbance. To denote severity of the disturbance stroke marks repressnt-ing the three quantitative criteria were employed. For example Sara T. (#9) and Jack N.(#10) who are classified within the category "primary behaviour disorders", have comparable symptomology. But i t was assumed that because Jack's behaviour was more inappropriate by reason of greater age, and because his problem was more persistent under Clinical treatment, that his disturbance was more severe than was Sara's. There was no attempt to rate the children classified as "severely disturbed children". The presence or absence of strokes indicating the kind of dis-order, and i t s severity, as illustrated in Chart II, divides the forty-two children into five groups. (1) Four children were thought to be predomin-antly normal. (2) In three cases, there was insufficient information to classify the children. (3) Nineteen children were grouped in the category of "primary behaviour disorders". (4) Twelve children were classified as predominantly anxious or "psychoneurotic children". (5) The final four children were thought to be "severely disturbed children". Chart II CLASSIFICATION AND SEVERITY GF THE CHILDREN'S DISTURBANCES Family Number Symptomology Primary Behaviour Disorders Neurotic Disorders Severely Disturbed Children Comments 1. Dick, E. 10:5 yrs. 106 I.Q. 2. Nancy I.* 10:3 yrs. 109 I.Q* 3. Bruce N." 9:3 yrs. 107 I.Q. A. Ricky I.* 6:11 yrs. 107 I.Q. 5. Dan H. 6:1 yrs. 96 I.Q. 6. Rudy 0. 9:5 yrs. 108 I.Q. 7. Ted N. 10: 1 yrs, 95 I.Q. Poor work habits at school and at home; Conscious day-dreaming, but no evidence of withdrawal. Some hostility toward father; upset by constant family conflict. Slow in school, feelings of inadequacy; ostracized by other children because of sex play incident when 5 yrs. of age. Lack of interest in school; some sibling rivalry; hostility toward father, occas-ional deafness in one ear - no apparent physical basis. Irritable and quarrelsome at school and at home; rivalry with sibling - sadistic at-tacks on the baby. Soils, fusses with his food; aggressive and negativistic at home and at school. Noisy and boisterous, aggressive with other children; some feelings of inade-quacy, jealous of father. ** / / / Case illustrations were made of these children. Due to limited space the column headed "Comments", has been deleted Chart II continued Family Number Symptomology Primary Behaviour Disorders Neurotic Disorders Severely Disturbed Children 8. Ron R. 11:0 93 I.Q. 9. Sara T. 6:1 yrs. 104 I.Q. 10. Jack N.* 8:3 yrs. 106 I.Q. 11. Leo U.* 8:6 yrs. 98 I.Q. 12. Grant N.* 7:5 yrs. 109 I.Q. 13. Morris K.* 6:6 yrs. 100 I.Q. 14. Mona G.* 6:7 yrs. 96 I.Q. 15. Larry B. 8:2 yrs. 95 I.Q. Poor school work; insubordinate and incorrigible at school and at home; some stealing. Masturbates; nocturnal enuresis; swears at mother; fi t s of uncontrolled rage, sibling rivalry. Masturbates habitually; eating and sleeping problem; hyperactive and aggres-sive at home and at school. Considerable soiling; nocturnal enuresis; aggressive and cruel at play; lacks inter-est in school-work. Slight soiling; food fussiness; hyper-active and aggressive at home; jealous of father, bad dreams. Enuretic; swears at mother; poor eater and restless sleeper; over aggressive and negativistic at home and at school; some evidence of inadequacy and withdrawal; lack of affection for anyone. Sucks thumb, scribbles on wall - kicks holes in plaster; restless and noisy; demands money, frequently steals money. Some soiling and enuresis; asocial and sadis tic with other children; insecure and some evidence of withdrawal; has nightmares; seems to seek punishment. /// /// // / / / / Chart II Continued Family-Number Symptomology Primary Behaviour Disorders Neurotic Disorders Severely Disturbed Children -• l6.Annie G.* 11:1 yrs. 96 I.Q. Defiant and aggressive at home and at school; asocial with other children; jealous of older male cousin; steals money. // / 17.Bill Y. 6:3 yrs. 101 I.Q. Some food fussiness, tantrums and general aggressiveness; overly fearful and depen-dent on parents; unusual behaviour at school, some withdrawal. // / 18.Nina N. 9:2 yrs. 95 I.Q. Aggressive and defiant at home and at school; intense rivalry with other sibling for father's affection; some anxiety. // / 19.Vernon I. 6:7 yrs. 106 I.Q. Sex play; habitual reference to a vulgar word; sensitive and a defeatist; con-cern over illness; fantasy. / / 20.Daniel I. 11:6 yrs. 90 I.Q. Defiant towards parents, jealous of siblings; lacks confidence and displays anxiety; difficulty i n reading. / / 21.Ken V. 6:1 yrs. 104 I.Q. Negativistic and asocial at home and at school; pre-occupation with disturbing dreams• / / 22.Ward G. 12:0 yrs. 90 I.Q. Obstinate at home, chronic li a r ; slow at school; some stealing and setting fires. / / 23.Coleen D. 8:4 yrs. 102 I.Q. Enuresis diurnal and nocturnal; intense sibling rivalry; feelings of inferiority; afraid of the dark. / / Chart II Continued Family Number Symptomology Primary Behaviour Disorders Neurotic Disorders Severely Disturbed Children 24. Greg N. 6:0 yrs. 109 I.Q. 25. Allan G. 10:8 yrs. 106 I.Q. 26. Robert P. 10:6 yrs. 104 I.Q. 27. Joe H. 8:8 yrs. 92 I.Q. 28.Sally L. 6:5 yrs. 109 I.Q. 29 .Barry C* 10:8 yrs. 101 I.Q. 30. Jane C* 8:4 yrs. 108 I.Q. 31. Peter 0. 10:4 yrs. 100 I.Q. 32. George D.* 11:11 yrs. 105 I.Q. Nocturnal enuresisj tense - lacks self confidence. Sibling rivalry; asocial with other child-ren; poor school work - reading defect; some stealing; apprehensive and anxious. Aggressive and destructful of property; petty thieving; alternate moods - depressed and elated. Some enuresis; steals occasionally; un-happy and insecure boy; sibling rivalry. Nocturnal enuresis; sibling rivalry; sensi-tive and tense - given to excessive self concern. Over conforming - timid; reading disability and speech difficulty. Some diurnal soiling; upset and cries a good deal; unable to complete school task; con-siderable day-dreaming; concern over health. Nocturnal enuresis; very insecure and fearful, Seclusive; episodes of exposing self and undressing small gi r l s . / / / / / / / // // // / Chart II Continued Family Number Symptomology Primary Behaviour Disorders Neurotic Disorders Severely Disturbed Children 33 • Ben M.* 7:8 yrs. 92 I.Q. 34. Sheila G.* 9:3 yrs. 107 I.Q. 35. Harriet D. 6:2 yrs. 93 I.Q. 36. Doug. E. 7:8 yrs. 107 I.Q. 37. Glen I. 6:8 yrs. 93 I.Q. 38. Susan T. 11:11 yrs. 109 I.Q. 39. Derek M.* 10:3 yrs. 99 I.Q. 40. Jenny E.* 10:11 yrs, 108 I.Q. Some nocturnal enuresis; minor food f ussi-nes s; irritable and fearful; bad dreams; a number of physical disorders without an organic basis. Irritable and suspicious; unable to do arithmetic; self inflicted topic dermati- t i s : general anxiety. Excitable, abdominal pains and vomiting when upset; marked fear of doctors. Irritable and high strung; sibling rivalry; chronic eczema with no apparent organic basis, Marked insecurity; refuses to go to school; when forced to has severe pain in stomach and elevation of temperature; sibling rivalry. Feelings of anxiety and inadequacy; speech defect; sensitive stomach and vomiting when upset. Jealous of siblings; alternately depressed and hyper-active; when hyper-active has high pulse rate; marked exhibitionist at times, -some reported " s i l l y behaviour". Feeling of inadequacy; guarded and suspicious; plays with smaller children; talkative at times, and some hysterical laughter. // // / / / / // / / / / // Chart II Continued Family Number Symptomology Primary Behaviour Disorders Neurotic Disorders Severely Disturbed Children 41. Charles D. 10:4 yrs. 98 I.Q. Very fearful; imaginative and pre-occu-pied with hobbiesj some sibling rivalry; many phobic fears - picks at self. // 42. Roger F. * 7:3 yrs. 93 I.Q. Marked insecurity; hyperactive and aggressive at school; l i t t l e affection for others; pre-occupation with phantasy. / // / 45 Bearing in mind the criteria of classification, a number of developmental histories was used to exemplify the three categories of dis-turbed children. Only a cursory description i s afforded for those child-ren who were thought to be predominantly normal, and for those children who could not be classified. (1) Predominantly Normal Children This group consists of three boys and one g i r l . Three of these children had at least one parent who was emotionally unadjusted, and the main purpose of the referral seemed to be to obtain help for the parents and not the child. Nancy 1.(2) father was diagnosed as "paranoidal" and "dangerous" by two psychiatrists, while the mother reported she woul d "black out" at times during quarrels with the father. Needless to say there was marked marital discord between the parents, and considering every-thing, Nancy coul d scarcely be thought disturbed because of her minor re-action to the conflict between the parents. Ricky I,(#4) parents were not emotionally unadjusted, but there was discord i n the home. The father was a Roman Catholic and wished that Ricky woulJd attend a parochial school of which the mother disapproved. The boy was jealous of his siblings, was hostile toward the father, had a read-ing difficulty and appeared to have lapses in hearing abiliity. However, i t was thought that the quality and quantity of these manifestations were not pronounced enough to render him a disturbed child. 4 6 (2) Insufficient Information to Classify In three cases there was either too insufficient infoimation or too contradictory information to classify the children's problems. Greg and Allan had only a very short contact with the Clinic. The former dis-played some disturbances that could have been classified as either a "behaviour disorder" or a "neurotic disorder"; the latter seemed more an anxious child and the cause of his reading difficulty is open to theoriza-tions. The information on Robert, the third boy, was contradictory. If some of the opinions were taken on face value i t would seem he was a very disturbed boy. On the other hand, i t was stated that Robert was no problem and would not have been examined had not his younger brother (a moron) been brought to the Clinic. (3 ) Predominantly Primary Behaviour Disorders Half of the thirty-eight children who were judged disturbed child-ren were classified within the grouping of primary behaviour disorder (four children were thought to be normally adjusted). The composition of this grouping by age, rated intelligence, and by sex ratio was representative of the sample as a whole. It included fourteen boys and five g i r l s . The dis-turbances ranged from a slight indication of a habit or a conduct disorder, to a f u l l blown habit and conduct disorder, with also perhaps some trace of a deeper disturbance. While generally i t can be said that the composition of this group-ing was representative of the sample, an obvious feature was observed. Four out of the five girls included in this classification were from minority 47 groups. Sara T's parents were recent immigrants from an Austrian dis-placed persons camp; Mona G's parents immigrated from Italy; Annie G's mother was Jewish and fled from Germany before W.W.II; and Coleen B was the daughter of the only Negro parents in the study. The size of the sample of children used in this study seriously limits any statistical inferences; and the number of girls from minority-group backgrounds, may be due to chance errors of sampling, and may not be a significant difference. Nevertheless, the possibility that cultural and social conflict may be related to the children's disorders should not be ruled out, and this phenomena deserves mention when the children's disorders are related to the home situation. To aid description of the classification group "primary behaviour disorder", a number of case illustrations are in order covering the onset and development of the disturbance. These case illustrations were selected from the central portion of the grouping. That i s , cases were chosen in which there was a fairly marked disturbance of pre-oedipal origin. Four boys and two girls have been selected as illustrations of primary behaviour disorders i n the children of this study. The first boy of this group seems to have been- a disturbed child from an early age. Jack manifests numerous persistent and inappropriate habit and conduct symptoms, which stem from early deprivations. 10. Jack N; Was 8 years 3 months when referred by a private physician for psychiatric help. The mother was undecided whether Jack had been wanted. The birth was difficult, and he cried incessantly 48 the f i r s t three months. During his f i r s t 2 years of l i f e the parents moved from Europe to South America, and finally to Canada. They encountered innumerable hardships. Jack had the usual childhood diseases and one severe temperature when 3 years of age. The Clinic doctor noted that his finger tips were bulbous, indicating a pos-sible pulmonary defect. He has a peculiar habit of turning his eyes sideways, and he complains of poor vision; an eye specialist found no reason for his complaint. Until recently he soiled, and suffered from noctur-nal and diurnal enuresis. He masturbates habitually, he i s suspicious and resisting towards affection exhibited by others, while at the same time i s unable to express affection for his siblings or his parents. He has always been a problem as to eating and sleeping, he i s underweight, irritable and markedly aggressive at school and at home. He has spent 2 years in Grade I despite the fact that his intelligence seore i s 106, and that the psychologist thought he would probably test higher under more suitable conditions. Leo V., a second child, has also been disturbed since an early age. He exhibits numerous symptoms of a conduct disorder, and his disturbed behaviour has persisted for some time, probably because adverse home cir-cumstances have limited the effectiveness of clinical treatment. 1 1 . Leo Vt Was 8 years 6 months of age when referred to the Clinic by the school principal. He was an unwanted child. The mother stated that the father had been awaiting posting overseas during the war and they were living in one room; thus they would be further inconvenienced by a baby. The pregnancy forced the mother to inactivity because her varicose veins became painful, and the birth was very difficult. Toilet training was started when Leo was 7 months of age. After i n i t i a l success he lapsed, and has soiled ever since. He has occasional nocturnal enuresis, he sucks his thumb habitually and he resorts to a temper tantrum at the slightest provocation. He i s aggressive and sadistic with his siblings and other children. He threatens to bite his baby sister. Leo had measles and mumps before he was 3, and had his tonsils removed at an "early age". Last year he developed 49 a leg complaint that was diagnosed as polio and the limb was immobilized. He seems to require an abnormal amount of sleep. Leo was uncooperative during his Clinical examination and the psychiatrist said he seemed to seek punishment and to be unaffected by i t . He displayed marked ambivalent feelings towards bis mother. The third child, Grant W«, displayed fairly severe conduct symptoms and also some anxiety symptoms which suggest neurotic causation. In addition, the unusual family background suggests possibility of a heredity factor. 