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Psychiatric perspectives on the socially-disadvantaged child
Psychiatric P e r s p e c t i v e s on the S o c i a l l y - D i s a d v a n t a g e d Chihl By
CARL P. MAL5IQUIST
i r l ~ H E A U T H O R HAS B E E N 1NIPRESSED by the expansion of writings, 1 . p a n e l s and pi-ojects on the socially d i s a d v a n t a g e d or culturally d e p r i v e d child. H e has also been impressed by the relative lack of contributions from psychiatrists to this problem. This has led him to (luestion if there m a y be anythil~g Specific which psychiatry call add from its perspective to the contributions from the fields of sociolog3,, social work; education and psychology. It is his belief that child psychiatrists in their work with children, adolescents, and families, as individuals and in family sessions, can make pertinent observations about these problems viewed from another v a n t a g e point. No specific a t t e m p t will be m a d e here to give a strict definition of "'lower class,'" which is not equivalent to the "'working class" group.' There is a d a n g e r in not having a specific definition, but since the ol)servations presented in this p a p e r are not part of a strictly controlled stu(ty, the generally 'ac~:epted m e a n i n g of this group as one on the p e r i p h e ~ ' of society in terms of occupa-. tion, education and residence will be used in referring to "'the lower class." T h e children and families in this discussion customarily live in the least suitable housing, have the lowest education, and are either u n e m p l o y e d or do the lowest paid menial and unskilled work from which they derive little satisfaction. One of the most striking impressions in dealing with culturally deprived children from the lower social classes is the (lii[qculty, in getting them and their parents to participate in p s y c h o t h e r a p y as it is traditionally practiced in child psyehiat~" clinics, with their middle class values, personnel, and communication pattenas: M a n y of the comments m a d e here are obviously generalizations to which exceptions can be made, but the purpose is, rather, to emphasize the most frequently seen trends. It is rare and almost u n k n o w n to have the parents from this social level seek out psychiatric aid on their own initiative. Clinicians customarily refer to such individuals as having "poor motivation" or being "poor treatment (:ases.'" Part of the hesitancy of these families for seeking treatment on their own is d u e to fear and misconceptions a b o u t the "headshrinker'" or "'psycho-doctor," which is aided and a b e t t e d by the mass media such as television. T h e portrayal of the psychiatrist's otfice on television, even when shown as a c o m m u n i t y facility, is often so physically attractive when compared to the rather deteriorated and barren facilities which make up m a n y c o m m u n i t y clinics, that parents lind little to identify with when they themselves come to a typical c o m m u n i t y facility. Such .u child and family are most commonly seen in the light of having b e i n g referred to a psychiatrist l)v another authority figure or group, such a s the school, a welfare agency or court service and typically present acting out and impulse-dvsconlrol problems. From the beginning, the relationship has a ditlrer 176 Co.~ll.lltillr;.~'SlVr: P.~Yt:lll,ln~'. Vol.. Iri. N o . . ! j (Jt'.~l~:). 1905
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e n t basis from that of tile m i d d l e or u p p e r m i d d l e class child a n d family; t h e latter are g e n e r a l l y r e f e r r e d b y t h e p a r e n t s , w h o a r e t h e m s e l v e s c o n c e r n e d a b o u t the b e h a v i o r m a n i f e s t e d b y t h e Child; o r b y a l o c a l p e d i a t r i c i a n . In those m o r e neurotic cases referred: b y t h e local p h y s i c i a n or the :Pediatric Clinic of a general l~ospita !, the family seeks i m l n e d i a t e results in t e r m s o f s y m p t o m a t i c treatment. This is not solely d u e t o lack of explanation of w h a t t h e r a p y entails, b u t r a t h e r seems to b e due, in some eases, to a failure of internalization a n d d e v e l o p m e n t of the ego's c a p a c i t y f o r d e l a y i n g gratification; v i e w e d from a f a m i l y perspective, the m i d d l e class V,k]:t~es of verbalization a n d p e r s e v e r a n c e for l o n g e r r a n g e goals s e c r e t 0 b e lacking. C o n c e p t s Such as "'good h e a l t h " a n d , p r e v e n t i o n " at t i m e s seem a h n o s t l u d i c r o u s l y lout o f context with these families. R i e s s m a n ' s strictures r e g a r d i n g t h e ~ i n a p p r o p r i a t e hess of m u c h of traditional p s y c l a o t h e r a p y S e e m s relevant. He: states, "Thougla p s y c h o a n a l y t i c t h e r a p y is b a s e d o n t h e a s s u m p t i o n s of a m i d d l e class, loveo r i e n t e d c h i l d h o o d p a t t e r n a n d its p r e s u m e d repetition in t h e t l l e r a p e u t i c situation, in the light of d i f f e r e n t emphasis on l o v e in a d i s a d v a n t a g e d •family, this m a y b e a m i s l e a d i n g assumption.