'• IIHHH I I ••■ ••••■•■•■■■■■■••■■«, •■>■■■■■■■■■•••■ • I ••■■■■■■■■■■■■•!• •■■(••«••*■■• II ( * t I ■•■ ■ ••*■■■• •■(■ ■■■■•■■••* . •«■>■' •■•■•• i(iMiiiiii(iiii|iiitiiitiiiuI|fl aUaaK al £*»a RaMia%aajSBa • • ••••••* i4aSi » ■ • ••■•• j • i ••«•••■ i •••••• aa ■ a aa a a a a ■ a aaaaaaa >■■> •■•■■itTitni* EMOTIONAL PROBLEMS associated with HANDICAPPING CONDITIONS -In CHILDREN *•■■■•■••>. ■•■■■*■■■■■■■■ {■■■■■■■•III • ■■•■■•■•■•■•■■■•■■•■a naaaaaaia •■■■ Hi • !■•• !•*•••' ■■■■■■■•■■■•■•■•■■•■■■a •••••••••••••■a •■■■■■■ •■■■■■■■•■•■■•■•■■•■■■a ■ iiiiiiiiiiiniiiiiiiii ■•••■■•■a •••••••••■■■•• • ••!•••••••• iiiiiiii in 'a iiiiiiiiiiiiiiiii iiiiiiiiimiiKii ia *■■■■■••■•■■ aaaa I I II !• Illllltlll a ■■■■■■•# a ••■■■■ a I ■ a a a • ■ a a a a a ■ a a a . aaaaa • • a a ■ • a a • • a #« ■ a • • • > ■ * • a a a* a • • ■ a ■ a a a • Mi l UilUiiii> aiaai > aaaaaaa aaaaa a aaaa a a ■•••■■ltl»A)(an&BMi|Bla»f (VuiA ••■■• -aaaaa :::::::::::::::c::::::::HiiS:{:*f«rT^:Jtrr: :::::!?!»:::::•:::::. IIIIIIIMIIIIII »»■ i"B ■■*■!« HI am— • — ■■■■ ••«» taaiaaa •••••••■■••••■•■•••••••••••••••••i*a a ■ ■■■■ • •■■■■•••■i iiiiiiiiimiiii ■ aaaa aaaaa ■■■■■• •■■■aaaa a » aaaaaaa ■•■■■■■ > •IIIMl II IIHIIIIIIIIIIIIIIIIIIIIM II - -• •••••III! ■•••■••••••••■••■I ■■■ ■■•••■■■■■■■■■■■■■•■••■■ ■■•■•II III II • aa iMiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiii a tail iiiiiiiniiiii iihh CHILDREN'S BUREAU PUBLICATION NO. 336 FEDERAL SECURITY AGENCY • Social Security Administration • Children's Bureau • 1952 CHILDREN'S BUREAU PUBLICATION NO. 336 This is one of a number of papers prepared at the request of the Technical Committee on Fact Finding of the Midcentury White House Conference on Children and Youth. Address inquiries to the National Midcentury Commit- tee for Children and Youth, 160 Broadway, New York 38, N. Y. These papers were re- viewed by the Committee for use in its work, although Conference procedures were not de- signed to provide for official approval. This report was prepared by Arthur Lesser, M. D., Chief, Program Planning Branch, Divi- sion of Health Services, Children's Bureau, from papers presented by Greta Bibring, M. D. ; Franklin M. Foote, M. D. ; Ben Gray ; William G. Hardy; Betty Huse, M. D. ; William G. Len- nox, M. D. ; Meyer A. Perlstein, M. D. ; Helen Ross; and Eunice Wilson. FEDERAL SECURITY AGENCY Social Security Administration • Children's Bureau • 1952 For sale by the Superintendent of Documents, U. S. Government Printing Office Washington 25, D. C. - Price 20 cents Digitized by the Internet Archive in 2012 with funding from University of Florida, George A. Smathers Libraries with support from LYRASIS and the Sloan Foundation http://www.archive.org/details/emotionalproblemOOunit contents Page Parent-child relationship 2 Reactions of the child who is handicapped 6 Special problems of the handicapped 10 Achieving independence 10 Achieving a feeling of adequacy 13 Adolescence and achieving a sense of identity 15 Reactions of society to the handicapped 17 EMOTIONAL PROBLEMS associated with HANDICAPPING CONDITIONS in CHILDHOOD AN UNDERSTANDING of the emotional problems which may be associated with handicapping conditions in childhood requires some knowledge of the fundamentals of the social and emotional growth and development of children, for the handicapped child is first a child and therefore becomes involved in the growth processes of all children. The fact that he is handicapped usually creates addi- tional difficulties in the growing up process, but no one is entirely free of these difficulties. How adequately these children are helped to grow up is of vital importance in their reaching the satisfactions of emo- tional maturity. There are many emotionally immature adults who are not physically handicapped and who exhibit the same kinds of reactions as the handicapped. We know that some children who have relatively minor physical defects may have more serious problems than others with major handicaps. The key to these situations, whether there is a physical handicap or not, lies essentially in the degree of security the child experiences in infancy and as he grows older and faces the progressive steps in emotional growth and de- velopment. For this reason, it cannot be said too often that the most important job parents have is to give their children the feeling that they are genuinely loved and wanted. All children need this feeling and handicapped children need it especially. 1 PARENT-CHILD RELATIONSHIP The relationship between the parents and the handicapped child is frequently just as healthy as that with a physically normal child; however, the presence of a handicapping condition always imposes a strain on the parent-child relationship. An understanding of this relationship is important, not only because having a handicapped or chronically sick child has a deep effect on the parent, but also because, in the final analysis, the understanding of the child and the attention given him have a profound influence on the kind of person he turns out to be. Acceptance of the handicap on a realistic basis can be, and often is, achieved. But parents (and the mother as central figure in all these problems has to be stressed) do not always respond rationally to the painful fact of having a handicapped or chronically sick child. They may react with a number of unconscious conflicts and emotions thus playing into the child's fantasies and fears. There is hardly a mother who does not respond with deep feelings of guilt and self-accusations to a congenital defect of the child, a birth injury or a chronic disease — even operation or accident leading to invalidism. Parents, in addition to their normal worry and com- passion for their handicapped or chronically ill child, frequently feel personally injured and attacked by fate, and are inclined to reject the child to some degree. This reaction and the resulting behavior might not be understood at all by the mother or a naive observer and nevertheless be of the greatest significance for the well-being of the child. Some mothers can hardly disguise their punishing attitude and act it out, often in the rigidity with which they hold their children to a restricting diet or painful medical