12. Grant W: Was 7 years 5 months when referred to the Clinic on suggestion of a friend of the parents. He was a premature baby and "sickly" from birth onwards. The mother made a token effort towards breast feeding, but soon changed to a formula for the baby. Grant has always been fussy about his food. He resisted bowel training for some time. At home he is hyperactive and outwardly aggressive, while at school he is fairly well behaved, although unable to persist in any undertaking. There i s considerably sibling rivalry, and he is troubled by bad dreams but cannot remember the content of them. In the examination he displayed feelings of inade-quacy; and he manifested tendencies of withdrawal from so-cial and interpersonal relationships. The psychiatrist felt that Grant displayed l i t t l e spontaneity and that he tended to intellectualize his problems, and to be quite unrealistic about them. Three of the mother's immediate family have been diagnosed at one time or other as "manic-depressive," while two of her siblings are on the "verge of nervous breakdowns." The father's mother i s also in Essondale, diagnosed as "manic-depressive." More will be mentioned as to the questionable hereditary background in Grant's disturbance. Ample evidence warrants classification as a conduct disorder with perhaps also some evidence of a neurotic disorder or graver disturbance. Another case i n which the child's disturbance can be traced to early deprivations i s afforded by Morris K. Separation from the mother, 50 and rejecting treatment by both parents possibly brought about the i n i t i a l arrest* 13* Morris Kt Was 6 years 8 months when referred to the Clinic by a private doctor (a neurologist). The parents had wanted a g i r l , and have rejected the boy considerably. He was cared for by a maid the f i r s t two months© At 4 Months he had the whooping-cough for which he was hospitalized for three weeks. The mother claims he cried incessantly while in hospital, and that she was not allowed to see him. At 9 months he had the measles, and at 10 months mumps. At 18 months he was taken to a psychia-tr i s t because he was such a problem. Once he was tied i n his crib overnight, and he fought "like a wild beast" the greater part of the night. He has always been enuretic, a fussy eater, over-aggressive and negativistic. He i s defiant and abusive to-wards his mother. He swears at her and kicks her. Morris is also very hostile towards the other siblings and children at school. In the Clinic examination, the display of aggression was pronounced, and Morris displayed evidence of insecurity and withdrawal. He i s unable to display affection for other children or his parents. Morris1 disturbance seemed to begin as habit disorder then developed into a conduct disorder. There are also indica-tions that a more severe disturbance might develop* However, his behaviour i s not as inappropriate as, say Jack's i s , be-cause he i s two years younger. Therefore, Morris Is classified as a moderate habit and conduct disorder, with some indications of a severe disturbance. An illustration i n which the onset of the disturbed behaviour seems rooted in the oral gratification and toilet training stage of development, i s afforded by the case of Mona C* Her behaviour suggests that there are also possibly neurotic elements, but after weighing the former evidence, she was classified as a habit and conduct disorder* 14. Mona C; Was 6 years 7 months when referred by her father because she was noisy, restless, demanded money or stole money, was unable to speak clearly, "had a one track mind" 51 and was generally aggressivei and destructive. Her parents emigrated recently from Italy. The mother felt i l l during most of the pregnancy. The birth and early development appeared to have been un-eventful. A younger brother was born when she was 17 months old, and her behaviour problem began at that point. Mona sucked her thumb habitually until last year. It was noticed she had difficulty in speaking when she was 2 years old. At 3 years she had chicken-pox, followed by measles and ran a very high temperature with the latter. Her tonsils were removed when she was 4 years. At present her blood-count i s low. As a small child she messed with her faeces, and she now scribbles on the walls of her room, tears the wall-paper and kicks holes in the plaster. At home and at school she is irritable, hyperactive, noisy and distrustful. Her sleeping i s disturbed and she often cries out "no, no". The last child in this group i s a g i r l who experienced early de-v privations i n the form of an unsettled home l i f e , and early separation from the mother. Annie i s classified as manifesting a conduct disorder, although there was possibly some neurotic involvement. 16.* Annie C; She was 11 years 1 month when referred to the Clinic through a friend of her mother, who works for the Vancouver Children's Aid Society. Annie's mother i s Jewish; she fled from Germany prior to W.W.H. Her father was sent to a concentration camp and died during the war. Annie was unplanned for as the mother was escaping from Germany. The pregnancy and birth were difficult (the mother was 36 years of age when Annie was born). She was a feeding problem from the f i r s t . When she was 9 months old, her mother went to the hospital for 3 months leaving Annie with a friend. Rigid bowel and bladder training methods were * Larry B #15 was excluded as an example in favour of Annie C , as i t was felt that another g i r l should be included. 52 implemented, and the mother brags that the child has had no "accidents" since she was 10 months of age. The mother is very prudish and has not given Annie any knowledge of menstruation or sex education. At present Annie is defiant and aggressive at home and at school, other children will not play with her. She is extremely jealous of her cousin (a man of 23 years). Annie is addicted to stealing - usually money from her mother. (A) Predominant]^ Neurotic Children Twelve of the thirty eight boys and girls that were considered disturbed children, were classified as predominantly anxious and neurotic children. " Again, ages and intelligence ratings of this group were repre-sentative of the sample, but the ratio between boys and girls was not the same as the ratio between boys and girls of the entire study. In this group of predominantly neurotic children, five out of the twelve children were girls. As before mentioned, statistical analysis of the differences be-tween the number of girls in this grouping and the number of girls i n the entire study i s not warranted. But, there is a suggestion that the girls i n this study tended to manifest disturbances that seemed neurotic in ori-gin; rather than disturbances stemming from a primary behaviour disorder origin. It i s very possible that innate sex differences, culture condition-ing or other influences, may predispose the girls in this study to manifest anxious and neurotic patterns rather than aggressive behaviour that i s characteristic of the primary behaviour disorder group. Studies of delinquent or disturbed children have inferred, with some authority, that such a sex 53 difference in character predisposition does exist. 1 However, to i l l u s -trate the predominantly neurotic children as a group, four case illustra-tions will be made, with description of the onset and development of each child's disorder. Remarks concerning two boys and two girls will make up the illustrations. The cases were selected to exemplify a range of distur-bances, as there was not thought to be any "typical" manifestation as was sought in the "primary behaviour disorder" grouping. The fi r s t case i s that of a boy who i s tense, anxious and over-conforming to the parents - particularly to the father. Because of his for-mer attachment to his mother and his apprehension as to his feelings around his father, Barry's disturbance i s classified as being predominantly neuro-t i c . 29. Barry C: Was 10 years 8 months when referred by a teacher because he was not doing well at school, and was having difficulty particularly with reading and spelling. Barry seemed to have been planned forj the pregi-nancy was normal and the birth uneventful. (His father left to go into the Army when he was about 1 year of age.) He was breast fed, and feeding, teething, walking and talking seem to have been normal. He had whooping cough at 2| years and mumps soon after. When he was about 3 years of age the father returned from overseas. The father felt at that time that Barry was spoiled and needed firmer discipline. The boy became i r r i -table and hostile under his father's strict discipline, and wandered away from home on one occasion. He was a very frightened boy when found by the police some hours later. Barry became hostile and anxious in the home. He quarreled with his younger brother but has a close attach-ment to his older sister. He seems at times to be hard of 1 Glueck, Sheldon & Eleanor, Unraveling Juvenile Delinquency. Ghap.19, "Dynamics of Temperament," New York, Commonwealth Fund, 1950. 5 4 hearing but no organic reason can be found. He is affec-tionate to the parents but timid and overconforraing, and jumps when spoken to. Jane G. was a very anxious and insecure child when she was brought to the Clinic. She was unsure of her mother's love and was extremely fearful of doing something wrong. The onset of her symptoms occurred when she was about 4 years old. At the time of referral her symptoms were so pronounced that she i s classified as a fairly severe neurotic disorder. 30. Jane C; Was B years 4 months when referred to the Clinic by the teacher because of daydreaming, excessive talking and general anxiety. The mother was unwell during the pregnancy, the birth required a Caesarian section, and the mother was extremely upset - remaining in hospital for 6 weeks. Jane was fed on a rigid schedule, and her appe-tite appears to have been poor. At 10 months of age, she was hospitalized because of an eye ailment and soon after-wards began wearing glasses. When she was between 3 and 4 years of age, she had her tonsils and adenoids removed, and had a series of operations on her eye. At about this time, she became over-dependent and fearful. In addition she caught frequent colds; which seemed to settle i n her ears. When she was about 5 years her adenoids were again removed. About the same time she scalded herself, requiring hospitali-zation again. Jane is subject to occasional soiling. She was insecure in relationships to adults and children and was seclusive in play. She compensated for loneliness by creating a make-believe world which she shared with a doll. Jane was hyperactive, over conscious of wearing glasses, and had extremely ambivalent feelings towards her mother. The psychiatrist described her as an "extremely disturbed child". The next example, Ben - i s a boy whose behaviour was less inappro-priate than was Jane's, but his chronic complaints of physical ailments with-out apparent organic basis, raises the question of neurotic causation. Pos-sibly his disturbance began as a behaviour disorder. However, his ability 55 to form personal relationships, and his marked anxiety, governed classify-ing him as a neurotic child. 33. Ben M: Was 7 years, 8 months when referred to the Clinic by a private physician, who was of the opinion that the boy's disturbance was predominantly psychological. The parents did not want Ben. The father had encouraged the mother to abort (this procedure disposed of the previous conception). The mother suffered from constant . nausea accompanied by violent headaches during the preg-nancy. Ben was a breast fed child. He had convulsions during teething (9 months). He walked at 15 months. His formation of words was slow and he first copied bird and animal noises. Ben seems to have been prone to accidents and i l l health. At 20 months he was briefly hospitalized with con-vulsions, at 3 years (coinciding with birth of a sibling) he broke his arm and then had a rapid procession of colds, bronchitis and chicken-pox. At 6 years had the mumps j this year had measles, then suffered a tonsilectomy. He i s a very active and excitable boy, he perspires freely and seems overly tense. He i s inattentive at school and is inclined to daydream. He has persistent nocturnal and diurnal enureses and has "bad dreams". He is quite affectionate with his parents and others, but i s irritable and cries at the slightest provocation. An example wherein the child is over-concerned i n her relationship to her father and mother i s afforded by Sheila G. The time of onset and the symptoms manifest suggest neurotic roots. The inappropriateness of the symptoms and their persistence under treatment suggests a rather severe dis-turbance. 34o Sheila G; 9:3 years, referred by the family physician, who , fe l t he could do nothing for her rash, diagnosed as "Topic Dermatitis". She was the second of two children, and appears to have been wanted and planned for. The early developmental history was uneventful until she was hospitalized when 3 years of age for a vague kidney or bladder ailment, which required her to urinate every 5 minutes. 56 Since then, she has been a very poor sleeper subject to vivid and disturbing nightmares,, In one dream she was oh a boat trip with her mother, the boat was like an arm chair, she was unable to remember why the dream frightened her. In another dream she was frightened by an "old witch" and awoke screaming. In the examination she was active and overtalkativej her span of attention was short and her persistence was aver-age; she seemed fairly well adjusted socially but displayed evidence of feelings of inadequacy in the inter-familial relationship© She thought her parents were "not nice", and complained that her father "did not spend much time with her." She realized that her rash would be better i f she ceased scratching i t , but was ambivalent as to whether she wished to be rid of i t or not. Again there are possible elements of a primary behaviour disorder in Sheila's disturbance, but from a careful study of the entire record i t is felt that the self-inflicted rash was more self-punishment than a method of controlling the parents. Hence, the disturbance is classified as a predominantly neurotic disturbance. (4) Severely Disturbed Children Four of the children in the study displayed symptomology of such an inappropriate and persistent a nature under treatment that they were classified as severely disturbed children. Three boys and one g i r l made up the group, and with the exception of one boy, a l l the children were over ten years of age. The younger boy Roger, possibly should have been classified as a predominantly neurotic child, but the extent of his withdrawal from reality suggested a more severe disturbance. 42. Roger Ft 7:2 was referred to the Clinic by his teacher. The pregnancy, birth and first few months of l i f e seemed uneventful, although the mother was evasive and un-co-operative in relaying this information. Roger walked when about 14 months of age. He was unable to talk in phrases when he entered the hospital for a hernia operation at 2|- years of age. 57 He was very upset in the hospital and would resort to tantrums and crying. At 3 years of age he was again hospit-alized for hydrocele and a tonsilectomy. The hospital reported a marked change in temperament, as he then appeared to be quite a depressed child, and he never smiled. The examining psychiatrist suggested that the unexplained separation from his parents with the subsequent painful experiences in the hospital, perhaps i n i -tiated a feeling of insecurity - or confirmed an existing feeling of that nature. In the examination, his performance was poor on those things involving retention or recall and he displayed evidence of a severe disturbance. His relationship to his mother was espe-cially poor and he indulged in a good deal of phantasy as a means of satisfaction. His sleep was disturbed, and he perspired until his pyjamas had to be changed. He played in a patternless way, and becomes quite withdrawn; his facial muscles become distorted and rigid as he verbalizes imaginary experiences. At one point he became very frightened and screamed he had killed a former female school teacher. In the developmental history of the g i r l in this group, there is also evidence of fairly early hospitalization experience. She manifested some anxiety and undue concern over real or imaginary bodily ailments that may have had a sexual connotation. 40. Jenny E: 10:11 years was referred by a Social Worker em-ployed in a neuropsychiatric ward of a hospital. The father was a patient in this ward, and in the course of the social worker1s contact with the family i t became evident that Jenny required attention from the Clinic. She i s an only child and seems to have been wanted. The mother's health was only fair during the pregnancy. It was an instrument birth. Jenny was breast fed the f i r s t few months, and feeding, teething, walking and talking followed uneventfully. At 2£ years she was rushed to the hospital with convulsions. The doctor was of the opinion that diseased tonsils had some relation to this attack and a tonsilectomy was performed. Jenny has since had measles, chicken-pox and mumps. Last July she complained of vague pains in her legs and was sure she had a vaginal discharge. A competent medical clinic could find no evidence of a discharge or any organic explanation for the pain. The referral was made because of a 58 marked deterioration in school work and because Jenny seemed high-strung and resorted to occasional hysterical laughter. In the examination she seemed fairly co-operative in doing the psychological tests and her span of attention was good but her persistence was poor. She seemed to suffer from feelings of inadequacy particularly of social relationships. The psychiatrist observed that she was very guarded and sus-picious in their interview. Altogether she seemed very imma-ture, and was fearful about the future without knowing why. Therefore, Jenny was classified as possibly a severely disturbed child. A disturbance resulting from extreme brutality on the part of the step-father is typified by Charles D. There i s evidence suggesting that the boy became somewhat anxious after the death of his natural father. But an appraisal of the over a l l developmental picture, and l i f e experiences, indi-cates that the step-father-boy relationship i s the paramount cause. 