• T h e f a c t t h a t this f a m i l y includes m a n y adults ( p a r e n t s u b s t i t t t t e s ) , a less intense r e l a t i o n s h i p of c h i l d to p a r e n t a n d m o r e sibling • c o n t a c t also has b e a r i n g o n psyclioanalytic c o n c e p t s o f t r e a t m e n t . - As w i t h ninny adults w h o c o m e to t h e t r e a t e r t o h a v e t h e i r p h y s i c a l pain r e m o v e d , in its most literal s e n s e , these p a r e n t s w a n t their o w n a n d their child's emotional pain r e m o v e d a n d that is t h e end of t r e a t ment. This is seen in t h e v a r i o u s m e d i c a l a n d p e d i a t r i c clinics a s a n e v e r e n d i n g search for the pill or d r u g w h i c h is g o i n g to solve their p r o b l e m s . T h e p a t t e r n of defenses u s e d b y low income p a t i e n t s a n d those in t h e m i d d l e class also seems to differ. In the former, t h e r e is a p r e d o m i n a n c e of externalization, projection, scapegoating, acting out,: denial, a n d s o m a t i z a t i o n ; t h e l a t t e r g r o u p uses m o r e isolation, ~reaction formation, a n d c o m p e n s a t i o n in their verbalized a n d introspective a p p r o a c h e s , z I n several of these~ c u l t u r a l l y d i s a d v a n t a g e d cases w h e r e t h e i n d i v i d u a l c h i l d s e e m s to h a v e t h e i n t e l l i g e n c e a n d v e r b a l a b i l i t y , c o u p l e d with t h e i n i t i a l t r a n s f e r e n c e reaction t o t h e therapist, c o n t i n u a n c e of t h e r a p y fol!ox~dng t h e i n i t i a l i m p r o v e m e n t , d e s p i t e p a r e n t a l approval given to t h e therapist, u s u a l l y d o e s n o t seem t o m a i n t a i n itself for a n y length of time. The. families p r e f e r t o r e t u r n on s e v e r a l occasions s c a t t e r e d over time inter~,als if the difficulty recurs in one form o r a n o t h e r , r a t h e r than obtain t h e " w o r k i n g t h r o u g h "~ t y p e of t r e a t m e n t whiela t h e coll e g e - e d u c a t e d family are" a w a r e o f a n d s e e k . Some h a v e s u g g e ~ e d t h a t a solution is t o "'reach out" t o t h e s e p e o p l e b y l s u c h w e l f a r e a p p r o a c h e s - a s e n v i r o n m e n t a l m a n i p u l a t i o n s , h o m e visits a n d n o t a c c e p t i n g t h e f a m i l y w i t h drawal: or resistance to f u r t h e r i n v o l v e m e n t . In ~ some cases this m a y h a v e some a d v a n t a g e if it is kept in m i n d t h a t the goal a n d n a t u r e of t h e psychot h e r a p e u t i c process have then b e e n q u i t e r a d i c a l l y a l t e r e d . A d o p t i o n of the t e c h n i q u e s of w e l f a r e d e p a r t m e n t s in d e a l i n g w i t h clients can o n l y b e called p s y c h m t n e t r e a t m e n t " b y w i d e n i n g t h e p h r a s e significantly b e y o n d its p r e s e n t connotation. This is n o t to be c o n s t r u e d as an a r g u m e n t against t h e use of these w o r k i n g p r o c e d u r e s b y a n y discipline i f t h e y are f o u n d v a l u a b l e ,
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CARL I'. ~XtAL.X,tQUIST
b u t to d e m o n s t r a t e t h e d i f f e r e n c e s e n t a i l e d f r o m t r a d i t i o n a l p s y c h o t h e r a p y in a clinical setting. ~,lary was a 5-year-old refezTed by a pediatrician because of worries and preoccupations about dying. This had affected her appetite, relations with other children, and kept her awake nights. After visits three times per week for three weeks, the overt problem had completely disappeared. The parents saw no need for any further appointments, and altlaough grateful for the therapeutic first-aid, which was given without f e e , they did not see any need for future sacrifices of bringing the girl back for even weekly visits. The problem of arranging for babysitters and paying them while getting to a clinic can be a major handicap to continuance of therapy with culturally disadvantaged families. I n some cases other comnnmity agencies can assist in these matters thereby making it possible for children and parents to attend the clinic. I n contrast to this e,mse was that of a similar presenting complaint in another 5'year-old girl, but with only one younger sibling as contrasted to the five siblings in the above ease. The parents here were college-educated a n d wanted to make sure their daughter, and themselves, participated so that the "conflicts were dealt with.'" T h e p r o b ! e m arises w i t h " s c h o o l p h o b i a s " i n m a n y cases. O n c e t h e c h i l d is b a c k i n s c h o o l , i t is difficult in m a n y cases f o r t h e r a p y t o c o n t i n u e for a n y l e n g t h o f t i m e . w i t h m a n y c h i l d r e n . "~Vith t h e c h i l d f r o m a l o w e r class socioe c o n o m i c s e t t i n g , i t is a h n o s t i m p o s s i b l e . A g a i n , it is t h e f o c u s