schedule. Others, in their attempt to cope with these tendencies, lean over backwards to a point where, with the same rigidity, their lives are sacrificed completely, respond- ing to an unjustifiable degree to the slightest need or demand of the little patient and to the detriment also of other members of the family. Another group express this conflict by behaving as if they were cursed and are determined never to have another child. Some parents — without comprehending the meaning of their emotions — feel ashamed of the child as if the fact that they have a defective child reveals a shameful weakness of their own, thus being the counterparts of the neurotically ambitious mothers and fathers who drive their healthy children, and demand from them outstanding success in every area as a token of their own greatness. Other parents cannot bring them- selves to see what is apparent to everyone else and they deny that here is a permanent situation they need to learn to live with. Such parents may go from one physician to another, to various healing practitioners and quacks, seeking support in their evasion of the situa- tion and the result is usually a postponement of treatment. Studies of the elements that make for helpful parental attitudes show that these are simply the qualities usually found in well-adjusted, emotionally secure people. Parents whose attitudes toward their handicapped children are not constructive are found to be either poorly informed about disease and the needs of children or emo- tionally unstable or immature. Such parents are in need of help in order that they may have a better understanding of their children and their needs. Disturbances in the parent-child relationship may, under some circumstances, create physical disease as well as emotional problems. Examples of this are asthma and "hospitalism." It has been observed that there is a high degree of sensitivity in the allergic child of both a physiological and a psychological nature. The allergic child is found to be "touchy" in disposition, emotionally insecure, and given to anxiety, especially in relation to any change of condition in his environment. Given the constitutional sensitivity, the child is likely to react to certain emotional situations with an outbreak of physio- logical symptoms. To what extent the child "uses" the attack to express his emotions is a highly individual matter. In all the asthma cases studied at the Institute for Psychoanalysis in Chicago there was found to be a disturbance between mother and child at an early age, for example, an event threatening to the child's physical nearness to the mother such as an actual separation; or a psychological estrangement such as a change in mother's attitude with the birth of a new child. This fear of losing the mother is believed to be characteristic of children who are asthmatic. In the study it was found that the attack did not always occur when the patient was exposed to the allergens, and that conversely attacks would occur when the patient was thrown into an emotional conflict, even though the allergens were not present. The conclusion was that removal of the emotional conflict would help the child to be less sensitive to the allergens. In the children studied this proved to be true. . The mother is usually over-anxious and often contributes to the child's emotional upsets. She is frequently a hovering mother and at the same time her strength and patience have often been drawn upon so much, especially in the case of the asthmatic child, that she is both angry with the child for not improving and angry with herself because her own ministrations have had such poor result. This pro- duces a clinging on both sides. These observations, made by many allergists as well as psychiatrists, should be useful in planning medication for the child and in helping the mother to be more patient and less anxious. For the very little child, some psychiatrists advise that the scratch tests not be given in the presence of the mother, partly because the mother is likely to over react, and partly because the child may unconsciously hold the mother responsible for the hurt and feel more estranged from her. There is a considerable amount of "secondary gain" in allergic attacks. The allergic child gets a great deal of extra attention; he learns that attacks can completely dominate the family and that they are a way of escaping things he does not like. Some children may give up the asthma but develop other symptoms. For these reasons it is advantageous for the allergist to work with the psychiatrist in gaining an understanding of the child and his psychologic response to treatment. The word "hospitalism" was applied years ago in lieu of a more specific diagnostic term to infants in hospitals and institutions who did poorly without known cause and usually died. It was soon learned that the absence of "mothering" resulted in loss of appetite, diarrhea, and loss of interest, which usually was not the result of con- taminated milk or parenteral infections. It was noted that those babies who were the pets of the nurses or attendants got along much better than the others. Recognition of the basis of "hospitalism," the need of infants for the mother or a mother figure, has resulted in a great reduction in the number of infants cared for in institutions and the provision of home care whenever possible, foster home care, and mothering in hospitals by nurses and attendants. The prevalence of "hospitalism" a generation or more ago and its revival in Europe during the last war when children were evacuated from large cities serves to emphasize the traumatic effects upon young children of long separation from the parents, of which "hospitalism" is the extreme example among infants. It is important to consider this since children frequently need to be taken to a hospital or con- valescent home. Separation from the parents may be very traumatic for the pre- school child and may seriously interfere with his ability to form satis- factory emotional relationships with people. Infants and preschool children need their mothers, or a mother substitute who should be one person and not a succession of people. The infant under 6 months, since he