41. Charles Dt 10:3 was referred by a visiting teacher because of his anxiety, phobic fears and habit of picking at himself. He was a wanted baby, the mother says she was reasonably well during the pregnancy. The birth required instruments. Charles was breast fed for 4 months, and there were no reports of trouble at weaning, or because of the rigid feeding schedule later adhered to. At present he picks at his food and must be coaxed to eat sufficiently for nutritive essentials. Toilet training was started at 3 months, and the mother reports he was thoroughly trained at 9 months. He has had intermittent nocturnal enuresis since he was 3 years of age and occasional soiling until he was about 8 years of age. He walked at 10 months, talked words at 11 months and teething was reported uneventful. Charles' natural father died when he was almost 3 years of age. The boy later developed bronchitis and complained of vague "leg pains". Later the same year his tonsils and adenoids were removed. The mother claims he was well prepared for this operation. When he was about 4 years, the mother married again to another man. The new step-father was and is a mentally i l l person prone to paranoidal outbursts of temper. Charles suffered 59 many brutal beatings at the hands of the step-father. Once he was beaten until unconscious - resulting in a permanent injury to his eye from the whip used. Another time the step-father seems to have tried to k i l l him by dumping bales of hay on him. At the time he was brought to the Clinic he was anxious, unable to concentrate at school, stole money occas-ionally from classmates, picked at himself and had occasional nocturnal enuresis. The Clinic staff found him to be very anxious, fearful and over-conforming. He was interested in science and inclined to be perfection!stic. One interest was making matches from a chemical formula and lighting fires; another was carving and assembling model planes and boats. While Charles responded very well to an excellent treatment regime, his behaviour manifestations at the time of referral justify classification as a severely disturbed boy. The fourth boy of this group was described in the social history and Clinic Conference notes as displaying quite bizarre behaviour. But the balance of the recorded information was so vague and non-factual that the final decision to include this boy in the "severely disturbed" group is made with the utmost caution. There seems to be sufficient information on his early development to warrant the onset of a disturbance, and the manifestation of alternately depressed and elated moods coupled with " s i l l y " behaviour suggests a severe disorder, but a more detailed evaluation of Derek might result in classifying the disturbance as a primary behaviour disorder. 39. Derek Mt Was 10 years 3 months when referred to the Clinic by a mental health clinic nurse for psychiatric treatment. The psychiatrist of the before-mentioned clinic believed Derek to be a "disturbed boy". Derek was premature. The parents had wanted a g i r l . (A psychiatrist later commented that "unconscious rejection by the parents" was in operation from the begin-ning.) He had severe feeding difficulty the f i r s t year and developed rickets at an early age. Eating i s s t i l l a problem 60 and he is consistently underweight. The boy walked at 13 months and spoke words at 18 months. There is also a history of early stammering. His sleeping has always been disturbed, and he has a habit of humming to himself while in bed. The mental health clinic that first examined Derek because of his "crazy behaviour" suggested that this might be an attention-getting device,. The teacher found him to be an "odd and impudent boy". His school work was poor. The other children refer to .him as being " s i l l y " . He was interested in science, was seclusive and wished to be left alone. He alternated between depressed moods and " s i l l y " elated moods. A Rorschach Psychological Test suggested a strong mother-child dependency with a strong drive toward masculinity. In addition, the test indicated that he was very reactive to immediate stimuli, and that he harbored an abnormal store of aggression that might be uncontrollable i f aroused. The psychiatrist fe l t the crux of the problem was the "unconscious rejection by the parents," and pointed out how Derek's constant attempts to regain parental favour had been unsuccessful. The fourteen case illustrations used in this chapter were select-ed in accordance with the previously mentioned qualitative and quantitative criteria for the respective disorders. In the group classified as predom-inantly "primary behaviour disorders", a number of cases displayed fairly clear-cut behaviour manifestations "typical" of this classification. These were grouped in the centre of the array and used as illustrations. Because of the disguised form that a neurotic disorder may take and the general difficulty in determining whether or not a child can be classified as predominantly anxious, no typical cases could be distinguished. Therefore, the cases for this group were selected simply with a view to "representativeness" and not from the centre of the array. For the "severe-ly disturbed" children i t was impossible to select a "typical" case and 61 because the group was too small for selection, - thus a l l of the cases were illustrated. The next task concerns the parents of these children,. In Chapter I, certain assumptions are made as to what constitutes optimum family re-lationships. Against this background or "standard", the parents of the present study group can be examined to determine the presence or absence of limiting influences or conditions in the family situation. Chapter III THE PARENTS GF THE CHILDREN Three general areas of information are thought of major impor-i tance in understanding and evaluating the parents of this study,, These are: (a) the background of the parents; (b) the inter-parental relation-ships; and (c) the child-parent relationships. While the information con-tained in these broad areas i s no doubt inter-related, the proposed arbitrary division facilitates the gathering and evaluating of the information. To collect comparable information systematically, both schedules and rating scales were used in the construction of three forms correspond-ing to the above mentioned subdivisions. Generally, quantitative informa-tion was collected by schedules, whereas rating scales were used to assess qualitative information. Form I which was used to gather information per-taining to the background of the parents, consisted of a combination of schedules and rating scales; Form II concerned information pertaining to the inter-parental relationship, and Form III concerned information refer-ring to the child-parent relationship, comprised only of rating scales. Background of Parents There are four.sub-headings in Form I, these are: identifying information; economic setting; psycho-social adjustment; and health. 63 Under the sub-heading of "Identifying Information", age, birthplace and other similar items were entered. The father's occupation, rating of present housing and other items of an economic nature appeared under the sub-heading "Economic Setting," Under the sub-heading "Psycho-Social Adjustment" a rating was made of the relationship between each parent and their parents. In addition, under the latter sub-head, some check was made upon the parents group participation and of their relationship to their siblings. Under the last sub-heading, "Health", were entered major illnesses, and an assessment of the limiting influence of any physical ailment. 64 Form I BACKGROUND OF PARENTS I. Identifying Information 1, Age 3. Nationality 5. Grade attainment 7. Number of, and 2. Birthplace 4. Date of Marriage 6. Religion place among siblings II. Economic Setting 1. Specific occupation of husband's father. 2. Husband's occupation, (own business) 3. Years of steady employment at above job, 4. Scale of job satisfaction: A B C D Husband and Only husband Neither wife satisfied satisfied satisfied No opinion 5. Present Housing: A B G D E Luxurious Very Adequate Borderline Inadequate Comfortable III. Psycho-Social Adjustment 1. Relationship to father: A Complete emancipa-tion B Almost com-plete eman-cipation C Occasional dependence D Considerable dependence E Pathological dependence 2. Relationship to mother: A B C D E 3. Relationship to other siblings: Felt a l l Other received Self receiv- Self received equally partial treat- ed partial adverse dis-treated ment treatment crimination 4. Group relationship: ( l i s t i f active member) (a) Church group (b) Education group (c) Interest group IV. Health 1. List major illnesses and major surgery. 2. Degree of limitation of disabling conditions or habits: Not at a l l Occasionally Low but A major steady drain factor 65 The fathers' ages ranged from 27 years to 54 years, and the mothers' ages ranged from 25 years to 44 years. The median age of the fathers was 39*5 years, while the median age of the mothers was 37 years. The frequency distributions of parents' ages illustrated by Table II shows there was a strong central tendency in both distributions. Class - Interval in years Fathers' . Ages Mothers' Ages 25 - 29 1 4 30 - 34 8 8 35 - 39 10 15 4 0 - 4 4 10 8 45 - 49 7 1 5 0 - 5 4 3 Totals 39 36 By checking the age of the parents against the date of marriage i t was found that a fairly large number of these parents married fairly young. While marriage date was available i n only 23 cases, 9 of the men married before age 25, and 5 of these were married by the time they were 22 years of age, A check of the wives' ages revealed that eight out of the 23 married by the time they were 22 years of age. As will be shown later, most of the parents in this study were persons of average schooling and above average financial circumstances. Therefore, i t i s suggested that a number of these parents married at an unusually early age. 66 Almost a l l of the parents had been born in Canada, and of Cana-dian born parents. The majority of a l l parents came from the three prairie provinces of Manitoba, Saskatchewan and Alberta. Information required to facilitate ethnic classification was mentioned in less than half of the cases. Of those mentioned, English, Irish and Scottish nationalities were predominant. But the heterogeneity of the group i s apparent when i t i s real-ized that among the fathers there were three Italians, two Germans, two Jews, one Frenchman, one Ukranian and one Negro. The religious denomination of these private Clinic cases affords a marked contrast to the religious denomination of a l l Clinic cases shown in the Roberts study.1 In the Roberts survey 86.8$ of a l l cases were of Protestant faith and only 10.9$ were Roman Catholics. In this study 44.4$ of the men whose religion was noted were Protestants, and 37.0$ were Roman Catholics. To further illustrate the contrast between the religious denom-inations noted in this study, and the Roberts study, and between this study and religious denominations for a l l of Vancouver, Table III was constructed. 1 Marie E.Roberts, Mental Health Clinical Services. Master of Social Work Thesis, University of British Columbia, 1949, p.46. 67 Table III Parents' Religious Denominations Population of Vancouver According to 1941 Census (a) Parents of Roberts Study 00 Parents of this Study N = 2? % % % Protestant 91.67 86.77 Roman Catholic 10.92 5.06 37.0 Buddhist & Confucian 3.88 mm -Jewish .99 .78 7»4 Greek Orthodox .64 1.16 -Other & not stated 1.90 6.23 11.2* 100.00 100.00 100.00 (a) Adapted from: Table 17 Religious denominations of the populations of 9 cities over 90,000 - Canada Year1Book, 1945, p.109. (b) Marie E.Roberts, Mental Health Clinical Services. * Since no information concerning religious denominations was avails able in 15 cases they were not included, and this proportion refers to other religions. The apparent increase in proportion of Roman Catholic children among private referrals can be largely explained by the fact that services of the Mental Hygiene Division of the Metropolitan Health Committee are not available to parochial schools. Perhaps a noteworthy mention i s that six out of the ten Roman Catholic men had married non-Catholic women. Four of the women had changed to the faith of their husbands, but two had not. It was found that there were generally from two to four children 63 in the parental home, although there was a number of exceptionally large families* The parents were more often "middle" children than "eldest" or "youngest" children. The school attainment of the parents provides some interesting comparisons. Table IV depicts the distribution of fathers and mothers by grade attained. Table IV Distribution of Parents by Grade Attained Class - Interval in Grades Fathers Mothers - 5 4 1 6 - 7 2 4 8 - 9 3 6 1G - 11 4 7 12 - 13 4 5 14 + 4 0 Unknown 21 19 Totals 42 42 Five fathers had grade five or less schooling, while only one mother reported so l i t t l e formal education.. At the other end of the scale, eight fathers had attained at least grade twelve, while only five of the mothers had attained grade twelve. That i s , there was a concentration of fathers at either end of the scale, while the distribution of mothers had a central tendency around grade ten. Closely allied to fathers distribution of grade attainment was the classification of his occupation, which was one of the items checked on under the sub-heading of "Economic Setting". An attempt was made to check on the occupations of both the par-ents and their parents. This wa3 achieved only to a limited degree. Seven 69 out of sixteen of the grandfathers of whom information was available, had had lower occupational status as measured by the Goodenough Occupational Scale** The occupations of the fathers were of a high order. Out of the 42 fathers, three were of professional status; eight owned their own bus-inesses or were employed i n a managerial capacity, and ten were skilled trades-men. Only six fathers could be classed as unskilled persons, and no infor-mation was available on eleven fathers. The professions mentioned consisted of a medical doctor, a lawyer and a high school principal; the unskilled persons included a longshoreman, a milkman and a beer-waiter. Further per-usal of the clinical information concerning "years of steady employment" and "present housing" made i t evident that Lack of income by fathers to maintain a minimum level of health and decency was present in perhaps four cases. The occupation i f any, of the mothers previous to marriage receiv-ed scant attention in the clinical information. Of the 19 that were noted, only one could be considered as having been a professional person, while the majority were clerical retail, or unskilled. Despite the previously mentioned rather high status of fathers occupations, there was a good deal of displeasure voiced by both parents concerning the choice in, and satisfactions derived from, the father 1s occu-Categories of occupational status on this scale are: 1. Professional; 2. Managerial and semi-professional; 3. Clerical and Retail; 4. Skilled Tradesmen; 5. Semi-skilled Tradesmen; 6. Unskilled labourer. 70 pation. Out of 29 cases where information was available, twelve pairs of parents registered dissatisfaction with the respective husband's occupation, and in seven additional cases - only the husband was satisfied; in the re-maining ten cases both husband and wife were satisfied. Possibly many of the remaining thirteen cases could be assumed to f a l l within the latter group where no mention was accorded to satisfaction in husband's occupation. Housing was rated i n accordance to a five-fold scale varying from "luxurious" to "inadequate". The present accommodation of the families of the study was rated as "adequate" in seventeen cases (1:1 ratio between per* sons and rooms used for living purposes). There were three families rated as having "luxurious" housing, and three families were rated as having "inadequate" housing. The items checked under the sub-heading "Psycho-social Adjust-ment" necessitated further use of the rating scale method of measurement. The f i r s t scale under this sub-heading was constructed to appraise the re-lationship of the parents to their own fathers and mothers. The theory be-hind the scale was that one measure of emotional maturity of a person i s the degree to which he has achieved emancipation, in every way, from his parents. The five fold scale, illustrated in Form I, to assess relation-ship of parents to their parents varies from (a) of complete emancipation, to (e) of pathological dependence'. Complete emancipation implies that a person has achieved economical, intellectual and psychological independence from his parents as was outlined in the general assumptions embodied in Chapter I, Pathological dependence i s the extreme opposite of complete emancipation. 