i n g on tile i m m e d i a t e g o a l as tile u l t i m a t e s o l u t i o n . H,_;turning to school, h a s " ' r e m o v e d t h e pain.'" A g a i n , c e n t r a l , v a l u e s y s t e m s as w e l l as c o m m u n i c a t i o n b a r r i e r s a p p e a r to b e o p e r a t i n g . I n m a n y o f t h e s e c h i l d r e n , w e see w h a t is f r e q u e n t l y d i a g n o s e d as a "'dep r e s s i o n . " Yet, tile p r o b l e m b e c o m e s m o r e c o m p l e x w h e n a m o r e p r o l o n g e d i n v e s t i g a t i o n is m~?de of t h e c h i l d a n d f a m i l y . I t b e c o m e s v e r y difficult to f i n d specific p r e c i p i t a t i n g or r e a c t i v e f a c t o r s w h i c h h a v e b r o u g h t a b o u t s u c h f e e l i n g s . I n fact, t h e c o n c e r n a b o u t t h e d e p r e s s i o n h a s u s u a l l y n o t c o m e f r o m file p a r e n t s , b u t t e a c h e r s or p h y s i c i a n s w h o d e t e c t t h e a p a t h y a n d listlessness of t h e s e c h i l d r e n . T h e p e d i a t r i c i a n o f t e n w o n d e r s i f t h e r e is n o t a v i t a m i n or n u t r i t i o n a l d e f i c i e n c y p r o b l e m w h i c h is o c c a s i o n a l l y , b u t n o t c u s t o m a r i l y , f o u n d . As t h e h i s t o r y a n d c o u r s e u n f o l d , it b e c o m e s a p p a r e n t t h a t t h e p i c t u r e o f h e l p l e s s n e s s , h o p e l e s s n e s s , a n d l a c k o f i n t e r e s t a r e "'just t h e w a y t h e c h i l d is" a c c o r d i n g to t h e p,'u'ents. I n o t h e r w o r d s , tim c h i l d h a s b e e n t h i s w a y f o r m a n ) , y e a r s o v e r t h e c o u r s e o f his d e v e l o p m e n t , so t h a t o n l y a n " o u t s i d e r " w o n d e r s if s o m e t h i n g is w r o n g . T h e c h i l d will g o t h r o u g h t h e m e c h a n i c s of l e a r n i n g in t h a t he a t t e n d s school, b u t t h e c o g n i t i v e p r o c e s s d o e s n o t s e e m to p r o g r e s s m u c h b e y o n d t h e b a r e r u d i m e n t s . T h e h o m e s e e m s to b e a l m o s t u n i v e r s a l l y d e v o i d of r e a d i n g m a t t e r or a n y intell e c t u a l s t i m u l a t i o n . A l t h o u g h t h e tele~dsion is on c o n s t a n t l y , it is t u n e d to t h e s a m e h a c k n e y e d p r o g r a m s a n d r a r e l y to t h e f e w d o c u m e n t a r y or e d u c a tional p r o g r a m s that are available. T h e q u e s t i o n m a y b e a s k e d ff t h e s e c h i l d r e n a r e r e a l l y d e p r e s s e d in t h e clinical, p s y c h i a t r i c sense, or i f t h e y a r e m e r e l y r e v e a l i n g b e h a v i o r w h i c h fulfills t h e n o r m s for t h o s e f r o m this s o e i o - e e o n o m i c s t r a t u m . O n e w r i t e r llas t h u s r e f e r r e d to A D C p a r e n t s as h a v i n g a " ' p s e u d o - d e p r e s s i o n " s y n d r o m e .
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"VVe found a continuation of immobilization w i t h r e g a r d to effective activity,
isolation from social relationsllips, depressed appearance, :~weigllt loss, poor appetite and chronic health problems. ''* The - p s e u d o , : i s n o t t o distinguish affected poses, b u t to r a t h e r differentiate these behavioral manifestations from the specific clinica ! diagnosi s of depression. Tt!is c o n c e p t of pseud0idepression in adults from the A D C population a c t u a l l y describes a situational depression, not in the specific sense of a current failure, or a series of Critical:rebuffs, leading t o a fall in self-esteem, b u t in the b r o a d e r cultural sense. It iS felt that t h e s e people are reacting to t i l e situation of marginal living with a l l its implications, a n d living a hand-to-mouth existence in:a Consumption~oriented society whose values d e m a n d that they lmve money a n d s p e n d it on m a t e r i a l possessions. The situation t h e y / a r o r e a c t i n g t o is a feeling of being itlie v u l ' n e r a b l e pawns of c o m m u n i t y agencies and t h e p e o p l e who i a d m i n i s t e r these services; ` such as the welfare agencies, c o u n t y hospitals, social workers, doctors, courts, etc. T h i s viewpoint is still focused on the reactive :process, but in a broader sense; T h e implication is t h a t if these environmental factors were altered, tile clinical picture p r e s e n t e d b y these parents w 0 u i d : t h e n clmnge: This is a t p r e s e n t difficult to establish as a Xalid generalization. Tile.proposal is not to o p p o s e efforts to i m p r o v e t h e living conditions and respect long due to these p e o p l e , b u t t o question it? the : issue i s n o t m o r e complicated: Thus, when a few of t h e s e m o t h e r s are fortunate enougl a t o : r e m o v e themselves from the situation of A D C p a y m e n t s a n d t h e never-ending w a i t i n g line for community services, there does not frequently s e e m to b e a d r a m a t i c change w i t h i n the Family structure. Perhaps, the cultural and psyclxologieal forces