has not yet identified his mother, adapts himself much more readily to a mother substitute than does the older child, and such attachments do take place with older children under good circum- stances. If a child under 6 years needs hospital care, the care should be given in small units so that a mother figure can be provided. Insti- tutional care, except for necessary brief periods of acute illness, is definitely undesirable for young children. When young children are kept too long in institutions or have a succession of mothers, they often revert to infantile habits — bed wetting, nightmares, mutism, failure to respond, failure to smile, etc. — and their mental and emo- tional growth is seriously delayed. Separation is usually less traumatic for the child from 6 years to adolescence, but may be serious for some children of this age. Usually at this time, the mental horizon is broader and the child has an increasing capacity to do things for himself. Because of the im- portance to the young child of the family relationship, particularly with the mother, every effort should be made to maintain this relation- ship. The implications of separation for the adolescent are different and group care is usually a satisfactory situation for him, as he is already beginning to form attachments outside the family and seeking independence from his parents. In recent years we have seen an increasing appreciation of the fun- damental emotional needs of children and understanding of their reactions to separation from their parents. Some hospitals are per- mitting participation by mothers in the care of young children, pedi- atric units in new hospitals tend to be smaller, a few hospitals permit the mother to feed her child with food brought from home, the availa- bility of antibiotics is relaxing the fear of cross infections and liberal- izing visiting, a few home care demonstrations have been started and programs are demonstrating that children who are blind or handi- capped by hearing loss can make excellent progress without neces- sarily being segregated in institutions. 954227°— 52- REACTIONS OF THE CHILD WHO IS HANDICAPPED The problem of disability and defectiveness exists in its funda- mental form as an ever-present concern in all of us, as a reaction to illness, accidents, operations, or shortcomings in our appearance and performance. Knowledge of these general psychological problems should be the background from which we proceed to an understanding of the specific problems of handicapped children. What are the basic concepts centering around disease, accident, and disability? We can observe that our own body, like our own per- sonality, in its integrity is the center of our normal interest. Usually this is a well-balanced, unobtrusive interest but inner or outer events may intensify it or upset the equilibrium. For instance, a normal, well-established interest in ourselves can be shifted to other objects in case of strong attachment to them, so that the well-being of a beloved object seems more important to us than our own health or life. Not only love for a person, but devotion to our work or to a cause, a movement, an idea, may bring about this shift of interest from ourselves to something outside of us, to such a point that it can diminish our usual concern for self-preservation or self-esteem. On the other hand, the normal balance can be upset in the opposite direc- tion so that interest is centered on one's own personality and body to such an extent that it excludes even the usual contact with the world or interest in the environment. This happens when a danger from outside threatens our security and integrity, especially if we are troubled by inner conflicts which demand the normal body and its normal functioning as reassurances against anxieties of all kinds. Whatever the reality of a disease and its cause may be, the child is usually inclined to link it up with these inner apprehensions. He interprets it as punishment for whatever he has learned to call bad in his thoughts and deeds; as the result of rejection or lack of love from his parents ; as a sign of his being either an outcast or a chosen one ; or as a debt owed him by his mother or the world, on which he can build his never-ending claims and demands. According to the different unconscious meanings that disease and handicap have for the child, we find different reactions and habitual attitudes which may interfere with the necessary management or some- times even lead to severe personality distortions. In addition to these unconscious problems we have to remember that there are specific frustrations related to different age groups. For the adolescent patient, interference with the fulfillment of his interests and realization of his talents, as well as disfiguration, have a much greater effect upon the feeling of security and courage than for the younger child. On the other hand, the problem of hospitali- zation and separation from the family or dietary measures and re- striction of mobility have a much greater impact on the younger child. Our task is to understand the signs and symptoms of these various conflicts, to help the child to cope with them, and, under favorable conditions, to eliminate their permanent psychological effect. The reactions of children who are not well adjusted to their handi- cap vary. They are usually found to be mixed or overlapping and only rarely exist in a clear-cut form. Some children, having a deep conviction that they are victims of injustice and that lack of devotion or care must be the cause of the condition, may express withdrawal, hostility, and, often, aggression to the more fortunate world. As a rule, the family approaches this type of child with great warmth but feels hurt and helpless when friendliness is answered with hostility and disdain. Quiet equanim- ity and patience, with unobtrusive signs of friendliness and under- standing, deprive the child of the arena of his battle and of the oppo- nents whom he wants compulsively to punish. At the same time, the family can demonstrate by steadiness that true devotion does exist and can lead the child to a new experience and strong attachment to the helpful person. There are other children