Psychopathology of Childhood
reviewed by G. Gail Gardner - 1967
Dr. Gardner here reviews two landmark books in the history of psychopathology, particularly as that history involves young children. She emphasizes the fact that both Anna Freud and Jane Kessler take seriously the qualitative differences between children and adults. Like John Dewey some years ago, they refuse to see the child as a miniature adult and thus go far in clearing up some confusions respecting the diagnosis of pathological symptoms, the determination of "readiness" to enter school, and certain developmental problems in speech and language as they confront many teachers. Not only do these two books represent a breakthrough in psychological literature; they hold, Dr. Gardner suggests, exciting relevance for the work now done in schools.
Boys grow up to be men and girls to be women. Since the beginning of history, ritual has celebrated this fact and great thinkers have pondered its meaning. Plato asked what sorts of experiences were needed to mold a newborn child into this or that sort of adult. Sigmund Freud observed neurotic adults and tried to recapture their childhood memories in order to learn how they had become what they were. While these questions have obvious value, they imply that childhood is important only insofar as it is a necessary precursor of adulthood.
As Western man has become more efficient and prosperous and has not had to concentrate so much on sheer survival, he has been able to allow himself to perceive childhood as a source of pleasure in itself and children as having the right to enjoy life's early years. In short, it is no longer demanded so soon that one put away childish things and become a man.
These developments are clearly outlined in the history of psychopathology. In the beginning, disturbed or defective children were left in the wilderness to die, for it was a sure prediction that they would not grow into productive adults. Later, troubled children were accorded the same right of survival as troubled adults, and they were herded together into asylums and prisons. In many places today, this is the extent of the progress. Children and adults may be geographically separated in institutions, but the varieties of punishment and treatment are often similar.
Even in psychiatric institutions serving only children, the categories of diagnosis have typically been modelled after the existing adult nomenclatures. Sensing that something was wrong with this procedure, the category "adjustment reaction of childhood" has been added, but this communicates little more than the psychiatrist's reticence to brand a child mentally ill.
Now there is finally a significant step toward breaking away from the idea that children are no more than adults in miniature. Anna Freud and Jane Kessler both insist that there are qualitative as well as quantitative differences between children and adults, and they complement each other in providing detailed descriptions of normal and pathological development in childhood, methods of childhood psychodiagnosis, and implications for child-rearing, education, and child psychotherapy.
Both Freud and Kessler criticize the current tendency to diagnose children on the basis of their symptoms. They emphasize that childhood is a time of development and change and that behavior which is pathological at one age is quite normal at another. Thus in order to evaluate the meaning of a given symptom, one must relate it to developmental lines. For example, excessive fear of strangers is pathognomic in a six-year-old child, but when it occurs in a child of eight months, it indicates the development of healthy emotional attachments and discriminatory powers.
Even at a given age, the presence of a symptom does not, by itself, indicate pathology. If a six-year-old craves frequent physical contact during the day, this suggests that development toward independence has been blocked. But if the same child asks to be close to his mother when he is frightened, tired, or hurt, this is quite normal, and absence of this dependent behavior might be considered pathological.
Even when a child displays a clearly pathological symptom, both Freud and Kessler are emphatic in pointing out that few conclusions can be drawn concerning etiology and appropriate treatment. In one area of pathology after another, Kessler notes the inconclusive and contradictory research findings, and she points to the fallacious notion that children in a given pathological category, e.g., brain damage or underachievement, are necessarily a homogeneous group. The sources and expressions of these and other symptom patterns are manifold, and the terms alone have little meaning.
A major contribution in both books is that the authors not only define inadequacies in previous classification systems, but they also offer solutions. Freud introduces her concept of developmental lines, stating that childhood psychopathology is present either when there is excessive disharmony in different areas of development or when psychic development is slowed down, blocked, or reversed. Kessler agrees essentially with this position.