h a v e produced ego alterations a n d family disorganizations t o an extent where the processes have effected sufficient injury So t h a t environmental and situational elmnges are no longer adequate to allow the ego of the child in these settings t o ;'catchup'" a n d cope with w h a t is a p p r o p r i a t e for the given stage o f de~,elopment. T h e obsern.ations m a d e above o n A D C families h a v e b e e n n o t e d by t h e a u t h o r in children of A D C m°thers, a n d those £-rornl the lower socio-economic groups. T h e same c o n t r o v e r s i a l issue a r i s e s as to whether altering, the: environment, after y e a r s of exposure t o the monotony a n d stultification o f t h e i r culturally deprived setting, w i t lead to the hoped-for enrichment and elinieal alteration in the majority: of e a s e s . A t this p o i n t , even~ if positiv0 proof i s lacking, it would s e e m praginatically justifiable to p r o c e e d as though tim result rnight be positive for the c h i l d r e n . Once engaged in t!aerapy, these c h i l d r e n often verbalize the same resentments a n d hostilities t o / a u t h o r i t y figures that their p a r e n t s do. C o u p l e d l w i t h this is the external a p a t l l y and indiffer~ence which i s so frequently observed, Except f o r t h o s e whose intelligence is in the moderately-retarded category or below, t h e r e rarely: seems t o be a quiescent acceptance o f their s t a t u s when their t r u s t w i t h the therapist has been :established; t h e whole ~problem of their difficulties regarding trust and mistrust with adults, peers and therapists is a major one with theist c[~ildren, as it seems to take them m u c h l o n g e r to work through these feelings with repetitive testings. This m a y b e due to their distrust not
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b e i n g solely, o r p o s s i b l y even p r i m a r i l y d u e to f a m i l i a l inte r a c tions b u t d u e to the suspicions of their cultural m i l i e u toward the "have's?" T h e o u t w a r d " m o l d i n g in" to the c u l t u r a l m i l i e u i s not as t r a n q u i l as m i g h t a ppe a r . T h e b e h a v i o r of these c h i l d r e n s e e m s to be the result of d e f e c t i v e ego d e v e l o p m e n t a n d organization d u e to a c u l m i n a t i o n of factors, suc h as maternal d e p r i v a t i o n , used in the b r o a d s e n s e of not o n l y death, desertion or a b a n d o n m e n t , b u t also tile p s y c h o l o g i c a l d e p r i v a t i o n that c o m e s from th e p r e s e n c e of a m o t h e r figure w h o is h e r s e l f i n a d e q u a t e , depressed, r e s e n t f u l a n d o v e r w h e l m e d w i t h e.xcessive pe r sona l a n d f a m i l y responsibilities. W h e n t h e s e f a m i l i e s arc s t u d i e d l o n g i t u d i n a l l y , the m o t h e r s t h e m s e l v e s f r e q u e n t l y h a v e e x p e r i e n c e d s i m i l a r Childhoods. Tile " a b s e n t father," or a series of diff e r e n t m a l e s w ho come a n d go out of the f a m i l y setting, also ma ke s a n e g a t i v e c o n t r i b u t i o n to ego d e v e l o p m e n t a n d i d e n t i t y models. W h e n some of th e s e c h i l d r e n b e g i n to s h o w b e h a v i o r p r o b l e m s ot an acting-out nature, a series of foster h o m e p l a c e m e n t s f r e q u e n t l y begins, t u r t h e r c o n t r i b u t i n g to th e f e e l i n g s o f a b a n d o n m e n t a n d de pr iva tion. This has b e e n r e f e r r e d to as the "'foster-home roulette" s y n d r o m e . In some of these ehillren, a true c l i n i c a l n e u r o t i c depression in the p s y c h i a t r i c sense m a y then exist w i t h feelings of a b a n d o n m e n t , worthlessness a n d self-deprecation. O n e 1 3 - y e a r - o l d boy, w h o h a d b e e n raised until 10 w i t h his m o t h e r a n d a series of m e n . w a s finally r e m o v e d on the g r o u n d s of his m o t h e r ' s i m m o r a l c o n d u c t . N o p s y c h i a tric i n v e s t i g a t i o n o f the b o y w a s n o t e d at the t i m e b u t school reports n o t e d h i m to be u n i n t e r e s t e d a n d b a r e l y p a s s i n ~ w o r k in 4 t h g r a d e . W h e n p l a c e d in foster homes, a c t i n g o u t b e h a v i o r b e g a n in a serious vein. w i t h thtr c u s t o m a r y p r o b a t i o n a n d a t t e n t i o n w h e n a p p r e h e n d e d . At 13, a serious s u i c i d e a t t e m p t was m a d e w h e n he took t w e n t y b a r b i t u r a t e t a b l e t s f r o m t h e t h c n - c u r r o n t foster m o t h e r . A f t e r c o i n i n g o u t o f his c o m a . h e v e r b a l i z e d i n t e n s e feelings of w o r t h l e s s n e s s , a n d e v e n t u a l l y m u c h a n g e r t o w a r d s his m o t h e r c o u p l e d w i t h a g r e a t n e e d to g o b a c k a n d r e c a p t u r e a t r u s t i n g r e l a t i o n s h i p w i t h a person, w h i c h he h a d n e v e r h a d . l i e was at t h a t t i m e n o t e d to h a v e an I Q o f 120 on t h e \ V I S E .