whose behavior is proud and rather rebel- lious and who reject pity and excessive demonstrations of kindness. They (more often boys than girls) ask for respect and are rather aloof. The only effective way to be of help is to accept the patient on his conditions. The necessary demands for diet, physiotherapy, and adjustment to regulations must never be made in a patronizing, even though kindly, form. Instead we must emphasize our apprecia- tion of his courage, patience, reasoning power, strength, and so forth. While we acknowledge these procedures as difficult we stress the conviction that the patient can fulfill the requirements better than anybody else. Other children remain, or become, dependent and demanding. They have an excessive need for signs of affection, care, and attention. It is difficult for them to make independent moves toward progress and, in fact, being helpless seems to assure them of the great amount of consideration they want. The demands on the family may become burdensome and may provoke irritability and defensiveness in those providing care; For some of these children (particularly adolescent girls) the disability and restrictions may appear to be desirable gratifications and the prospect of getting well may not be welcome. It is undesirable with such patients to suggest that they could get better if they wanted to, since this usually results in an increase in expressions of dependency. The preferable approach is to combine a greater amount of attention and interest with a friendly but firm demand for the child's contributions to our effort. It is a process of give and take in which we try to teach the child that certain re- strictions on his demands are unavoidable, not because of our lack of love but because of a reality situation which makes innumerable de- mands upon all of us. At the same time we have to direct the child into a new area of relationship which heretofore he has scarcely touched, because of his personality structure. Such children usually have not discovered that striving and achievement are followed by admiration and affection, and feel that only helplessness generates kindliness. Work with these children is slow and cautious. There are some children, just as there are some adults, who feel that illness is punishment for acts they have been taught to regard as bad. Their guilt feelings cause the illness to be filled with dis- proportionate anxieties and threatening connotations. Often there may result resistance to new methods of treatment and the necessity for an operation may cause great fear. In order to cope with his deep anxieties, special efforts have to be made to reassure the child and give him the feeling of our protective strength. For any kind of patient of whatever age, an essential part of the doctor's role is to re- new in him the old, childhood feeling that he has nothing to fear if the parents stand behind him, but in no other type of patient is this conviction of greater importance than in those with anxieties and guilt feelings. Furthermore, it is advisable to introduce simple and comprehensible explanations and information about pending medical procedures in order to allay the devious and always exaggerated neu- rotic anxieties and replace them with reality factors which almost never have as threatening connotations as the imagined ones. We are all aware of patients who feel that their situation is becom- ing hopeless. They feel like giving up altogether and food and medi- cation may be refused. Such a situation is most unfavorable since the wish to cooperate, the desire and striving for improvement, is neces- sary for recovery and adjustment. A large amount of attention, stimulation, and care from the nursing person, and if possible also 8 from other members of the environment, is usually necessary to re- verse this condition and attach the child to the people around him so that his interest in them is awakened and he thus accepts himself again. Reactions such as these are considered by some to be more prevalent among children with the more serious handicaps. It has been observed however that the basis for the reaction lies in the individual personality rather than in the degree of handicap. In fact, some individuals with- out obvious handicaps suffer more than those for whom a visibly handicapping condition offers a measure of protection to the ego. Nor are such behavior reactions characteristic of the handicapped. They are found in all walks of life, among the physically healthy as well as the sick and disabled. SPECIAL PROBLEMS OF THE HANDICAPPED All people have problems centered about gaining independence, overcoming feelings of inadequacy, and establishing themselves as accepted individuals^ These problems are apt to be aggravated among the handicapped. Achieving independence Dependency at different periods in varying degrees is a normal condition for all of us. A handicapped child may have increased dependency needs, or he may have increased dependency imposed upon him by overprotection. Strains within the family and problems in relations with the siblings may also contribute to prolonging the dependency period. Infants, particularly if their handicap is congenital, are likely to show retardation in social and emotional development. Handicaps in infants and young children usually create prolonged dependency needs since the learning rate as well as the ability to do things is affected. Such dependency is found among children who are blind from infancy with a resulting tendency on the part of the parents to do so much for the child that he does not develop the skills needed in a normal environment. This in turn makes it difficult for him to develop emotional maturity. Too often we teiKLto assume that a blind person is dependent on us for assistance, when in fact he is not and actually rejects efforts which tend to make him dependent. For the young child who is handicapped by cerebral palsy the neuromuscular dysfunction itself prolongs the period of infantile dependency. While a normal baby usually holds his head erect at 3 to 4 months, the spastic child's environment continues to be restricted 10 because he is delayed in this by the spasticity of the neck