71 Analysis of the result of this rating scale showed a predominance at the negative extreme, but since information was lacking on approximately one-half of the parents respective mothers and fathers the evidence is non-conclusive. Three men stated their fathers had forced them to terminate their education at a youthful age (13 years, 14 years and 15 years respect-ively) and make their own l iving; five others expressed anger at.their fathers for beatings inflicted upon them; and a further five spoke of a general atmosphere of harshness and rigidity. Turning to parental relationships of the mother, a noticeable fact was that three out of the twenty-six fathers died at a very early age. Three other mothers related examples of the punitiveness and rejection suf-fered them by their mother. One g i r l who married a Roman Catholic against her mother's wishes (her mother was a Jehovah's Witness) was asked by her mother after the birth of her f irst child, i f the priest was the father. Another spoke of how her mother "played cruel jokes on her," and, frightened her about men, e.g., one day during her tenth year when she came home from school, her mother hid in her closet with a dummy of a man. When the g i r l opened the closet door to hang up her clothes the mother shoved this dummy out at her, and the child fled screaming from the houseI Relationship of parents to other siblings in their families was generally not mentioned, nor was the extent to which parents participated with groups. However, fairly complete information was obtained on the state of health of the parents. Eight fathers and thirteen mothers com-plained of physical ailments or conditions. Three fathers complained of 72 gastro-intestinal condition, - two claiming they had peptic ulcers. Two fathers had allergies, one having been asthmatic since he was fifteen years of age. One father had an injured shoulder, and the remaining two fathers complained of vague i l l health. Among the mothers, the greatest number of complaints concerned gynecological disorders. These mothers had had uterine cysts or tumours removed, followed by continuing discomfort. In addition, one of these moth-ers was considered tuberculosis quiescent and suffered from arthritis. A fourth mother also complained of arthritis. Two mothers had ailments of the circulatory system, and two mothers required medication to alleviate thyroid imbalance. Of the remaining five mothers, one complained of vague ill-health, one was subject to epileptic seizures, and the remaining three complained of migraine headaches. In addition to this inventory of physical ailments there were evidences of considerable severe emotional disturbance among three parents. Two fathers and at,least one mother had been diagnosed as pre-psychotic, and a considerable number of parents exhibited grave symptomology. By reason of the apparently rather high incidence of physical and mental ill-health, i t was decided that this aspect would receive more detailed attention when a classification was made of the limiting influences affecting the total family situation. Inter-Parental Relationships The second broad area of information evaluated centered around the relationships between the parents0 Having learned something of their back-73 / ground, and the forces or influences acting upon these parents, i t was considered pertinent to enquire into the kinds of attitudes these parents entertained on entering the marriage. Further, i t was hoped that by observing the reactions these parents manifested to certain situations some measure of their emotional s t a b i l i t y might be gained. In order to make the information available comparable from case to case, the items checked on Form 2, Inter-Parental Relationships, were necessarily of a general nature. The form was divided under two sub-headings. Under the sub-heading "Index of Agreement on Domestic Issues" was a four fold rating scale. This scale was designed t© measure the extent of parental agreement on the handling of family finances; the sharing of household tasksj the sharing of interests and a c t i v i t i e s ; and the disciplining of the children. Under the second sub-heading "Family Relationships" were rating scales constructed with a view to measure the following features: marital relationship; desire and active planning for the child; parental concern over the child's problem; and parental recognition of the relationship of the total environment to this problem. 74 Form 2. Intert-Parental Relationships 1. Index of Agreement on Domestic Issues. Items Always Agree Occasion-ally Disagree Often Disagree Always Disagree Handling Family Finances A (1) B (10) C (6) -• D (4) Sharing Household Tasks E (3) F (7) G (7) H (3) Disciplining Children I (1) J (4) K (7) L (11) Sharing Interests and Activities M (4) N (3) 0 (7) P (7) * The number of scores for each rating are entered in brackets. As previously mentioned, the items in the "Index of Agreement on Domestic Issues" were measured by a four-fold rating. Proceeding from the positive end of the scale to the negative end of the scale, these ratings were: "Always Agree"; "Occasionally Disagree"; "Often Disagree"; and "Always Disagree". The number of cases in which sufficient information was found on which to base these ratings ranged from twenty to twenty-four cases. Twenty-one cases contained opinions as to extent of agreement on handling family finances. Of these ten were rated as "Occasionally Dis-agree"; six were rated as "Often Disagree"; and four were rated as "Always Disagree". Financial difficulty was evident in these last four cases, and in one of these cases i t was of a very grave nature as the husband's business was failing and he had substantial debts. 75 Regarding extent of agreement on sharing household tasks, seven out of the twenty cases were rated as "Occasionally Disagreeing", and a further seven cases were rated as "Often Disagreeing", Mothers often re-ported that the fathers were unwilling to assist i n caring for the children. This leads quite naturally to a discussion of agreement on disciplining the children. Out of twenty-three cases where information was available, eleven sets of parents reported that they "Always Disagreed", while an additional seven sets of parents reported they "Often Disagreed". The extent of dis-agreement on this item appears to be significant. The last item in the index of domestic issues i s the agreement on sharing of interests and activities. Again, the ratings tended to be concentrated at the negative end of the scale. Out of twenty-four cases, seven were rated as "Always Disagree" and seven were rated as "Often Disagree". From the cases themselves i t was apparent that interests were often diametrically opposed. One wife was interested in ballet dancing and in singing and took part in amateur and professional entertainment productions. Her husband on the other hand liked to go out with his fellow workers for a game of pool. 76 Form 2. Inter-Parental Relationships • Family Relationships lo Marital Relationship - Acceptance and consideration of spouse's individual needs. (a) Husband A (0) B (4) e (10) D (11) E (8) Complete Almost always Sometimes Often unac- No accept-acceptance accepting; unaccepting cepting; l i t - ance high capa- good capacity fair capa- tle capacity no capacity city to give to give city to give to give to give (b) Wife A (0) B (3) C (12) D (21) E (1) 2. Desire and active planning for child. (a) By Husband A (0) B (4) G (11) D (7) E (5) Complete Infrequent Occasional Frequent Overt emotional ambivalent ambivalent ambivalent rejection and physical feelings; feelings; feelings; of the preg-preparation good pre- fair pre- l i t t l e pre- nancy; no paration paration paration preparation (b) By wife A (0) B (15) G (15) D (9) E (9) 3« Parental concern over problem. j p ^ - n u a M A (0) High degree of realistic concern; found Clinic B (6) Fairly real -i s t i c concern; actively seek help C (9) Concern but l i t t l e d i r -ection; de-sire help D (6) Concern no direction ambivalent towards help E (14) No concern; no accept-ance of help (b) By wife A (0) B (8) G (9) D (14) E (0) 4e Parental recognition of relation of total environment to problem. (a) By husband A (0) B (5) C (6) D (11) E (9) Full Some L i t t l e No Refusal to recognition recognition recognition recognition recognize (b) By wife A (0) B (7) C (15) B (5) E (2) * The number of scores for each rating are entered in brackets. 77 The first scale under the second sub-heading of Form 2 attempt-ed to afford a measure of the marriage relationship itself„ In some cases there were direct quotes of both parents concerning even the more intimate aspects of the marriage; however, this was the exception. As a rule the rating had to be based upon the opinions of the various Clinic staff memr-bers. And i t is upon the accuracy of their sensitivity and intuitiveness that these ratings were predicated. A five-fold scale was constructed to measure this f i r s t item -defined as "acceptance and consideration of spouse's individual needs". The extreme positive rating was - "complete acceptance (of spouse's indi-vidual needs); high capacity to give (understanding and affection)"; the extreme negative rating was "no acceptance (of spouse's individual needs); no capacity to give (understanding and affection)". The three other ratings were thought to be three distinct variations between the two extremes. As will be noticed from the distribution of ratings interest on FormS, II, I, page 76, no parents were rated in the extreme positive position - so in reality the rating became a four-fold scale. Concerning the item "marital relationship ..." the distribution of ratings for both husbands and wives was skewed negatively. Eleven of the thirty-three husbands were rated in the second to the most negative position - that of "often unaccepting ... no capacity to give ...", while an additional ten husbands were rated in the next position to the left (towards the^positive end of the scale) - that of "sometimes unaccepting ... fair capacity to give ...". Eight husbands were rated in the extreme negative position. 7a Regarding this same item, the wives' ratings were likewise concentrated in the third and fourth positions (i.e., "sometimes unaccept-ing ... fair capacity to give ...", and "often unaccepting ... no capacity to give ...".) Twenty-one out of the thirty-seven wives were rated as "often unaccepting ... no capacity to give ...", and an additional twelve wives were rated "occasionally unaccepting ... fair capacity to give ..."• The second scale under this sub-heading was constructed to try to measure each parent's "desire and active planning for the c h i l d ^ Again the rating was five-fold, and again no parent was scored in the extreme positive rating of "complete emotional and physical preparation". The extreme negative rating was "overt rejection of the pregnancy; no (emotional and physical) preparation". The distributions of scored ratings for hus-bands and wives were positively skewed for this item, and the husbands' distribution had more of a central tendency than did the wives'. Eleven out of twenty-seven husbands were rated i n the central position, that of - "occasional ambivalent feelings; fair (physical and emotional) preparation". Seven husbands were rated in the next position to the right that of "frequent ambivalent feelings; l i t t l e ... preparation". Turning to wives, fifteen out of thirty-eight were scored in the central rating, and seven were scored in the next rating to the right. A further fifteen wives were scored in the second rating - that of "infrequent ambivalent feelings; good (physical and emotional) preparation". There-fore, with reference to "desire and.active planning for the child", there is a suggestion that the wives entertained more wholesome attitudes and took a more positive part in the planning. 79 The third item rated for husbands and wives under family rela-tionships, was "parental concern over the child's problem,," As in the pre-vious two scales, the positive rating received no scores. The ratings varied from positive of "high degree of realistic concern; found Clinic, (and referred child to i t " , to negative of "no concern (for child's pro-blem); no acceptance of (Clinic's) help". For this item, the distribu-tion of scored ratings for the husbands was bi-modal - a slight, modal effect being exhibited at the centre rating of the scale, and a marked modal effect at the extreme negative rating. The distribution of the wives' rat-ings had a central tendency between the third and fourth ratings ("concern but l i t t l e direction; desire (for Clinic help)", and "concern but no dir-ection; ambivalent towards (Clinic) help"), and the distribution was negatively skewed. Fourteen out of thirty-five husbands were scored in the extreme negative rating of "no concern ... no acceptance of help ...". This seems to be a rather significant proportion of a l l husbands, and i t raises the question that perhaps, during the referral process, the father might have been alienated from participating in the whole procedure? As was sho wn earlier, the mother most often made the referral; and from the records i t appeared that the Clinic staff tended to include the mother more than the father during the several phases of the Clinic contact. Therefore, i t i s suggested that perhaps there was bias on this rating and that possibly the husbands had more concern about their children's problems than the rating-scale shows. Regarding the wives' concern over their children's problems, fourteen out of thirty-one wives wefce scored in the fourth rating of "marked 80 concern; no direction; ambivalent towards (Clinic) help". Nine other wives were scored in the central rating of "concern but l i t t l e direction; desiring of (Clinic) help", and the remainder were scored in the second rating of "fairly realistic concern; actively seeking (Clinic) help". With respect to those wives who scored in the modal rating, i t can be said that most of them exhibited marked concern over the child's problem, but they did not seem to have any idea what should, or could, be done about the problem. The final rating scale on Form 2, that of measuring "Parental recognition of (the relation) of (the) total environment to (the child's) problem", was closely allied to the above scale. The five-fold scale varied from " f u l l recognition ...", to "refusal to recognize ...", and, again, the extreme positive rating received no scores. The distribution of husbands' scored ratings was negatively skewed around the fourth rating "no recognition (of the relation of the total environment to the child's problem)". The wives' distribution was positively skewed around the central rating - " l i t t l e recognition (of the relation of the total environment to the child's pro-blem)". In absolute terms, eleven out of thirty-one husbands were scored as displaying "no recognition while an additional nine husbands were scored in the extreme negative rating of "refusal to recognize These two ratings contain two-thirds of a l l husbands on whom this information could be rated, and i t points out the indifference of the father and perhaps also suggests that he felt quite hostile towards the Clinic. For their spouses, fifteen out of twenty-nine wives were scored in the central rating as exhibiting " l i t t l e recognition (of the relation of total 81 environment to problem)", and seven were scored in the second rating of "some recognition The latter group i s of no small importance, for as could be expected, those mothers and fathers exhibiting "some recogni-tion of the relation of the total environment to the child's problem were often able to participate more positively in the treatment plan. Child-Parent Relationships The area termed child-parent relationships was the final area of information concerning the parents and the children of this study. The child-parent relationships were examined and evaluated for the success with which the basic needs of the children were satisfied. The evaluation appears in Form 3. The basic needs of children, as outlined in Chapter I, are: the need for adequate physical care, the need for love and for a feeling of security, and the need for stimulation to learn. A further need was added to this l i s t , that of being respected as a person with rights and privileges, and responsibilities increasing with the child's increasing capacities. Some of the above needs, such as "physical care" would appear to be more vital at one particular period of the child's l i f e than at another period. But, needs such as "love and security", and "respect for the child as a person", are important whether the child i s two or twelve years old. These are perhaps universal human needs at any age. Due to the subjective nature of the measurements to be made, the rating-scale technique was again used in Form 3 to evaluate parental ade-quacy in meeting these four needs. The f i r s t scale concerned the need "physical care". For this item, separate scales were constructed for fathers Form 3. CHILD-PARENT RELATIONSHIPS A : • • • • B c D E by husband. l.