N o t all cases i l l u s t r a t i n g some of the f e e l i n g s of these c u l t u r a l l y d e p r i v e d c h i l d r e n are so d e e p l y conflicted. Some of t h e m can v e r b a l i z e their resentm e n t s a b o u t " s c u m m y li,,~ing. " A n l 1 - y e a r - o l d girl living w i t h h e r p a r e n t s a n d e i g h t siblings in a h o u s i n g p r o j e c t rel a t e d h e r f e e l i n g s o f rejection w i t h r e s p e c t to h e r r e a d i n g . p r o b l e m a n d n o t b e i n g a b l e to o b t a i n a n y h e l p for it. She h a d initially b e e n r e f e r r e d for p s y c h i a t r i c h e l p w i t h an e n u r e s i s p r o b l e m , a n d in a r o u t i n e p s y c h o l o g i c a l e x a m i n a t i o n h a d b e e n f o u n d to be r e a d i n g at a 2.3 g r a d e level w h i l e in sixth g r a d e . C o n u n u n i c a t i o n w i t h t h e s c h o o l s y s t e m w a s u n a b l e to s e c u r e a n y .special r e n d i n g i n s t r u c t i o n d u e to t h e girl's r e p o r t e d l y b e i n g in t h e u p p e r h a l f o f h e r class in r e a d i n g ability. T h e r e m a i n d e r o f h e r i n t e | l i g e n c e t e s t i n g d i d n o t r e v e a l m e n t a l d e f i c i e n c y or a b r a i n d a m a g e p r o b l e m , n o r d i d t h e clinical i n v e s t i g a t i o n . H e r i n d i f f e r e n c e to s c h o o l w a s ' n o t e d as p a r t o f t h e n o r m s p r e v a i l i n g a t school.
T i l e e n t i r e r a n g e of b e h a v i o r p r o b l e m s seems to a p p e a r in these c h i l d r e n , b u t there is a p r e d o m i n a n c e of p r o b l e m s with an acting-out basis, such as stealing, r u n n i n g aw ay, promisc uity, g a n g a n d i n d i v i d u a l overt p h y s i c a l .,ggression, r a t h e r than tile more restricted n e u r o t i c b e h a v i o r such as phol)ias
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and obsessive-compulsive reactions. In m a n y of these children, tlae acting-out behavior appears to b e a defense against underlying painful, depressive feelings which riley are warding off. '~ N,lany o f these families operate on the primacy of the pleasure principle as a way of l i f e w h i c h has been witnessed and internalized. They, consequently, oiten have difficulties :in ' tolerating tension and frustration and are consequently impaired in this a r e a o f psychological functioning. Their impulsivity a n d hyperactivity will often manifest itself in a motorized quality to their behavior. Such belmvior is often incorrect],y diagnosed as "'brain damage" on the assumption that l llyperactivity is equivalent to brain d a m a g e : Thus, t h e s e inner conflicts and difllculties in impulse control accentuate the culturally-given situation of the baseline of: minimal intellectual stimulation: A self-concept of being personally inadequate and unable to master n e w s k i l l s is r e i n f o r c e d b y the unrewarding milieu in which the child is Supposed to, learn and I mature, a reinforcement f r o m t h e family and culture combined. I n some of the earliest school years, these c h i l d r e n will verbalize and express through various therapeutic m e d i a t h e i r unworthiness t o achieve suc~ cess and competence. One 8-year-old with m a j o r learning problems w o u l d repetitively Verbalize tiis depreciated self-image by lstating, " I ' m a : n u t t i n . , I n s o m e of these children, a defense of w i t h d r a w a l may be noted in their peer relationships and in any competitive venture, where ~not t a k i n g any risks avoids the chance of failure, an example of ego reStriction. T h e stage is thus set for the t:uture development of multiple learning problems, e v e n apart from any organic deficiencies that may happen to b e present r It is believed that, without the ability to trust, the ability to learn must b e d a m a g e d t o some extent. Learning will also require delay o f gratification a n d the ability to alternate beha~dor, from being active to passive; such a s s p e a k i n g or sitting, and compl>dng with others" wishes.C" I n t e r m s of ego psychologTi learning is a function of the conflict-free eg0, and i n a ettild with internal conflicts with respect to handling hiss;repulses, o r in a social environment where he is not free to use his energies for l e a r n i n g a n d creative activities, he will be prone to emotional and educational p r o b l e m s . Freud once rendered a dicl/um t h a t t h e p o o r will be l e s s willing t o part with their neuroses t h a n the rich, as f i l e life t h a t awaitsl them w h e n : t h e y recover has even less attraction. One wonders how itruei: t h i s may !with respect to the cul[urally disadvantaged child, for whom the therapist ex-peets t o work t h r o u g h painful e m o t i o n a l :feelings a n d •experiences. Y e t , it is believed that, unless some of these cliildren a r e g i v e n the opportuniby i~o:form a trusting re]ationship ~fit,h an a d u l t person, and t o c l a r i f y ; m a n y of: t h e painful feelings of anger, rage a n d resentment,: t h e y will continue:t0 b e : cultural 'Or emotional misfits e v e n if they later get a el~ance t o be exposed to culturally-stimulating events and activities. In psychological terms, the ego of the child must be freed so that h e b e c o m e s capable of enjo)dng and appreciating the world about him. As simple a s it appears, there seems t o b e a correlation between the child's being given a chance to t a l k a b o u t h i s or her feelings, as in therapy, and his capacity to delay action and make,