muscles. Similarly, the ability to grasp an object voluntarily at 4 months, a step in normal decrease in infantile dependency, is delayed in spas- ticity. The spastic stretch reflex causes an opposing muscular reaction to voluntary efforts which limits the child's ability to learn to walk and do things for himself and may even produce fear of voluntary efforts. In contrast with the spastic, the athetoid does not fear voluntary effort since he is moving anyway, has more opportunity for achieving purposeful movement, and therefore is less apt to have continuing frustrations. Because the cortex is undamaged, in contrast with the spastic, mental deficiency is unusual. Like the spastic child, however, there is restriction in normal experience. He is disabled because of involuntary movements and the necessity of maintaining his balance. The disorders of speech and hearing, common in cerebral palsy, further retard the process of maturation. The result is that by the age of 2 years, when the normal child through his experiences has been able to accomplish satisfying achievements, the child with mod- erate to severe cerebral palsy, even if he has normal intelligence, is still excessively dependent and socially retarded. Another type of handicap which prolongs the normal period of dependency is any disorder of communication which occurs early in life. Speech and hearing are the basic elements of communication and of language ; together with their derivative forms of reading and writing, they provide the foundations for much of human behavior. Communication is not a simple process, however. The learning, the perceiving and the production of language involve a complex rela- tionship among auditory, visual, and muscular stimuli and responses, and between peripheral and central nervous systems. Inasmuch as language is chiefly learned through the hearing mechanism by imita- tion, the child learns to speak not only because but as he hears. Communication begins very early in infancy, as the baby reacts to the requirements for food and creature comfort. Soon he begins to babble, a stage of development which is probably a pleasurable com- bination of muscular and auditory stimulation and response. Toward the end of the first year and through the second year, the baby ex- periments freely with sounds, and some combinations begin to reflect the rhythm, form and structure of the speech that he hears. This is the onset of language. In the third year the child usually becomes sharply aware of himself as a being different from others and takes enormous strides in relating this self to the world. His use of language takes a great spurt and moves at an increasing rate until, by the age of 8 or 9, the basic language pattern is fairly well established and is an important aspect of behavior and adjustment. This pattern of language does not develop unaided if there is a 11 considerable hearing impairment. Whether or not special preschool facilities are available, the mother has the major role in helping the •young child develop language. This requires persistent effort, lots of attention, encouragement and a centering of her teaching around the child's needs and interests. First the diagnostic picture must be clarified, in both physical and development terms, and appropriate medical treatment carried out. Then it is the business of the audio- logic center to guide and teach parents the needs of the child ; to work out a program designed to stimulate language and behavioral develop- ment; to study and carry through the child's needs in amplification (whether an individual hearing aid or a binaural, training amplifier) and in the training of residual auditory pathways; to introduce parents to the facts of speech (lip) reading as a concomitant or adjunct to the use of residual hearing; and to stimulate the development of normal conversational habits. This is done on an outpatient basis, and frequently involves multiple consultation and the use of whatever local facilities are available. The key to audiologic work with pre- school children — the age of 18 to 24 months is the time to begin — is parental insight and understanding. Dependency is also fostered by acute or prolonged illness. Any sick individual tends to return, at least temporarily, to earlier patterns and some of these, such as enuresis, thumb-sucking, feeding problems, more intense dependence on the mother, may recur. If previous levels of development were more satisfactory than the present, or if they were not very well dealt with originally, it may be difficult for the child to move away from them again. Sometimes, on the other hand, a successful encounter with a physical illness seems to precede a real spurt of emotional development. Return to earlier periods of dependency is very likely in a pro- longed illness like rheumatic fever. It will help if the child is given an opportunity to talk about his feelings and to tell as much as he can about what the experience means to him. Allowing him to take some active part in managing the situation is usually helpful : the small child may be given a chance to choose whether he gets his medi- cine straight or in applesauce and to make similar decisions within the limits of the medical treatment that is required; an older child can be given a more decisive role. The child's regressive behavior at the onset of illness should be accepted, but he should be helped to regain his former developmental level as soon as feasible through en- couragement and increasing responsibility. The limits of his physical restrictions should be clear to him. He should be treated consistently. He should be prepared for new experiences, as far as possible, by understandable and realistic explanations. He should be given op- portunities for play, schooling, and creative activities consistent with his physical status and his age. 12 The parents should have a careful and realistic discussion of the medical picture and prognosis. They should be allowed to talk about their worries, and they should be helped to see whether they are being unrealistically indulgent or restrictive. They should be helped to understand what the experience means to their child and how they can best give him support. Achieving