(a) Physical Care constant active participation from birth (0) constant but limited active participation after first month (0) sporadic active participation af-ter first month (4) l i t t l e active participation (3) no active participation (22) 2 e(a) Love & Security constant gentle hand-ling and vocalized affection (0) -frequent gentle handling and vocal-ized affection (3) inconsistent hand-ling; occasional vocalized affection (10) occasional re-jecting; l i t t l e vocalized af-fection (9) rejecting hand-ling; depreca-tory remarks (6) 3«va; Stimulation to Learn patient stimulation i n accord with capa-cities (0) sporadic patient stimulationj fair thought as to capa-city (3) occasionally im-patient stimulation; l i t t l e thought for capacity (3) need to have child perform beyond capaci-ties (18) no stimulation (5) - - -Zula) Respect for Child as a Person-respects as an individual (1) some respect (12) slight tendency to control (13) marked tendency to control try to completely control by wife lAh) Physical Care satisfactory in every wayj feedings anticipated (1) feeds child adequate-ly; child occasion-ally has to wait (12) feeds child adequate-ly; tendency to f o l -low a schedule (13) occasional in-adequate feed-ing; rigid schedule (9) inadequate feeding or deprivation; rigid schedule (4) 2.(b) Love & Security (o) (1) (15) (10) (3) _ .. 3«(b) Stimulation to Learn (0) (1) (7) (19) (2) 4.(b) identification with Child (1) „ - _ (3) (2) (16) (3) The number of scores for each rating are entered in brackets $3 and mothers because i t was thought that in our culture mothers are per-haps more intimately concerned with the care of young children than are fathers. Both scales were particularly concerned with the f i r s t few months of a child's l i f e . The five-fold scale for fathers on the item "physical care" rated the father's participation in caring for the child. These ratings varied continuously from the positive extreme of "constant active participation from birth" to "no active participation". Twenty-two out of twenty-nine fathers were scored i n the latter rating. Again this seems to lend further weight to the indication that the mothers were often almost solely res-ponsible for the rearing of the children. The mother's scale, measuring adequacy in meeting the child's physi-cal needs, varied from the positive extreme of "satisfactory in every wayj feedings anticipated", to the negative extreme of "inadequate feedings or deprivation; rigid schedule". It was found that the scores were fairly evenly distributed around the central rating of "feeds child adequately; tendency to schedulize". Thirteen out of the twenty-five mothers were scored in the above rating; twelve were scored in the f i r s t rating to the left of centre - that of "feeds child adequately; child occasionally has to wait". The second need measured by a five-fold rating scale i n Form 3 was "love and security". This scale was identical for fathers and mothers, and i t varied from positive of "constant gentle handling and vocalized af-fection" to "rejecting handling, deprecatory remarks". The distribution of scores for both parents had a modal tendency around the central rating 84 of "inconsistent handlingj occasional vocalized affection". Fifteen out of twenty-eight fathers were scored in the central rating and nine more fathers were scored i n the fourth rating of "occasionally rejecting; l i t t l e vocalized affection". The mother's distribution of scores was almost identical - fifteen out of twenty-nine were scored in the central rating and nine were scored in the fourth rating. Six fathers and three mothers were scored in the negative rating of ''rejecting handling; depre-catory remarks". Thus, while there appeared to be a slight tendency for fathers to exhibit less love to their children - and to make their child-ren feel less secure than did the mother, both parents exhibited rather marked rejection of their children. The third scale concerned the adequacy of the parents in stimu-lating the child to learn, in a manner commensurate with the child's innate capacities. The five-fold scale for both parents varied from "patient s t i -mulation; in accordance with capacities" to "no stimulation". For both fathers and mothers the scored ratings were heavily concentrated i n the fourth rating of "need to have the child perform beyond (his) capacities". Gut of twenty-nine fathers, eighteen were scored i n the above rating, and nineteen out of twenty-nine mothers were accorded similar rat-ings. It should be remembered that school authorities were responsible (at least indirectly) for suggesting that fourteen of these children come to the Clinic for help. But, the heavy concentration of scores in this rather negative rating suggests the degree to which parents lacked under-standing of their children's capacity to learn, and also suggests the im-portance that these parents placed upon high scholastic standing. 85 The final need, "respect for the child as a person", was more difficult to define than the previous needs© The fi r s t three rating scales were designed to show, in part, the overt care accorded by the parents in meeting the child's needs of physical care, love and affection, and stimula-tion to learn© But while this overt care coul d be quite positive, either parent could be identifying with the child in a pathological manner. That i s , the child coul d be smothered with attention and affection in order to satisfy the parents' projected need for affection T i d i i c h may have resulted from a lack in childhood. Again, the child might have been accorded quite positive care as long as he emulated the parents, but would be denied i t i f he displayed any uniqueness of expression in meeting day to day situations. The five-fold scale on this item then, placed special import on the need for the parents to implement controls that were not warranted. The scale varied from "respect (for child) as an individual" to "completely con-r-trol child (in the broadest possible sense)". The scored ratings for fathers and mothers were heavily concentrated in the fourth rating of "marked tendency to control". That i s , sixteen out of twenty-seven fathers were scored i n this rating, and sixteen out of twenty-five mothers were rated the same. Indications of Limiting Parental Influences In summary, the background information concerning these parents suggests they were representative of the general population with regard to ethnic grouping, place of birth, extent of schooling, and housing accommoda-tion, A number of these parents seemed to have mauled at a fairly young age. Of these parents those classified as unskilled workers on the one hand, and successful business men on the other hand, were in slightly greater num-86 bers than were other categories of workers. However, the three most note-worthy features of the backgrounds of these parents were: the number of Roman Catholic parents - and the incidence of cross-religion marriages; the harshness and lack of understanding accorded these parents i n their own family homes; and the high incidence of apparent physical or mental i l l -health. In many of these marriages both parents seemed to have entered the marriage with set ideas about running the household, which led to con-f l i c t . They particularly lacked agreement on the sharing of tasks and the disciplining of the children. There seemed to be an inflexibility about these parents that permeated even the marital relationship itself - they had l i t t l e understanding of each other's need for affection, and they sel-dom shared common interests or activities. There seemed to be some uncer-tainty as to whether or not the child was desired — particularly on the part of the husband. The parents were fairly concerned over the child's problem but were often unable or unwilling to understand that they perhaps had precipitated the Initial upset and had contributed towards i t s develop-ment • Concerning more directly the child-parent relationship itself, i t appeared that few fathers took responsibility for the physical care of the child, and although the mother usually provided adequate physical care, both parents often imposed their routine upon the child. Both parents seem-ed to have been inconsistent in meeting the child's- need for affection, and the' child often seemed to have felt insecure from a very early age. There seemed to be a definite indication that the majority of parents desired their 87 children to perform tasks or comprehend learning experiences beyond their capacity. And finally, in many families both parents seemed motivated to impose unwarranted controls upon their children. Stating the findings of this chapter more generally, there are several fairly discernible influences affecting these parents and in turn hindering the family as a functioning unit. The extent of physical and mental ill-health suggests that emotional disturbances and physical a i l -ments manifested by the parents might be related to the child's problem. Set and inflexible ideas about running the household and managing the child-ren could also be considered as attitudes possibly detrimental to the child's normal development. In addition, there was ample evidence of lack of af-fection between the parents - or marital discord, and of other features, such as warry over financial matters, that would tend to produce an atmos-phere of tension and uncertainty which is not conducive to the child's need for understanding and security. Chapter IV THE RELATION OF LIMITING FAMILY INFLUENCES TO THE CHILDREN'S DISORDERS A classification was made of the previous mentioned limiting parental influences. This was necessary, difficult as i t was, before any attempt could be made to relate the children's disorders to the influences limiting parental adequacy. After considerable t r i a l and error the limit-ing influences were categorized as: (a) emotional disturbancesj (b) unhealthy parental attitudes; (c) physical ailments; (d) mental dis-cord; and (e) other influences. Unhealthy attitudes denote a set of ideas and emotions brought into the marriage. These must be regarded as separate from emotions. which are reactions to, and develop out of, personal and family experien-ces and situations. Marital discord could quite naturally result from either unhealthy parental attitudes, or from emotional disturbances, or from any combination of these two forces plus other Limiting influences. In this study, the process of exclusion was used to define marital discord; and i t s meaning i s possibly synonymous with a lack of mutual parental af-fection and understanding. If on close examination emotional disturbances, unhealthy attitudes, limiting physical ailments or other adverse influences such as a lack of money, did not seem responsible for the marked friction between the parents, the term "marital discord" was used to.describe this limiting influence. 89 Categorizing under "limiting physical ailment" depended upon a medical opinion, or upon ample evidence that the person was fairly ser-iously disabled, e.g., one man complained of a shoulder injury and received Workmen's Compensation benefits for the injury. The general category of "other" included cultural, economic and influences peculiar to one or two families. Finally, i t must be clearly understood that the categories ap-pearing in Chart III are overlapping categories. In some families such as that of Jenny E. (#40) the categories were mutually exclusive. The father was a very unstable alcoholic who exerted a very disturbing influence on the whole family, and there were psychiatric and medical opinions stating he was severely emotionally disturbed - i f not mentally i l l . On the other hand, the majority of families had more than one limiting influence. Allan C's parents (#25), seemed to have carried sets of unhealthy ideas into their marriage. They could not resolve their religious or educational differences. In addition, the father has an ulcer which limited his physical well-being. Chart III Classification and Effect of Limiting Influences Affecting the Parents Emotion-ally dis-turbed Unheal-thy at-titude Physical Ailments Marital Discord Other Influences Family Number Evidence of Limiting Influences Father* 2. Mother diagnosed as "paranoidal and dangerous*' /// / gynecological ailment; feels depressed; spells of "blacking out". / Father* Mother probably paranoidal and dangerous arthritic; seeks punishment; unable to make decisions. /// / / 16. Mother* tense, uncontrolled weeping; rejects child; diagnosed as "seriously emotionally disturb-ed. /// c.o. / 42. Mother* appearance deteriorating; requires unusual amount of sleep; decided loss of affect; withdrawn. /// Father* Mother alcoholic; twice in mental hospital; jeal-ous and critical; impulsive. complains of arthritis /// / / Father* 33. alcoholic; disgusting behaviour; dependent; unstable, and unduly critical of family /// Father 10. Mother* drinks heavily; displays l i t t l e interest in or affection for other members of family. // inadequate, thought to be a moron; very un-stable "funny feelings in her head"; thyroid imbalance. /// / / Mother or father considered an "inadequate." parent. Chart III Continued Family Number Evidence of Limiting Influences Emotion-ally dis-turbed Unheal-• thy at-titude Physical Ailments Marital Discord Other Influences Father* 8. Mother* apprehensive about " a nervous breakdown"} // vague physical ailments; often feels as "in a dream"; unable to f u l f i l female role. // / Father* 6. Mother* unaffectionate; ill-tempered; dominating. / appearance deteriorating; hoards unusual items; inappropriate laughter; has had a "nervous breakdown". //. Father 35. Mother* numerous allergies; asthmatic since 15; / / "hysterical" blindness at childbirth; tense; cold and rejecting of child. // / Father* 14. Mother* tics; stuttering; unusual mannerisms; hyperactive and dominating person. immature and retiring; uterine tumor; arthritis; T.B.qufescent. // / // c.c. / Father Mother* insecure person; irritable with the fam-i l y . epileptic seizures; socially ambitious; very unstable person; they are "displaced persons". // 7 / -Cr.S. / 21. Mother* apparently mentally i l l after birth of child; rigid person; dominated by her mother -dependent. •// Father* h father has a "nervous condition", unable to work; dependent person. // Chart HI Continued Family Number Father 31. Mother* Father 12. Mother* Father 22. Mother* 1M. Mother* Father 11. Mother* Evidence of Limiting Influences need for effi ci ency. egotistical; impulsive; lack of planful-ness; unable to meet child's needs. worried about mental illness. "nervous breakdown"; irritable and depress-ed moods; ambivalent feelings toward child-ren (mental illness in both sides of family) parents separated "nervous breakdown"; immaturity and lack of planfulness; poverty and ethnic prejudice present. feels inadequate; subject to migraine headr aches; and says i s upset by menopause. Father* 17. Father Mother* chronic stomach ailment periods of depression; irritable and pre-disposed to tears; history of minor physi-cal ailments. dependent and demanding; shoulder injury neglects family; ambitious; l i t t l e warmth dominated by mother; feelings of reference; feels inadequate and unhappy. Emotion-ally dis-turbed // // / / Unheal-thy at-titude / / Physical Ailments / / / / Marital Ms cord Other Influences / c»co CoCl4 / / Chart III Continued Family Number Evidence of Limiting Influences Emotion-ally dis-turbed Unheal-thy at-titude Physical Ailments Marital Discord Other Influences Father* 13. Mother* sullen; critical of wife; rejecting