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b e l i e v e , which are both crucial f o r ego development, interpersonal relations and learning ability. T h e r e is one final point to mention about the "'natural history" of such Children. This pertains to w h a t happens to some of the exceptional, culturally d e p r i v e d children who seem to rise out of the morass fi'om which they have c o m e and becorne "affluent.'" Thd.~e are u n d o u b t e d l y a minority, with most of them s e e m i n g to p e r p e t u a t e themseh,es and their children in the same type of existence from which they have come. H o w e v e r , different therapists have had the o c c a s i o n to later see some of t h e s e "'exceptional children," as late adolescents or adults who a p p e a r to be functioning adequately in several spheres. A s one works with these p a t i e n t s in their 20"s and 30's, an unresolved depression s e e m s to be one of the m o s t prominent dynamic a n d m o t i v a t i n g factors in their personality makeup. In some of these cases, their need to achieve appears to be contingent upon anxiety as the stimulus which prevents them from regressing to the life they o n c e knew as a child and which haunts them by d a y and by d r e a m s at night. In some of these people, a " W h a t Makes S a m m y Run" character structure seems to develop, where other people a r e used as disposable ~tepping stones in their own drive for s u c c e s s a n d aelaievement. In some, the recognition that there really is no "'Room At the Top" b r i n g s on an acute depressive episode which leads thein to s e e k therapy. I m p a i r m e n t in interpersonal relations, with difficul~" in gett i n g close and trusting others and maintenance of social distance is also evident. Ambivalence algout their successes may .also be noted in that they feel t h a t they have thus, in turn, "'abandoned" their parents as they themselves were once abandone& This m a y engender guilt over rejecting theh" familv's w a y of life. In some cases, "success phobias" are present. The emergence of these conflicts can aJso be s e e n in aspiring adolescents from such conflicted or deprived families. -In most of the cases like these, the scars from their early experiences still seem operative in their d a i l y , adult motivational patterns. An interesting project would involve a tollow-up comparison stud)" of those w h o have also escaped from such a childhood background, but who have n o t subsequently felt the need for psychotherapy. A l t h o u g h often going tlarough the motions of u p p e r middle class living, these individuals w l i o have later become "'successful" seem plagued b y their past as though t h e y had never resolved this hangover from their childhood. A p r o f e s s i o n a l l~r-':on w h o h a d l o n g since left " t h e o t h e r A m e r i"c a "" w a s p l a g u e d b y c h r o n i c d i s c o n t e n t a n d feelings o f dissatisfaction. D e s p i t e a c h i e v e m e n t professionally a n d financially, his d i f f i c u l t y in i d e n t i f y i n g w i t h those w i t h w h o m he w o r k e d a n d lived c r e a t e d a f e e l i n g o f isolation from his c o n t e m p o r a r i e s . F o l l o w i n g P r e s i d e n t K e n n e d y ' s assassination, h e h a d a d r e a m in w h i c h h e w a s r i d i n g in o n e of t h e processional cars on t h e w a y to A r l i n g t o n N a t i o n a l C e m e t e r y , ms p o r t r a y e d on t h e nation's television screens. H e was p o i n t i n g o u t various n a t i o n a l m o n u m e n t s to his wife, w h o w a s c o m f o r t a b l e a n d c o n t e n t that' t h e y no~" lived in "Washington in a s t i m u l a t i n g e n v i r o n m e n t a n d associated w i t h p e o p l e f r o m t h e i r o w n social class. As t h e procession e r o ~ e d t h e b r i d g e to e n t e r t h e c e m e t e r y , he b e g a n to cry, w h i c h he c o u l d n o t eventl~ally c o n c e a l f r o m his wife. a n d at this p o i n t a w a k e n e d f r o m his d r e a m . l t i s associations to this d r e a m w e r e p r e d o m i n a n t l y a l o n g t h e line of his f e e l i n g t h a t
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he could never reach the goals h e set out for himself anymore than the late d e a d President now could. Though he is still alive mad materially prosperous, h e is inwardly still deprived. The return to t h e "'emptiness and poverty of the earth" are inescapable for him and "'one's background remains ever present:" The disiUusionment which is present when he realizes the frailities and foibles of his professional achievements leaves/a gap in his attempt to escape the iinp0verishment and depression accompanying his own past life exl)eriences. This is a laighly condensed and abstracted selection from a fascinating case. Tlaere are innumerable individual neurotic components which have led this individual to these feelings and conflicts, but the point to be stressed here is how often this same theme seems to occur repetitively with this type of patient.
In summar); the author wislms to stress tlmt there does seem t o b e individualized emotional scars from culturally deprived backgrounds which are added to the conflicts with which all claildren: in dae course 0t? their psycho-social-sexual development~ Some c.fthese :problems would~n0t be a l tered by changing the cultural milieu. Yet, it would seem hard to deny tlmtl t o the extent tlmt any form of disadvantageous social or emotional deprivation can b e eliminated, a step has been taken to preyent some future social or emotional prt)blems for children and families. Within this framework. adequate mental llealtll facilities for childrenandfamilies with c0mpetently "trained psychiatrists should play a role, along xsdthsuch ifaetors as improved educational programs, medical care, youth employment and training, housing developments and slum clearance, as o n e p a r t of a preventive psychiat~% program for the culturally deprived child~ 1. 2.
3.
REFERENCES diagnostic groups among juvenile deCohen. J.: Soq!al XVork and the Culture of Poverty. Social Work 9:3-11, 1964. linquents: The schizophrenic and t h e Riessman: F.: The CultuarHy Deprived impulse ridden Ch,-u'aeter disorder. J. Child. New York, Harper & Row, inc. , : Am. Acad) Child Psychiat. 2:292--,318; 1962, pp. 47--48. 1963. Visotsky, H, M . : Social-psychiat~, ra6. Sperry, B., et. aI.: Renunciation and: de, tionale: Administrative and planning nial in learning : difficulties.- Am. J, approaches~ AJn. J. PsychiaL 121:433Orthopsychiat. 28:98-111;Jau.,: 1958. 441~ 1964. "~Viltse, K." Orthopsychiatrie progress for 7. Katan. :A.: Some tli6ilghts about the role o f verbalization i n e a r l y , childhood. socially deprived groups. Am, J. Orthopsai! Sta,dy:;:Of thechild~:i!6:i~8, psYcliiat. 33: 806--813, 1963. 1961. Kaufman, I.~ et. al.: Delineation of t w o ,
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5.