a feeling of adequacy Beginning in the early preschool years, we become aware of our- selves as individuals and develop a growing consciousness of how we are different from others. Initially, the parents seem to be able to do everything, and the young child in his dependence upon them feels inferior in comparison with them. Later, as he plays with other children, he becomes aware of differences in ability in relation to them. If there are younger children in the family or among his playmates, his superior abilities afford him some compensation. The fantasies of children, such as their identification with cowboys and Superman are normal mechanisms in childhood for overcoming the feeling of inferiority. In the process of growing up, most people are able to make adjustments in relating themselves to other people, although there may be temporary crises such as rivalry for promotions, love, and so forth. The problem of gaining a feeling of adequacy exists in all of us since we are all inferior to certain powers, whether in man or nature. We are more aware of our inferiority at some times than at others. At such times, we are overly sensitive and feel dissatisfied with our lot, inadequate and discouraged. These attitudes have their roots in our primitive feelings of envy, hate, and guilt. Although the feeling of inferiority exists in all of us, it is apt to be much more acute in children who have physical handicaps and present obvious defects. The child with a crippled leg soon becomes aware of his inability to run and play with his age-mates. The disappoint- ment of the parents in the child heightens his sense of inferiority. If he is disfigured, as by a cleft palate and lip and "talks funny," he is apt not to be ignored by other children but to be taunted by them and to be the recipient of cruel pranks. When these handicaps are obvious there is little protection from episodes which give great mental pain. Even should the adults in the neighborhood be enlightened, there is always the problem of the attitudes of other children. Where the handicap is not severely disabling or disfiguring most children of preschool and school years are able to make a good adjust- ment and to be readily accepted. The wearing of glasses is today so common that other children do not regard it as different. The young 13 wearer of a leg brace often attracts attention of other children that is not unwelcome and after the novelty in the classroom wears off he is not regarded as unusual. Young children take to wearing hearing aids with considerable satisfaction as a new world of hearing is opened to them. Whether or not the handicapped child can also participate freely in games with others is a major question for him. Even with acceptance some children may use the wearing of glasses or a brace as a protective device to avoid the rough and tumble of childhood play. This, however, usually has its roots in a lack of security and is not attributable to the handicap itself which is used as a protection. When children are frustrated, as by a handicap, their behavior may not be socially acceptable. Behavior which is expected of all young children, but which they learn to control as they are influenced by parental approval and disapproval and by accepted social stand- ards, may persist beyond the period where it is expected. Or the school child or adolescent who acquires a handicap may revert or regress to earlier behavior patterns. Such conduct may include ex- cessive aggressiveness, lying, stealing, anxiety, excessive demands, withdrawal, and so on. This may be true, for example, of cross-eyed children who may suffer the gibes of their school-mates and either retreat within themselves or become cocky, swaggering bullies. Treat- ment where feasible, as in strabismus, may mean the difference be- tween an adjusted child and a behavior problem. There are mechanisms in our physiology and psychology which attempt to make up for some deficiencies. All of us are able to read lips to a limited degree, but this potentiality is much more fully real- ized by hard of hearing people who can often acquire remarkable proficiency in lip reading. The sense of touch can be developed to an extraordinary degree in blind people and used in reading or in identi- fying objects. Such achievements tend to make up for these percep- tional deficiencies. Sometimes the method of compensating creates a special problem. Thus the young child w T ho hears poorly or not at all does not develop language unaided. He will make his needs known by various signs. This is regarded by some as the "natural" language of the deaf and speech as the "second" language. As a result, sign language and finger spelling are taught. But this is conspicuous and accentuates the dif- ferences between the hard of hearing from the normally hearing child. Today there is increasing emphasis on oral communication which utilizes the maximum development of skill in lip reading (or speech reading, to use the better term) , hearing aids, auditory training, and the teaching of speech. Opponents of this method question its general applicability and ask whether it may not engender feelings of anxiety and inferiority among children who have difficulty in learning speech. Judging from the accomplishments of the past few years, there is 14 little reason to think of speech as a '"second language"' superimposed on a "basic language" of sign and gesture to the detriment of the child. It is most important to take advantage of the child's language potential which develops rapidly in the preschool years, and not postpone ther- apy until the school years. But if the impairment is diagnosed early and clinical and guided parental work is begun by the age of 2 or 3, the language of signs need not develop. The idea that sign-language or manual-language is the "natural" language of the child with pro- found hearing impairment can be maintained only in spite of — not because of — known facts of infant and childhood behavior, the neuro- physiology of the association centers in the brain, and the use of com- pensatory adjuncts to the impaired hearing mechanism in early linguistic and behavioral training. This has been demonstrated by the accomplishment