of the children. migraine headaches since 16; married for security; openly rejecting of children. Father 36. Mo-Idler* overindulges child; critical of wife. sleeps with boy; unable to f u l f i l female role; competes with father for boy's affection. Father* 30. Mother* immature, self-centered; critical of wife; inconsistent handling of child. unable to f u l f i l female role, fears more cysts of uterus; immature; meticulous and tense person. Father* 22. Mother* suspicious; cold and rejecting of boy; poor economic planfulness. neglects children and home for outside i n -terests; austere and inflexible person. Father* Mother "cold, egocentric & punitive person" fails to meet families need of warmth. feeling of inadequacy, and fear of meno-pause . Father* 26. Mother openly unfaithful to wife; avoids economic responsibility. deepseated fear of men; need to depreciate self. / / / / / / / / // / // /// /// / /// / / / / / e.d. / Chart III Continued Family Number Father* 37. Mother* perfectionistic; complains of ulcers; questionable allergy of ear. socially ambitious person; rigid with child-ren - l i t t l e understanding of family's af-fectional needs. Father* 25 Mother Father* 22. Father* 18. Mother* Father5* 19. Mother Father* 32. Mother Evidence of Limiting Influences cold person; dissatisfied and ambitious; complains of ulcers. feeLs inferior; l i t t l e understanding of children or husband's need of warmth, (marked family discord). rigid with children; rude and unaffection-ate to wife. (marked parental discord). immature; feels inadequate; poor work his-tory; openly critical of wife. marriage "a raw deal"; ashamed of children; "thoughts.crowd i n on her", fearful of i l l -ness. tense person; very dependent on wife; com-plains of ulcers. delights in manipulating husband; says she has "complex for approval". unnatural relationship to son. thyroid imbalance. Emotion-ally dis-turbed / / / Unheal-thy at-titude // // / // / // / / / Physical Ailments / // // / Marital Discord / / Other Influences Chart III Continued Emotion-ally dis-turbed Unheal-thy at-titude Family Number Evidence of T.iraiting Influences Physical Ailments Marital Discord Other Influences / Father 4. Mother objects to helping with children's care pushes children beyond capacity, (marital conflict over religion) / Father 7 . Mother quite demanding somewhat rigid with children. / Father 20. Mother expects too much of children claims has damaeged heart. / .e.d, / father Mother rejected pregnancy; somewhat ambivalent towards child. Father 2 7 . Mother difficulty managing household; a need for social status. Father 28. Mother some in-law conflict; an epileptic sibling in the home. epileptic / Father 22. Mother feels inferior; history of minor physical ailments. sets high standards for family. / / Father chronic poor health / s^d. 34. "Mother (low economic and social standards in home) / Father 38. ""Mother irritable and tense person; unable to understand children. (some evidence of ethnic prejudice). c.c. / * Mother or father considered an ''inadequate" parent. 96 Limiting Family Influences Two procedures were used in categorizing and weighing the Clinical- information concerning the parents. The information contained on the schedules and rating scales used in Chapter III was re-evaluated. In addition, the case records were re-read, and a composite case summary was made for each case. In these summaries, special care was taken to evaluate, as objectively as possible, the forces and influences acting and interacting upon the total family situation. The weighing idiich i s indi-cated i n Chart III by strokes i s entirely subjective. Why respective par-ents were thus classified, will be explained by illustrations from pertin-ent cases of the five categories. In Chart III, the sets of parents were so listed that the two main categories "emotionally disturbed parents" and "unhealthy parental attitudes" were kept as distinct as possible from one another. Further, the sets of parents were arranged within these two categories i n descending order of weighting. Effort was made to delineate the two categories "mari-ta l discord" and "limiting physical conditions", but with only limited success. Table V Limiting Influences in the Family Situation (N a h2) Limiting Influences or Condi-tions (overlapping categories) Fathers Mothers Families Affected (a) emotionally disturbed parents 13 19 27 (b) unhealthy parental attitudes 16 13 19 (c) physical ailments 8 13 20 (d) marital discord 11 11 11 (e) other 9 9 97 Table V shows how many fathers and mothers were placed in each category, as well depicting the number of families affected. It will be useful, now, to discuss each category, both generally and par-ticularly. (A) Emotionally Disturbed Parents In twenty-seven out of a possible forty-two families, at least one of the parents was evaluated as displaying some evidence of being emotionally disturbed. Despite the fact that many were marginal cases, there were a sufficient number of severely disturbed parents to suggest evidence of a serious mental health problem. 0f this group of emotionally disturbed parents, thirteen were fathers and nineteen were mothers. To discuss some of these parents more fully, four cases were chosen arbitrarily from the top end of the cate-gory (the cases the most heavily weighted), two were chosen from the centre of the array, and two cases were chosen from the lower end of the category. The case numbers of these sets of parents are underscored in Chart III (the eight case numbers are: 2,41,16,42; - 21,1; - 3,11). The father of Nancy I (#2) was a severely disturbed person, while the mother displayed only slight emotional instability. The father was an extremely tense and unstable person; he was extremely jealous and suspicious of his wife and committed such bizarre acts as having his wife's undergarments analyzed to see i f she was faithful to him. He had been i n an institution for the mentally i l l and was diagnosed by a psychiatrist as "paranoic and potentially dangerous". The mother was very dramatic; she 98 was unable to make decisions or carry through plans, and she had spells when "everything went black". In case #41, Charles' step-father was also a very disturbed and dangerous mane He was crit i c a l and impatient with his wife, and brutal in his treatment of Charles, The step-father was rigid and obsessive about minor household routine; he flew into a rage at the slightest pro-vocation. He has beaten the boy repeatedly - on one occasion rendering him unconscious and permanently injuring his eye. Other examples'of the step-father's behaviour are: deliberately running into other motorists' cars when displeased; running down a man; and keeping an axe in his bed-room for "burglars". The examining psychiatrist suggested that the father was probably paranoic. Charles' mother suffered from arthritis, and was indecisive about trying to plan realistically for the boy; however, in other respects she was a fairly adequate mother. The third case from the mere disturbed end of the array concerns the mother of Annie G #16. This mother fled from race persecution in Ger-many. During her ordeal she became separated from her husband, and as i t was also at this time that she became pregnant with Annie, she blames the child for causing the father to desert her. She was a shy, tense person, subject to violent weeping spells, and complained of innumerable vague physical ailments. She felt inadequate and thought that people were schem-ing against her because of her ethnic background. This mother was in a state of constant emotional upset, and was described by a psychiatrist as being "seriously disturbed emotionally". The last case used to exemplify a severely disturbed person, 99 concerns the mother of Roger A #42. This mother longed for routine fac-tory work, and left most of the homemaking tasks to her mother«, She is tense, her appearance is deteriorating and she seems to require an abnor-mal amount of sleep* The Glinic staff remarked on her indifference and lack of total affect. Throughout the case record this mother displayed a considerable amount of withdrawal. These are but four of the more disturbed parents. A glance at the symptomology in Chart H I reveals that at least four others were eq-ually disturbed. But to depict something of the range of disturbances, two illustrations can be used from the centre of the array. Ken V's (#21) mother was a tense, rigid person who was dominated by her mother. When Ken was born, the mother was confined to bed rest for one year, leaving the child i n the care of a housekeeper of limited i n t e l l i -gence. The record suggests that this was a mental illness, but the mother was unwilling to discuss the nature of her ailment more fully, or to allow the social worker to contact her doctor. The second of these two intermediate examples of a disturbed per-son concerns the father of Dick F (#1). This father stated he had had a "nervous breakdown" and at present had such a severe "nervous condition" that he was unable to work. His past employment record was erratic and the social history of the family suggests that he had been a disrupting influ-ence in the family situation for some time. Although he had been taking chiropractor treatments for his "nervous condition", i t would seem that the main purpose of the referral was to obtain psychiatric help for him. 100 The final two illustrations were chosen from the bottom of the category of emotionally disturbed parents. The disturbance i s very mar-ginal in these two cases, and possibly these parents should be considered well adjusted from an emotional standpoint. The mother of Bruce N (#3) was very conscious of her social sta-tus, and projected her thirst for a higher education in her children. She admitted she had had migraine headaches for some time and that she was "going through menopause and living on hormones". She had no social friends and justified her seclusiveness by explaining that her neighbours gossiped about her. In sum total, there was no definite evidence of a severe emo-tional disturbance, but there was some evidence that this mother was some-what unstable. The final illustration from the array is also one in which the mother seems slightly emotionally disturbed. Leo V's (#11) mother had per-iods of depression and was extremely fearful of pain. She was anxious, and predisposed to periods of weeping. In addition, she became violently angry on occasion and seems to have l i t t l e control of herself. (B) Unhealthy Parental Attitudes Twenty-nine of the parents appeared to have entered marriage with set ideas that were to become disrupting influences to these marriages. Some of these ideas were: attitudes towards religion; attitudes about the place of authority in the family; and attitudes about the care and discip-line of children. The fathers outnumbered the mothers sixteen to thirteen in this category. At least one parent in nineteen of the forty-two families was thought to display attitudes which limited the optimum functioning of the family unit. 101 Three examples were chosen from families i n which very unhealthy attitudes were held by one or both of the parents. Two other examples i l -lustrate cases in which the parental attitudes were thought to be only slightly unhealthy. These two groups of illustrations furnish a measure of the variation in this category, (the case numbers of the families are 39, 15, 26, 22, 5). Both of Derek M's (#39) parents displayed attitudes which limited the optimum well-being of the family. The mother was a very religious and rigid person, who seemed to believe that a home atmosphere of coldness and inflexibility was conducive to family harmony. She dominated the father--and was unduly critical of him and the children. She neglected the family in order to spend a good deal of time with the Pentecostal religious sect. The father wanted a g i r l instead of Derek, and has rejected the boy ever since his birth. Derek's father was entirely wrapped up in his work and displayed l i t t l e understanding of the family's need for affection. At the time of the referral he was engrossed in his business difficulties and re*-sented the "psychiatrist's prying questions". The parents of Larry B (#15) also displayed unhealthy attitudes, but in this case, the father was the major disrupting influence. This father was a punitive person and required the mother to work in his store until she was seven months pregnant, as he disapproved of the pregnancy. The examining psychiatrist described him as "cold and egocentric ... unable or unwilling to recognize any problem in the patient ... fails to recognize the need for more affectionate, open and easier relationships between him-self and the family". Larry's mother was also unaffectionate towards him. 102 She was an insecure person, and nagged the children consistently but with-out expecting them to obey her. Again, in the case of Robert P (#26), both parents manifested un-healthy attitudes and, again, the father seemed to be the main dd-srupting force. This father was dogmatic about his ideas concerning the family. He assumed l i t t l e responsibility i n caring for the children, and supported the family grudgingly. He was openly unfaithful to his wife and expected her to accept her lot. The mother, on the other hand, seemed to have entered the marriage with distorted ideas about men, due to childhood frights. She was cold and unrelaxed with her husband. She seemed to have expected the worst treatment possible from him, and in some ways, provoked i t . The case of Ward C (#22) was chosen for illustrative purposes be-cause of its intermediate position in the category of "unhealthy parental attitudes". Ward's natural mother had died and the father had married a second time. The father was unable to give any encouragement to the boy and was brutal in his disciplinary measures. He seemed to have re-married only to obtain a housekeeper and had l i t t l e understanding of his wife's feelings, and l i t t l e consideration for her as a person. Due to the difficulty of sorting the cases by more than one c r i -terion, the final case selected to illustrate a minor unhealthy parental attitude, was taken from the category of "emotionally disturbed parents". The father of Dan H. (#5) displayed a slight evidence of an unhealthy at-titude, while his wife displayed an equally slight evidence of emotional instability. Concerning the father, i t was found he neglected his wife 103 during her pregnancies with the vague excuse of being busy at the office, when in reality he was playing golf. There were other instances also of indifferent and unresponsible behaviour on his part. (G) Physical Conditions or Ailments Eight fathers and thirteen mothers complained of physical a i l -ments; twenty families were involved to some degree. In each of twenty families at least one parent complained of some ailment, but many of these ailments were vague and ill-defined. No attempt has been made to discuss the medical nature and severity of these ailments. It was thought suffi-cient to group parents having the same complaint, and to discuss the gener-al effects of their aibaent on the family. Three of the fathers had gastro-intestinal complaints. In two of these cases the fathers claimed that ulcers were the cause of their discom-fort. Of two fathers complaining of allergies, one was allergic to various materials encountered at work and, in addition, had suffered asthma since he was fifteen years of age. The second father suffered discomfort in one ear wfaemever he confronted an unpleasant task. The sixth father appeared to be prone to minor ailments. In 1949 he injured his shoulder and he re-ceived Workmen's Compensation benefits continuously since that time. The last two fathers in this group complained of vague i l l health. The first, of these was married to a domineering woman three years his senior. This man spent a period in hospital following discharge from the army, and he returned periodically to the hospital because of i l l defined complaints. The second father had sore hands from steam at his place of work. He also complained that his health was "not very good". 