The concept of developmental lines is a solution which requires courage as well as experience and understanding of children. The process of delineating the many developmental lines and mastering their vicissitudes is much more taxing on both intellect and intuition than was mastery of the previous set of one-to-one formulae. Moreover, this shift of focus forces us to give up the tempting satisfaction and sense of immediate worth that results from being able to arrive at a diagnosis with speed and certainty and being able to prescribe treatment accordingly. But the courage required to confess ignorance and confusion can result in rewarding increments of our knowledge and ability to help children.
The following anecdote illustrates how a hasty conclusion concerning the meaning of a symptom may result in serious disservice to a child. A boy in kindergarten selected only black whenever he participated in activities involving a variety of colors. His teacher wondered if this behavior might be pathological and consulted the school psychologist. Inquiry revealed that there was no evidence of any depression or morbid preoccupation with hostile wishes, illness, death, and the like. When the psychologist asked the boy about the color black, he proudly described how his daddy wears black pants and works on the black choo-choo. For this child, black represented themes of admiration, affection, and achievement, while other colors had little or no personal significance.
Parenthetically, if Freud and Kessler took two steps foward in their discussion of childhood psychopathology, they may have taken one step backward with respect to adults. Both agree that, in adulthood, psycho diagnosis is directly related to symptom formation. This writer looks forward to the time when diagnosis of psychopathology in adults achieves the sophistication and apprecation of nuances that now begin to be enjoyed in the field of childhood psychopathology.
Turning now to the subject of education in early childhood, both Freud and Kessler make significant contributions in this area. Too often we believe educators who tell us that a child should enter kindergarten when he is ready to master kindergarten work and that readiness is achieved when the child is five years old. Then we are astonished at the numerous school failures of five-year-olds whose preparation for school consists largely of having patiently marked time for five years.
Freud and Kessler attempt to define more specifically the prerequisites for success in lie early school years. These include (1) capacity to feel relatively secure while separated from mother, (2) relative independence in areas of feeding and toilet training, (3) progress beyond the stage of perceiving other children as objects to be pushed around and toward the stage of perceiving children as helpmates and partners in their own right, (4) ability to use toys as a means to greater mastery and motility rather than simply as a substitute for mother, (5) capacity for delay, (6) capacity to tolerate frustration and disappointment, (7) capacity to reason, (8) capacity for pleasure in task completion and problem solving, (9) development of speech and verbal comprehension so that the child can understand another person's point of view, can communicate his own, and can revise and correct his misperceptions, (10) development of a relatively high degree of perceptual discrimination, (11) capacity for positive interpersonal relations and a desire to do something to please another person. It would seem that these items and others could be developed into a scale that could assess school readiness with greater accuracy than is permitted by the instruments currently available. Moreover, if a parent or preschool educator knows what is involved in having a child succeed in school, she can then formulate plans to help the child achieve these requisite goals.
Kessler's book is particularly relevant for educators, since it contains excellent chapters on learning disorders, mental subnormality, and developmental problems in speech and language. In a concluding chapter on prevention of emotional disorders, she gives educators a tantalizing bit of information concerning treatment priorities. She states that "treatment of phobias proceeds much more quickly and surely than that of learning disorders, for example. Some referrals should be put ahead of other cases which require more involved and prolonged treatment, but it is more common to refer the seriously and chronically disturbed children first, because of the reality problems they create and because there is no longer any question about the permanence of their problems" (p. 500).
This comment raises a number of issues. First it points to the need for more research to provide information about the appropriate techniques and relative speed with which a wide variety of disorders can be treated. Second, it raises the issue of the teacher's reticence to refer milder problems, lest she be considered foolish, and her need to satisfy society's demand that she, unlike any other professional, be able to cope with every situation that confronts her. Third, it makes one wonder why the teacher doesn't have adequate lines of communication with the school psychologist so that she can use the knowledge that does exist.
In sum, much remains to be accomplished in the area of childhood psychopathology, but the books by Freud and Kessler have at least marked the end of the beginning.