of many children. It is no rare thing nowadays for a child of 4, with a severe hearing impairment to be well on the way to a good vocabulary and a happy adjustment to the family and the world around him and to be able at the normal period to enter a regular school with or without the need for special adjunctive edu- cation. Not all handicaps lend themselves to such a specific mechanism of compensation^ Some people are helped more generally by developing interests or occupations which are within their capabilities. Some people pursue hobbies such as reading, gardening, modeling, and paint- ing. Others find considerable satisfaction in their religion and in work with organizations. There is, after all, present in all of us the need for achieving a balance in living that will enable us to make a satisfactory adjustment to our problems and the environment. Adolescence and achieving a sense of identity Adolescence, with its own peculiar and difficult problems, is prob- ably the most painful period in growing up. This period involves the biologic development of sexual maturity, the further progression of the process of mental and emotional growth, and the difficulties in reconciling the biologic and cultural demands upon the individual. The adolescent is neither adult nor child although he has something of each, and in addition the characteristics of this period. At this time, the adolescent is trying to break away from close familial depend- ence and establish his own identity and his role in life as an adult. With individuals of this age, group activities become an important part of life and are being successfully utilized in the treatment of handicapped adolescents. Physical illness at this time has a somewhat different significance 15 than it has earlier. The adolescent may react to it as though it were a threat to his prestige. He may, therefore, fear illness and deny its reality to himself and reject treatment. The considerable concern for his body may exaggerate the threat to it of even a minor illness. Many of the psychological and psychosomatic difficulties in adolescence have their roots in infancy and childhood ; the stresses of adolescence bring- ing them to the fore. Adolescents who are handicapped are able to adjust well to this difficult period when they have been fully accepted by their parents in previous years. At this time, female attractiveness is of the greatest significance to the girl, and masculine strength and independence to the boy. The wearing of a leg brace which may not have bothered the 8-year-old girl much may deeply affect the adolescent. A study of the acceptance of hearing aids revealed that girls who used them satisfactorily in the school years began to refuse to wear them in adolescence, with result- ing increase in problems due to difficulties in communication. Even though the earpiece can be concealed, the presence of the battery on the chest seemed to increase their sensitivity regarding the developing breasts. Surgery, in this period, particularly if mutilating, has a more tragic significance than at any other time. Furthermore, it increases the primitive fear of mutilation which exists in all of us and may be inter- preted as punishment for early impulses that are regarded as bad. A boy of 16 denied to himself for over a year the existence of a sarcoma of the leg, believing it to be simply a football injury. Even in the hospital, he showed no reaction to the decision to amputate the limb. This was a pathological attempt to protect himself from his fear of a future in which his ideal of manliness — to be the captain of the football team — was threatened. Through psychotherapy it was possible to help this boy face the reality and at the same time see that he could still fulfill his role as a man. Regular contact and conversations during this therapy with a successful war veteran who had lost both legs in the service was a great help to the boy. In this way advantage is taken of the fact that adolescence is a period of attachments to ideal adult figures outside the family often amounting to hero worship. 16 REACTIONS OF SOCIETY TO THE HANDICAPPED The reactions of the community toward the handicapped have under- gone considerable changes in the past generation. Ridicule through the application of nicknames to individuals on the basis of their handi- caps has markedly declined. The work of many individuals and public and voluntary organizations has contributed a great deal to the enlightenment of the public and toward an attitude of sympathetic understanding for the needs of the handicapped and the contribution they are making to society. The community's attitude toward some handicaps is frequently no more rational than that of some parents. A feeling of curiosity is, of course, common. Pity is so excessive, on the part of some people, as to be comparable to maternal over-protection. Such over-solicitous- ness represents efforts to overcome a deep-seated rejection of the handi- capped and is an attempt to make up for unconscious hostility, to appease one's conscience. Many people are uneasy when they are with handicapped people. This may be because they have fears about things which are different and poorly understood ; or it may be because they are self-conscious and uncertain how to behave without being patronizing or unnatural. Disfigurements, such as cleft palate and lip, burn scars and extensive facial hemangiomas seem to create feelings of revulsion in some people. They may, as a result, try to ignore the handicapped altogether and have nothing to do with them. Sometimes a handicapping condition has a stigma attached to it. From antiquity convulsive seizures have been associated with posses- sion by devils and even though not many people still believe this, there seems to be something about the seizure in a normal appearing person which is deeply repeilant. Even though therapy is effective in about 80 percent of the patients, the general public and professional groups are not greatly interested in the problems presented by this illness and comparatively few children have been able to obtain the treatment they need. The situation is further complicated by a general belief 17 that seizures are