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Carl P . Malmquist,:~M.D., DepL:crf PsyChia~ry,: Heunepin County General Hoepital; Minneapolis,: iuinn~
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i r l ~ H E A U T H O R HAS B E E N 1NIPRESSED by the expansion of writings, 1 . p a n e l s and pi-ojects on the socially d i s a d v a n t a g e d or culturally d e p r i v e d child. H e has also been impressed by the relative lack of contributions from psychiatrists to this problem. This has led him to (luestion if there m a y be anythil~g Specific which psychiatry call add from its perspective to the contributions from the fields of sociolog3,, social work; education and psychology. It is his belief that child psychiatrists in their work with children, adolescents, and families, as individuals and in family sessions, can make pertinent observations about these problems viewed from another v a n t a g e point. No specific a t t e m p t will be m a d e here to give a strict definition of "'lower class,'" which is not equivalent to the "'working class" group.' There is a d a n g e r in not having a specific definition, but since the ol)servations presented in this p a p e r are not part of a strictly controlled stu(ty, the generally 'ac~:epted m e a n i n g of this group as one on the p e r i p h e ~ ' of society in terms of occupa-. tion, education and residence will be used in referring to "'the lower class." T h e children and families in this discussion customarily live in the least suitable housing, have the lowest education, and are either u n e m p l o y e d or do the lowest paid menial and unskilled work from which they derive little satisfaction. One of the most striking impressions in dealing with culturally deprived children from the lower social classes is the (lii[qculty, in getting them and their parents to participate in p s y c h o t h e r a p y as it is traditionally practiced in child psyehiat~" clinics, with their middle class values, personnel, and communication pattenas: M a n y of the comments m a d e here are obviously generalizations to which exceptions can be made, but the purpose is, rather, to emphasize the most frequently seen trends. It is rare and almost u n k n o w n to have the parents from this social level seek out psychiatric aid on their own initiative. Clinicians customarily refer to such individuals as having "poor motivation" or being "poor treatment (:ases.'" Part of the hesitancy of these families for seeking treatment on their own is d u e to fear and misconceptions a b o u t the "headshrinker'" or "'psycho-doctor," which is aided and a b e t t e d by the mass media such as television. T h e portrayal of the psychiatrist's otfice on television, even when shown as a c o m m u n i t y facility, is often so physically attractive when compared to the rather deteriorated and barren facilities which make up m a n y c o m m u n i t y clinics, that parents lind little to identify with when they themselves come to a typical c o m m u n i t y facility. Such .u child and family are most commonly seen in the light of having b e i n g referred to a psychiatrist l)v another authority figure or group, such a s the school, a welfare agency or court service and typically present acting out and impulse-dvsconlrol problems. From the beginning, the relationship has a ditlrer 176 Co.~ll.lltillr;.~'SlVr: P.~Yt:lll,ln~'. Vol.. Iri. N o . . ! j (Jt'.~l~:). 1905
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e n t basis from that of tile m i d d l e or u p p e r m i d d l e class child a n d family; t h e latter are g e n e r a l l y r e f e r r e d b y t h e p a r e n t s , w h o a r e t h e m s e l v e s c o n c e r n e d a b o u t the b e h a v i o r m a n i f e s t e d b y t h e Child; o r b y a l o c a l p e d i a t r i c i a n . In those m o r e neurotic cases referred: b y t h e local p h y s i c i a n or the :Pediatric Clinic of a general l~ospita !, the family seeks i m l n e d i a t e results in t e r m s o f s y m p t o m a t i c treatment. This is not solely d u e t o lack of explanation of w h a t t h e r a p y entails, b u t r a t h e r seems to b e due, in some eases, to a failure of internalization a n d d e v e l o p m e n t of the ego's c a p a c i t y f o r d e l a y i n g gratification; v i e w e d from a f a m i l y perspective, the m i d d l e class V,k]:t~es of verbalization a n d p e r s e v e r a n c e for l o n g e r r a n g e goals s e c r e t 0 b e lacking. C o n c e p t s Such as "'good h e a l t h " a n d , p r e v e n t i o n " at t i m e s seem a h n o s t l u d i c r o u s l y lout o f context with these families. R i e s s m a n ' s strictures r e g a r d i n g t h e ~ i n a p p r o p r i a t e hess of m u c h of traditional p s y c l a o t h e r a p y S e e m s relevant. He: states, "Thougla p s y c h o a n a l y t i c t h e r a p y is b a s e d o n t h e a s s u m p t i o n s of a m i d d l e class, loveo r i e n t e d c h i l d h o o d p a t t e r n a n d its p r e s u m e d repetition in t h e t l l e r a p e u t i c situation, in the light of d i f f e r e n t emphasis on l o v e in a d i s a d v a n t a g e d •family, this m a y b e a m i s l e a d i n g assumption.