104 While the incidence of physical ailments amongst the fathers was one i n five, the incidence of ill-health amongst the mothers was a l -most one in three. The largest sub-group of definite ailments consisted of three mothers who complained of gynecological disorders. Each of these women had had a cyst or a tumor removed from her uterus, and she was exper-iencing continuing discomfort. In addition one of these woman had a hernia, was diagnosed as tuberculosic quiescent, and also had arthritis. - A fourth mother also complained of arthritic discomfort. Two mothers complained of circulatory disorders. One suffered from high blood pressure, while the second claimed she had "a damaged heart". Two other mothers required medicine to alleviate a thyroid imbalanceo One of these also had marked menstrual discomfort and habitual headaches. Ano-ther mother suffered intermittent epileptic seizures. Finally, three mothers complained of severe headaches. One asso-ciated her headaches with climacterium changes, while a second said her headaches occurred in cycles and were worse during menstruation. The third mother had suffered migraine headaches since she was sixteen years old. Her physician was unable to find any cause or cure for this condition. (D) Marital Discord It was very difficult to decide whether an emotional disturbance, unhealthy parental attitudes or an aggravating ailment was responsible for the degree of marital discord in some cases, or whether this latter cate-gory was a separate entity. In eleven cases i t was decided that the amount of discord present could not be explained by other causes, and so the cater gory was considered justifiable. 105 Three illustrations of marital discord have been chosen: the f i r s t concerns a family where one parent was obviously an emotionally dis«« turbed person, the second concerns a family giving ample evidence of an unhealthy parental attitude, and the last illustration is one in which one of the parents complained of a physical ailment. The father of Jenny' E (#40) was a habitual alcoholic. He was unable to keep a job, he was impulsive, and he criticized his wife and daughter harshly. He was exceedingly jealous of any attention accorded the child by his wife. He told the social worker at one point "there are only three roads open to me ... death ... suicide, or a mental hospital". Incidentally, he had received institutional treatment of a psychiatric na-ture on two previous occasions. However, the amount of family discord that he perpetrated, despite the understanding accorded by his wife, could not be entirely explained by his disturbed state. Both parents of Rudy 0 (#6) displayed influences other than mari-tal discord, which limited optimum family relationships. The mother was an insecure, perfectionistic, and a punishing person. Her appearance was de-teriorating. She hoarded unusual articles and when attention was drawn to her odd behaviour, she tended to cover up with inappropriate laughter. This mother was considered somewhat emotionally disturbed. Rudy's father had a very bad temper, and meted out unduly severe punishment to the children. He would yell at Rudy or beat him for soiling. He accorded his wife and children l i t t l e affection, and was considered to have an unhealthy parental attitude. Nevertheless, i t was felt that the father's attitude and the mother's emotional upset could not be held entirely responsible for the apparent extent of marital discord between these parents. 106 The last illustration concerns a family in which the father com-plained of vague i l l health. Both of Barry C's (#29) parents came from un-happy families. The father, at the time of referral, complained of chronic i l l health. The mother dominated the family to some extent and was quite critical, but could scarcely be said to display an unhealthy family a t t i -tude. Nevertheless, those Clinic staff members who interviewed the parents agreed that there was very strained relations between the parents. (E) Other Limiting Influences . . . Besides the four main categories of influences which rendered a limiting effect upon the respective families, a number of miscellaneous ad-verse factors were discernable. In nine families these factors were of suf-ficient severity to warrant mentioning, but only in two cases were they the only limiting influences present. In five cases the families in question belonged to minority ethnic groups, and in three of these, the families were also recent immigrants to Canada. A unique feature was that in each of these cases a daughter was re-ferred to the Clinic, and in only one case was she an "only" child. As men-tioned previously, a further unique feature was that three out of five of these girls were classified as "primary behaviour disorders". However, in only one of the above cases was cultural conflict the only limiting influence in the family. Sheila G's (#34) parents were Jewish. Both had had rather barren and rigid home backgrounds themselves. The father was a tense, critical person who was impatient with the children. The mother did not seem to understand her children and was bewildered by such things as sibling rivalry. However, both were adjudged as adequate 107 parents. The child herself had suffered early physical ailments and had been intensely hostile towards her older brother whom she alleged received partial treatment, when she entered school she suffered a series of unfor-tunate accidents caused by the other children and the teacher. Her extremely upset behaviour, and the self-inflicted rash became evident soon after she entered school. Economic difficulties were present in four families though in only two of these were they of major proportions. Derek M's (#39) parents were previously discussed as displaying very unhealthy parental attitudes. But the grave financial condition of the family and the large debts of money no doubt brought further disrupting pressures upon the entire family. In the other family, Coleen D's (#23) mother was separated from the father and seemed to be a slightly disturbed person. However, the difficulty of sup-porting herself and the child, and the necessity of living in crowded quar-ters with relatives, added to the total family problem. Finally, there was one case in which none of the previous factors or influences were thought responsible for contributing to the child's dis-turbance. In the case of Susan T (#38) the parents and the home seemed ade-quate in a l l but one regard. Susan's older sister was a fairly limited child with respect to intellectual capacity, and in addition, was subject to epil-eptic seizures of the grand mal nature. The parents, in their endeavour to encourage the older sister and accord her affection and understanding had caused Susan to become very jealous of the older sister. In summary: in twenty-seven families there was evidence of emo-tional disturbance in one or both parents; in nineteen families there was 108 considered to be evidence of unhealthy parental attitudes; in twenty families one or both parents complained of a physical ailment; and in nine families there were evidences of other limiting influences or condi-tions. To draw together these impressions, Table VI was constructed. This table shows the number of families in which both parents were thought to be inadequate; those families in which one parent was thought to be inade-quate; and those families in which both parents were thought to be reason-ably adequate. Table VI Parental Adequacy Family Rating Number of Families % of Total Families Two inadequate parents 8 19.2 One inadequate parent 25* 59.5 Two adequate parents 9 21.3 Total 42 100.0 * 12 fathers were considered inadequate, as against 13 mothers. Thus far, the children's disorders and the limiting influences in the homes have been classified. From an evaluation of the limiting influences in the homes, the fathers and mothers have been rated with res-pect to parental adequacy. The final task is to determine whether a rela-tionship i s apparent between the kind or severity of the child's disorder and the limiting influences in the family situation. Relation of Children's Disorders to Limiting Parental Influences Chart IV attempts to depict graphically the relation between the kind and severity of the child's disorder and the limiting influence or ' CHART T3 RELATION OF CHILDREN'S DISORDERS TO P A R E N T A L LIMITING I N F L U E N C E r/tw mm CHILDRENS DISC ) R D E R S INADEQUATE PARENT L I M I T I N G F A M I L Y I N F L U E N C E S PRIMARY BEHAVIOR DISORDER NEUROTIC DISORDER SEVERELY DISTURBED EMOTIONAL DISTURBANCE UNHEALTHY ATTITUDE PHYSICAL COMPLAINT MARITAL DISCORD O T H E R DIFFICULTIES 5. 6. 7 / / / M O T H E R F A T H E R M O T H E R / / / / -/ / 8. 9 I Q II. 12. (3. 14b 15. 16. 17 18. II II III III ll II II II II II // 1 1 1 1 1 1 / F A T H E R M O T H E R M O T H E R MOTHER M O T H E R M O T H E R F A T H E R M O T H E R FATHER MOTHER F A T H E R M O T H E R FATHER P A T H E P M O T H E R / / / / / / . . / / / / / / / i / / / / / / / / / / / / / f / / / / / / / / / / / / / / / C U L T U R A L CULTVRM C U L T U R A L 19. 2a 21. 22. 2 3 \ 1 1 1 1 1 1 / f / / F A T H E R M O T H E R F A T H E R M O T H E R / / ll " / / " / / E C O N O M I C " c o r T f R A L E C O N O M I C 27 2a 2 9 . / / 1 . . . . / / E PILE F T / C 30, 3f. 32. 33, 34 35. 36-37 38. 3 9 . 4 0 . 4 1 . 4 Z . . . . II II II II II 1, 1 1 / II 1/ II II / 1 1 / II II II F A T H E R M O T H E R M O T H E R FATHER FATHER M O T H E R M O T H E R F A T H E R F A T H E R M O T H E R F A T H E R F A T H E R M O T H E R / / / /it n / / I/I Hi in / / f / / / / / IH / / / / / / / ~ / / / E C O N O M I C GUtH /RAL E C O N O M I C 109 condition affecting each of his parents. Seven families do not appear on this chart. As explained in Chapter II, four children (family numbers: 1, 2, 3, and 4) had disturbances not sufficiently serious to warrant men-tion, and three other i C h i l d r e n (family numbers: 24, 25 and 26) had problems which could not be classified because of insufficient information. The children were listed by family number in Chart IV in the same order as in Chart II. In addition, the classification of each disorder and it s respective weighting was also similar to that used in Chart II. The parents were listed according to the order of the children, and were not grouped by category of limiting influence. But, the influences limiting parental adequacy, were marked with respect to category and weighting just as in Chart IV. m other words, the children were listed i n the i n i t i a l order of ascending family numbers which also governed the listing of the parents. From a close study of the pattern of check marks on ChartIV, three tentative conclusions can be drawn. First, no direct relationship is apparent between the kind of disorder manifested by the children and the kind of influence impairing parental adequacy. Secondly, there i s a slight relationship between the severity of the child's disorder, and the severity of the limiting influence or condition affecting either or both  parents. Finally, there appeared to be a relationship between the kind  and severity of the child's disorder and the particular parent who was  "inadequate" during the child's early formative years. For the two main classification groups of children, those of "primary behaviour disorders" and "neurotic or anxious children", there 110 i s no significant relationship between the kind of disorder displayed by the child and the kind of influence limiting parental adequacy. There i s a relationship between children classified as "severely disturbed" and parents categorized as "emotionally disturbed". Out of four sets of par-ents whose children are classified as "severely disturbed", two fathers (#40,#41) had been diagnosed by psychiatrists as pre-psychotic, and a mother i n a third family (#42) was considered to be a very disturbed woman. However, the comparatively small number of children and parents concerned, limits the significance of this relationship. The above relationship, of course, carried over into the second tentative conclusion, that of the relationship between the severity of the child's disorder, and the severity of the limiting influence or condition affecting either or both of the parents. This relationship i s most evident for those children classified as "primary behaviour disorders" and for those children classified as "severely disturbed children". Because the latter group was fully discussed in the above paragraph, repetition has been 1 avoided, and only the former classification group has been discussed in detail. As the weighting illustrates, the more severely disturbed children were placed in the centre of the array of that group of children classified as "primary behaviour disorders". In considering those parents whose child's disorder received a weighting of at least two strokes (//) (family numbers 8 to 18 inclusive), i t i s evident that the parents themselves had limiting influences or conditions that were equally heavily weighted. For example, one might note the marked contrasts between the weighted limiting influences for parents of the group #8 to #18 inclusive, and the weighted influences for those parents i n the groups #5 to #7 inclusive and #19 to #23 inclu-sive. For the purpose of discussing the third tentative conclusion, that there was a relationship between the kind and severity of the child's disorder and the particular parent who was "inadequate" during the child's early formative years, the children considered "neurotic or anxious" were grouped with "severely disturbed children". This was done because i t i s felt that the period of i n i t i a l arrest and the manifested symptomology was fairly common to both of these groups. Considering the classification group "primary behaviour disorder", thirteen mothers were rated as "inadequate", as compared with nine fathers so rated. For the more disturbed children of this group (#8 to #18 inclu-sive), nine of eleven mothers were rated as "inadequate", while only six of eleven fathers rated as "inadequate?1. To point out, in another manner, the relationship between "inadequate" mothers and children classified as "primary behaviour disorders", each of the five mothers of the eleven men-tioned above, was the only "inadequate" parent in the family, while in only two cases was the father rated as being the only "inadequate" parent in the family. For the composite group - "neurotic and anxious children" and "severely disturbed children", the relationship between the kind and sever-ity of the disorder and the parental adequacy, was more involved. In the f i r s t place, an equal number (7:6). of fathers and mothers were considered "inadequate", and where there was only one "inadequate" parent in the family 112 this parent was more often the father than the mother. In addition to these differences as compared with the group above, the children of this last composite group seemed to be particularly confused in identi-fying with the parent of the same sex, or in relating to the parent of the opposite sex. The fathers of four out of eight boys in this group, had been absent from home for a long period during the child's early l i f e , or else they were weak father figures. Two boys had brutal rejecting fathers; one boy's mother had rejected him from birth, and the mother of the second boy slept with her son although he was nearly ten years old. It was possible that the second boy had a need to irritate his eczema as a means of self-punishment for incestuous thoughts that he might have en-tertained. Four of five girls in this group had fathers who were very weak father figures. The fifth g i r l had an immature retiring mother and a stern dominating father. Despite the exploratory nature of this study, the above conclu-sions would appear to warrant further study. The diagnosis and treatment of children's emotional disturbances would be simplified were i t found that certain disorders were caused by inadequate mothering, or by confused identification with the father. A systematic multi-disciplined research approach to the relation of children's disorders to influences affecting parental adequacy could test these postulates more objectively than was possible in this study. A less ambitious undertaking might be carried out by the Vancouver Child Guidance Clinic. If the incidence of emotional disturbances among 113 parents i s as high for a l l private Clinic cases as i t was for the parents in this study, should not treatment facilities be afforded for these parents by the Clinic or an adult mental health Clinic? The method used in this study could be tested for validity and reliability and then used with some improvements by the Clinic for such a study. 