evidence of a tainted family stock and that repeated convulsions inevitably lead to mental deterioration. Thus the tragedy for the average epileptic child lies principally in the needless severe restrictions which society places upon him. The stigma generally attached to epilepsy and the poor utilization of pres- ent knowledge of the disease have resulted in what appears to be a conspiracy against him. Dr. Leo Kanner has furnished a most en- lightening statement about this frustration: The epileptic person, struggling for a place in his community, finds himself constantly and unremittingly in a position which does not differ essentially from Peer Gynt's allegorical dilemma. Wherever he turns, in whichever direction he tries to proceed, there stands menacingly and prohibitingly the massive Boyg of shoulder-shrugging public miscomprehension. The doors of opportunity are slammed in his face. He wishes to get an education and most schools either won't take him in or, if they have done so, send him away when his convulsive phenomena become a problem in the classroom. He wants to play with other children and he is chased off the playgrounds, often with deriding epithets ring- ing painfully in his ears. He may not go swimming, ride on a bicycle, or, when he gets older, drive an automobile. He wants a job and employers have no use for him ; they think of the laws which make them liable for any injury which a worker sustains while at work. He is excluded from all branches of military service. He finds himself a social outcast and an economic burden on his family or on the relief agencies. It is, therefore, not suprising that the epileptic child reacts, as he so often does, with behavior that is socially unacceptable. He may become overly aggressive and domineering or, if less assertive, may be overcome with shame and fear and withdraw from social contacts. This has been misconstrued so that it was formerly believed that there is an epileptic personality, specific for the disease and a part of it. This is not warranted since the behavior of the frustrated epileptic child is not specific but may result from frustrations from any cause. There is a steadily increasing number of children with treated epilepsy who are making a good adjustment and are socially accepted. The fact that in the past few months a large national magazine and a widely circulated Sunday newspaper supplement devoted articles to two such individuals indicates that it is still news to most people that a person with epilepsy can lead an average normal life. One of the great reasons for the neglect of cerebral palsy has been the attitude held by many people that a child with this affliction is evi- dence of a family taint. The proportion of broken homes is very high where cerebral palsied children exist, and quite often one family will blame the child's condition on some taint in the other family. Inasmuch as these children are avoided and held in derision by their playmates and by their neighbors, the parents frequently hide them to avoid embarrassment. If well to do, they may hire a caretaker for back-room custody. If not well to do, they may be glad to commit the child to an institution for the feebleminded regardless of his 18 mental potentialities. The recent activities of public and private organizations and the work of parents themselves are helping to over- come these attitudes of society. The attitude of the patient's family and of the community to his handicap are of extreme importance to the child's adjustment, regard- less of the degree of his handicap. Since both the child and his family react in a large measure to the handicap according to the expectations of the community, the child, his family and the community need re- orientation and education simultaneously, as to what can be expected of him. If the handicapped child is to have an adequate personality, he must be able to share in the lives of physically normal individuals. The social environment, therefore, should offer opportunities and services which recognize the needs of the handicapped child and yet not to a degree that interferes with the drive of the individual to de- velop from one emotional level to another. For this reason, we feel that services which are directed toward establishing healthy parental and community attitudes, and toward the social and emotional adjust- ment of the handicapped individual, should be given equal considera- tion with the medical, the education, and the training programs. Ob- jective evaluation of the total adjustment of the handicapped in view of their degree of disability, their type of education, and their segre- gation or nonsegregation with similarly handicapped individuals, are all of tremendous importance if the handicapped child is to accept his limitations, make full use of his assets, and relate to normal society in a mature and realistic way. Here are some Children's Bureau publications which discuss the problems of handicapped children. The Child With Cerebral Palsy — Folder 34 Prepared especially for parents of children with cerebral palsy, this book- let answers many of the questions parents have about this disease. The Child With Epilepsy— Folder 35 A general discussion of epilepsy and what can be done to help the child with epilepsy, written for parents. The Child Who Is Hard of Hearing— Folder 36 A parents' bulletin, this booklet tells how children can be helped to use the hearing ability they have and ways to adjust to the handicap of impaired hearing. Children With Impaired Hearing — An Audiologic Perspective — Publication 326. A discussion of the steps involved in handling children with impaired hearing. Emotional Problems Associated With Handicapping Conditions in Childhood — Publication 336. Designed to help professional workers understand the emotional problems handicapped children may have. Services for the Child Who Is Hard of Hearing — Publication 334 A guide to the development of programs to benefit children who do not hear well. Single copies of the above publications may be obtained free from the Children's Bureau, Federal Security Agency, Washington 25, D. C. 19 U. S. GOVERNMENT PRINTING OFFICE: 1952 UNIVERSITY OF FLORIDA 3 1262 08484 2227