114 Appendix A. (1) SOCIAL HISTORY OUTLINE A guide to preparation of Social Histories for the Child Guidance Clinics. NAME: BIRTHDATE: ' PARENTS: (FATHER) (MOTHER) (MAIDEN NAME) TELEPHONE: -DATE WRITTEN: DATE OF.EXAMINATION: STATUS: (Ward, Non-Ward, etc.) BIRTHDATE: BIRTHDATE: ADDRESS: S.S.INDEX: SOURCE OF REFERRAL: (By whom and how) PROBLEM: (1) As stated and seen by parents, child and any other closely . . involved persons. What help are they asking for? How long have parents, child or others been aware of the problem(s)? How do they feel about receiving help? (2) Social worker's general picture of problem. Estimate client's awareness of the presenting problem and other problems seen by the social worker. Reason for referral to Clinic at this time. What specific help i s desired by social worker? DATE OF PREVIOUS EXAMINATION AT C.G.G., E.P.H., Etc. (Child or relatives) FAMILY HISTORY SETTING: Pertinent and brief descriptive material of present home setting —economic and community status; housingj persons in home. FATHER: (1) (2) (3) Identifying information - name; present agej place of birthj religion. Social and cultural background - others i n family, agesj father's description of paternal grandparents; father's estimate of his adjustment to family, school, religion and social groups; extent of education; work record; health; any serious illnesses or operations. Family relationships — father's feelings about and relation-ship to child, to wife, to others i n family; Father's attitude and contribution with regard to problem(s); How does he handle it? Appendix A. (1) : 115 (4) Paternal relatives •'— information pertinent to child and . _ parents' adjustment. MOTHER: Information as for father ( l ) , (2), (3). (4) Maternal relatives -~» information pertinent to child and parents' . . adjustment. MARITAL ADJUSTMENT: When, where and how did parents meet? Courtship} Sexual adjustment. STEP-PARENTS OR FOSTER HOMES: As above with dates child was with them and reasons for leaving. Indicate and evaluate relationships, adjustment and the meaning of the experience to the child. (in chronological order) SIBLINGS: Identifying information - namej date and place of birth; religion. How do they f i t into the family, inter-personal relationships? PERSONAL HISTORY DEVELOPMENTAL FACTS: Date, place of birth; Age weaned;. Bladder control at: toilet training began: Bowel control at: Teethed at: Walked at: Talked at (words) (sentence formation) DESCRIPTION OF DEVELOPMENT TO DATE: Mother's health, attitudes and feelings about child during pregnancy; method of delivery; length of labour; birth injuries. (1) Eating: Method of early feeding; Method of weaning any early feeding or present eating difficulties; Food fads or fussiness; Indigestion or any indication of gastro-intestinal disorder. (2) Elimination: Method and attitudes in training child; Difficulties; Any indications of frequent constipation or diarrhea; Any incidents of enuresis; Soiling; Smearing; Any present unusual attitudes or habits regarding elinination. (3) Sexual development: Interest in sexual information; Any incidents of exhibitationism; Sex play; Masturbation or intercourse (describe, including age and frequency of such incidents) Extent of sexual knowledge; From whom obtained; Evidence of development; 116 Appendix A. (1) . _ . . r v ' Age of puberty; Attitude toward i t ; If menses established is i t regular? Painful? Has someone discussed puberty and sexual role with child? Any indication of abnormal sexual behaviour? (4) Physical development: Has physical growth been normal? Give incidents of illness, disease (ages) sequelae (disability, etc.) Reactions of child and parents to serious illnesses; Disabilities j Operations and preparation of child for these (age); Child's attitude to and estimate of present health; Any over-compensation or over-concern. Physical description; any indications of nervous habits; fears, disturbances of sleep; recurrent or significant dreams. General picture of the child's outstanding relationships and how he (she) uses these. How does he (she) handle feelings and needs such as anger, affection, dependency in relation to his (her) closest relationships. Attitudes to school, teachers, people in authority. Interest and Recreation: adjustment to social groups, employment, particular friends of both sexes. Ambitions and goals. Estimate of child's insight, intelligence, humor. EVALUATION AND PLAN PERSONALITY AND APPEARANCE: Worker's evaluation of case from work done by the presenting agency. Evaluation of strengths and weaknesses i n child, parents and parent-child relationship. What has been done? How frequent are the contacts? How strong i s worker-child relation? What methods have been tried i n working with child and parent(s)? What has been tried by family members in dealing with problems? How successful? What possible resources are there i n family or community to help meet child's needs? What are worker's suggestions for carrying on from the point? Questions around which social worker would like discussion. ALL HISTORIES SHOULD BE SIGNED BY THE WORKER AND FOUR COPIES SUBMITTED TO THE CLINIC. Appendix A (2) 117 ' P H Y S I C A L E X A M I N A T I O N D O C T O R ' S N A M E : D A T E O F E X A M I N A T I O N : F I L E No. P A T I E N T ' S N A M E : A P P E A R A N C E : H E A D : E Y E S : E A R S : N O S E : T H R O A T : M O U T H : N E C K : Shape Vision Hearing Septum Tonsils Tongue Teeth Thyroid Glands D A T E O F B I R T H : Hair Size Pupils Canals Turbinates Enlarged Protrudes Enamel Enlarged Enlarged H E I G H T : W E I G H T : Eyes • Injuries Fundi Drums Discharge ' Diseased Gums R E S P I R A T O R Y S Y S T E M : C I R C U L A T O R Y S Y S T E M : A B D O M E N : P R E L I M I N A R Y N E R V O U S S Y S T E M : G A I T A N D P O S T U R E : S K I N : E X T R E M I T I E S : G E N I T O U R I N A R Y : R E M A R K S : N U R S E ' S R E M A R K S : F 181-40—500-1251-2178 Inspection Palpation Percussion Auscultation Inspection Palpation Percussion Auscultation Pulse rate Inspection Tenderness Speech Motor Co-ordination Reflexes Babinski R. T . Hernia Rigidity Nerves Sensory Superficial Oppenheim B.P. U R I N A L Y S I S Col. Reaction Alb. Sug. S.G. Arteries Masses Tremors Deep Rhomberg 118 Appendix A (3) CHILD GUIDANCE CLINIC PLAYROOM OBSERVATIONS GENERAL: 1. Name of child, age and sex. Time of arrival, departure, and absences from playroom. 2. Names, sex and relationship of adults accompanying the child. Age, sex and relationship of other children in family party. Number and sex of other adults in playroom. Number, age and sex of other children in playroom. 3. Child's behaviour on arrival. How does he start to play? Describe play activities. How does he react to separation from parents? Other Children? How does he react to going home, etc.? Attitude of parent towards child and the child towards parents. The conversation of parent to child and the others waiting in playroom regarding the child. SPECIFIC: 1. Energy - Over or under-active? Impulsive? Mischievous? 2. Social Habits - How does he get along with children? With Adults? Is he shy? Polite? Seclusive? Need urging? Bold? Boisterous? Selfish? Shovr Off? Does he make a play for attention? Does he seem to prefer older or younger children, etc.? 3. Emotional Habits - Any evidence of instability? Easily moved to tears? Anger? Temper tantrums? Feelings easily hurt? Jealousy? etc.? 4. Work and Play Habits - Short span of interest and attention? Slovenly?1 Awkward? Neat? Dexterous? How does he react to suggestion and guidance, etc. 5. Physical Condition: Appear well, handicapped, etc. In what manner does he compensate any physical handicaps, etc.? 6. Other notes to suit peculiar situation. 119 Appendix A (li) CHILD GUIDANCE CLINIC at . . PSYCHOLOGIST'S REPORT Name Date , Address School . Birthdate Grade Birthplace Age . . . .Sex . . . . Problem . Tests Administered: Intelligence School Achievement . . . . . Telebinocular . . Personality . . . Vocational . Stanford Binet Form . . . . CA. M.A. I.Q. I 3 Wechsler Form . . . . Verb . . . . Perf. . . . , F.S Appearance: Handedness Test Behaviour: Summary of Phyeaologist's Findings: 120 Appendix B ( l ) SCATTER-DIAGRAM OF AGE. AND INTELLIGENCE SCORE OF C H I L D R E N F R O M V A N C O U V E R W H O W E R E R E F E R R E D P R I V A T E L Y T O T H E C H I L D - G U I D A N C E - C L I N I C D U R I N G 1 9 4 B A G E C L A S S - I N T E R V A L OF INTELLIGENCE-SCORES IN TOTAL YEARS 0-25 26-50 51-70 7 1 - 9 0 9I-//0 Ul-120 1. / 1 2 // / • 3 3. ' / // 1 4-4. / / z 5. / / / III III- 9 6 . // II 1 1 6 7 / //// I I ii 1 1°_ 8. / in 4 9 . 1 III II II 6 10. 1 II i 11. It 2 12. I i 2 13. // 1 3 1 4 / • ll I 4. 15 1 1 - I6. _ // 2 1 7 / _ 1 16. / J r ~ 111 " ~iu~ 9 TOTAL 3 2 0 12 1 5 /4 n 7 5 121 Appendix B (2) SCATTER-DIAGRAM OF AGE A N D INTELLIGENCE SCORE OF CHILDREN F R O M VANCOUVER WHO WERE REFERRED PRIVATELY TO THE CHILD-GUIDANCE-CLINIC DURING 1949 AGE CLASS - INTERVAL OF INTELIGENCE-SCORES IN YEARS 0-- 2 5 2 6 - 5 0 51-70 7 1 - 9 0 9\-\\0 \n-\2o 1 2 0 -TOTAL 1. / I 2 . / / / / 4 3 . /// /// / / 8 4 . /// / /// 7 5 . / / // / /// 8 6 . / // /// 6 7 . / / /// // / 8 8 . // // 7 9 . // // / 5 1 0 . / / //// / 7 1 1 II /II / 6 1 2 / I // ' 4 1 3 - // 2 1 4 I / ! 5 ' / 1/1/ 5 1 6 1 7 / / 1 8 / / / / 4 TOTAL 5 6 ia 3 3 8 / 4 8 4 122 A p p e n d i x B (.3) SCATTER-DIAGRAM O F A G E A N D INTELLIGENCE S C O R E O F C H I L D R E N F R O M V A N C O U V E R W H O W E R E R E F E R R E D P R I V A T E L Y T O T H E C H I L D - G U I D A N C L - C L I N I C D U R I N G 1950 AGE CLASS- INTERVAL OF INTELL IGENCE - S C O R E S T O T A L IN YEARS 0 - 2 5 2 6 - 5 / - 7 0 7 1 - 9 0 9 1 — lit 110- /2C 121-I . 2 3 . 4. s 6 7 8 9 10 II 12 13 14 f 5 16 17 18 / // // / // / / / / /// // /// / // / / / / / _/ ~//~ /// m // /// _ ^ / / / / // / / / / / m /// M /// i //// m / / " /// /// /// / /// / /// / / / / // / / / /_ //// 1/ f / / / / / / / 8 14 1 9 1 7 15 21 5 9 7 8 2 2 2 4, 2 / TOTAL I 1 0 18 3 0 3 7 i 2 . 4 . 141 Appendix G (1) Form I 123 BACKGROUND OF PARENTS I. Identifying Information 1, Age 3. Nationality 5. Grade Attainment 7. Number of, and 2. Birthplace 4. Date of Marriage 6. Religion place among siblings II. Economic Setting 1. Specific occupation of husband's father. 2. Husband's occupation, (own business) 3. Years of steady employment at above job. 4. Scale of job satisfaction: A B C D Husband and Only husband Neither wife satisfied satisfied satisfied No opinion 5. Present Housing: A B G D E Luxurious Very Comfortable Adequate Borderline Inadequate III. Psycho-Social Adjustment 1. Relationship to father: A Complete emancipa-tion B Almost com-plete eman-cipation C Occasional dependence D Considerable dependence E Pathological dependence • Relationship to mother: A B G D E 3. Relationship to other siblings: Felt a l l Other received Self receiv- Self received equally partial treat- ed partial adverse dis-treated ment treatment crimination 4. Group relationship: ( l i s t i f active member) (a) Church group (b) Education group (c) Interest group IV. Health 1. List major illnesses and major surgery. 2. Degree of limitation of disabling conditions or habits: Not at a l l Occasionally Low but A major steady drain factor Appendix G (2) Form 2, Inter-Parental Relationships1 1© Index of Agreement on Domestic Issues Occasion-Items Always ally Often Always Agree Disagree Disagree Disagree Handling Family- A B C D Finances (1) (10) (6) (4) Sharing Household E F G H Tasks (3) (7) (7) (3) Disciplining I J K L Children (1) (4) (7) (11) Sharing Interests M N- 0 P and Activities (4) (3) (7) (7) The number of scores for each rating are entered in brackets Appendix C (2) 125 Form 2. Inter-Parental Relationships * II. Family Relationships " 1« ' Marital Relationship - Acceptance and consideration of spouse's individual needs. (a) Husband A (0) Complete acceptance high capa-city to give B (4) Almost always accepting; good capacity to give C (10) Sometimes unaccepting fair capa-city go give D (11) Often unac-cepting; l i t -tle capacity to give E (8) No accept-ance; no capacity to give (b) Wife A (0) B (3) C (12) D (21) E (1) 2. Desire and active planning for child. (a) By Husband A (0) r B (4) C (11) D (7) E (5) Complete Infrequent Occasional Frequent Overt emotional ambivalent ambivalent ambivalent rejection and physical feelings; feelings; feelings; of the preg-preparation good pre- fair pre- l i t t l e pre- nancy; no paration paration paration preparation (b) By wife A (0) B (15) G (15) D (9) E (9) 3« Parental concern over problem. (a) By husba A (0) High degree of realistic concern; found Clinic nd B (6) Fairly real-i s t i c concern; actively seek help G (9) Concern but U t t l e dir-ection; de-sire help D (6) Concern no direction ambivalent towards help , E (14) No concern; no accept-ance of help (b) By wife A (0) B (S) G (9) D (14) E (0) 4e Parental recognition of relation of total environment to problem. (a) By husband A (0) B (5) G (6) D (11) E (9) Full Some Little No Refusal to recognition recognition recognition recognition recognize' (b) By wife A (0) B (7) C (15) B (5) E (2) The number of scores for each rating are entered in brackets. Form 3. CHILD-PARENT RELATIONSHIPS C D E A B Little active participation (3) no active participation (22) By husband. l.(a) Physical Care constant active participation from birth (0) constant but limited active participation after first month (0) sporadic active participation af-ter first month (4) 2.(a) Love & Secur-i t y constant gentle handling and vocaliz-ed affection (0) frequent gentle • handling and vocal-ized affection (3) inconsistent hand-ling; occasional vocalized affection (10) occasional re-jecting; l i t t l e vocalized af- . fection (9) rejecting hand-ling; depreca-tory remarks (6) 3 .U) Stimulation to Learn patient stimulation in accord with capa-cities (o) sporadic patient stimulation; fair thought as to capa-city (3) occasionally im* patient stimulation; l i t t l e thought for capacity (3) need to have child perform beyond capaci-ties (18) no stimulation (5) LAa.) Resoect for Child as a Person respects as an individual (1) some respect (12) slight tendency to control (13) marked tendency to control try to completely control by wife l.(b) Physical Care satisfactory in every way; feedings anticipated (1) feeds child adequate-ly; child occasion-ally has to wait (12) feeds child adequa-tely; tendency to follow schedule (13) occasional in-adequate feed-ing; rigid schedule (9) inadequate feeding or deprivation; rigid schedule (4) (1) (15) (10) 2«(b) Love and Se c u r e (0) (3) (19) 3.(b) Stimulation to Learn (0) (1) . (7) (2) Zt.(b) Identifica-tion with Child (1) (3) (2) (16) (3) The number of scores for each rating are entered in brackets. 127 Appendix D BIBLIOGRAPHY GENERAL REFERENCES Books Burgess, Ernest W. and Locke, Henry J, The Family. American Book Co.Ltd., New York, 1945. Friedlander, Kate, The Psycho-Analytical Approach to Juvenile Delin- quency. Routledge and Kegan Paul, Ltd., London, 1947. Harms, Ernest, ed., Handbook of Child Guidance. Child Can. Publica-tions, New York, 1947. Hamilton, Gordon, Theory and Practice of Social Case Work. Columbia University Press, New York, second revised edition, 1951. Towle, Charlotte, Common Human Needs. United States Gov. Printing Office, Washington, 1945. Witmer, Helen L., Psychiatric Clinics for Children. The Commonwealth Fund, New York, 1940. Articles Berkman, Tessie D., "Research i n Psychiatric Social Work", Journ. of  Psychiatric Social Work. Vol. XXItl, (1951) pp.S-15. Hunt, J. MeV., "Measuring Movement i n Casework", Journ. of Social  Casework. Vol.XXIX (Nov., 1948) PP. 343-51. SPECIFIC REFERENCES Books Bowlby, John, Forty-Four Juvenile Thievest Their Characters and  Home Life. Bailliere, Tendallr& Cox, London, 1947. Freud, Anna, War and Children. Medical War Books, New York, 1943. Glueck, Eleanor and Sheldon, Unraveling Juvenile Delinquency. Common-wealth Fund, New York, 1950. Hamilton, Gordon, Psychotherapy in Child Guidance. Columbia University Press, New York, 1947. Jewish Board of Guardians, Primary Behaviour Disorders - Two Case Studies. Family Service Assoc. of America, New York, 1945. 128 Appendix D BIBLIOGRAPHY Articles. Reports and Other Studies Gallagher James, J., "A Commentary on Research", Journ. of Social Casework. Vol. XXXIII:6 (1952) PP 255-257. "~ Lowrey, Lawson G., "Psychiatry for Children", American Journal of  Psychiatry. Nov., 1944, PP. 572-581. Maas, Henry S. and Vamon, Edith, "The Case Worker in Clinical and Sociopsychological Research", Social Service Review. Vol.XXIII:3, (1949), PP. 302-314. Mead, Margaret, "What: is Happening to the American Family", Journ. of Social Casework. Vol. XXVIII:9, (1947), PP. 323-330. Government of British Columbia, Annual Report of Mental Hospitals. King's Printer, Victoria, 1932-1951. Government of British Columbia, Annual Report of the Social Welfare  Branch. King's Printer, Victoria, 1947-1951. Roberts, Evelyn M., Mental Health Clinical Services. Master of Social Work Thesis, University of British Columbia, 1949. 

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