• T h e f a c t t h a t this f a m i l y includes m a n y adults ( p a r e n t s u b s t i t t t t e s ) , a less intense r e l a t i o n s h i p of c h i l d to p a r e n t a n d m o r e sibling • c o n t a c t also has b e a r i n g o n psyclioanalytic c o n c e p t s o f t r e a t m e n t . - As w i t h ninny adults w h o c o m e to t h e t r e a t e r t o h a v e t h e i r p h y s i c a l pain r e m o v e d , in its most literal s e n s e , these p a r e n t s w a n t their o w n a n d their child's emotional pain r e m o v e d a n d that is t h e end of t r e a t ment. This is seen in t h e v a r i o u s m e d i c a l a n d p e d i a t r i c clinics a s a n e v e r e n d i n g search for the pill or d r u g w h i c h is g o i n g to solve their p r o b l e m s . T h e p a t t e r n of defenses u s e d b y low income p a t i e n t s a n d those in t h e m i d d l e class also seems to differ. In the former, t h e r e is a p r e d o m i n a n c e of externalization, projection, scapegoating, acting out,: denial, a n d s o m a t i z a t i o n ; t h e l a t t e r g r o u p uses m o r e isolation, ~reaction formation, a n d c o m p e n s a t i o n in their verbalized a n d introspective a p p r o a c h e s , z I n several of these~ c u l t u r a l l y d i s a d v a n t a g e d cases w h e r e t h e i n d i v i d u a l c h i l d s e e m s to h a v e t h e i n t e l l i g e n c e a n d v e r b a l a b i l i t y , c o u p l e d with t h e i n i t i a l t r a n s f e r e n c e reaction t o t h e therapist, c o n t i n u a n c e of t h e r a p y fol!ox~dng t h e i n i t i a l i m p r o v e m e n t , d e s p i t e p a r e n t a l approval given to t h e therapist, u s u a l l y d o e s n o t seem t o m a i n t a i n itself for a n y length of time. The. families p r e f e r t o r e t u r n on s e v e r a l occasions s c a t t e r e d over time inter~,als if the difficulty recurs in one form o r a n o t h e r , r a t h e r than obtain t h e " w o r k i n g t h r o u g h "~ t y p e of t r e a t m e n t whiela t h e coll e g e - e d u c a t e d family are" a w a r e o f a n d s e e k . Some h a v e s u g g e ~ e d t h a t a solution is t o "'reach out" t o t h e s e p e o p l e b y l s u c h w e l f a r e a p p r o a c h e s - a s e n v i r o n m e n t a l m a n i p u l a t i o n s , h o m e visits a n d n o t a c c e p t i n g t h e f a m i l y w i t h drawal: or resistance to f u r t h e r i n v o l v e m e n t . In ~ some cases this m a y h a v e some a d v a n t a g e if it is kept in m i n d t h a t the goal a n d n a t u r e of t h e psychot h e r a p e u t i c process have then b e e n q u i t e r a d i c a l l y a l t e r e d . A d o p t i o n of the t e c h n i q u e s of w e l f a r e d e p a r t m e n t s in d e a l i n g w i t h clients can o n l y b e called p s y c h m t n e t r e a t m e n t " b y w i d e n i n g t h e p h r a s e significantly b e y o n d its p r e s e n t connotation. This is n o t to be c o n s t r u e d as an a r g u m e n t against t h e use of these w o r k i n g p r o c e d u r e s b y a n y discipline i f t h e y are f o u n d v a l u a b l e ,
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b u t to d e m o n s t r a t e t h e d i f f e r e n c e s e n t a i l e d f r o m t r a d i t i o n a l p s y c h o t h e r a p y in a clinical setting. ~,lary was a 5-year-old refezTed by a pediatrician because of worries and preoccupations about dying. This had affected her appetite, relations with other children, and kept her awake nights. After visits three times per week for three weeks, the overt problem had completely disappeared. The parents saw no need for any further appointments, and altlaough grateful for the therapeutic first-aid, which was given without f e e , they did not see any need for future sacrifices of bringing the girl back for even weekly visits. The problem of arranging for babysitters and paying them while getting to a clinic can be a major handicap to continuance of therapy with culturally disadvantaged families. I n some cases other comnnmity agencies can assist in these matters thereby making it possible for children and parents to attend the clinic. I n contrast to this e,mse was that of a similar presenting complaint in another 5'year-old girl, but with only one younger sibling as contrasted to the five siblings in the above ease. The parents here were college-educated a n d wanted to make sure their daughter, and themselves, participated so that the "conflicts were dealt with.'" T h e p r o b ! e m arises w i t h " s c h o o l p h o b i a s " i n m a n y cases. O n c e t h e c h i l d is b a c k i n s c h o o l , i t is difficult in m a n y cases f o r t h e r a p y t o c o n t i n u e for a n y l e n g t h o f t i m e . w i t h m a n y c h i l d r e n . "~Vith t h e c h i l d f r o m a l o w e r class socioe c o n o m i c s e t t i n g , i t is a h n o s t i m p o s s i b l e . A g a i n , it is t h e f o c u s i n g on tile i m m e d i a t e g o a l as tile u l t i m a t e s o l u t i o n . H,_;turning to school, h a s " ' r e m o v e d t h e pain.'" A g a i n , c e n t r a l , v a l u e s y s t e m s as w e l l as c o m m u n i c a t i o n b a r r i e r s a p p e a r to b e o p e r a t i n g . I n m a n y o f t h e s e c h i l d r e n , w e see w h a t is f r e q u e n t l y d i a g n o s e d as a "'dep r e s s i o n . " Yet, tile p r o b l e m b e c o m e s m o r e c o m p l e x w h e n a m o r e p r o l o n g e d i n v e s t i g a t i o n is m~?de of t h e c h i l d a n d f a m i l y . I t b e c o m e s v e r y difficult to f i n d specific p r e c i p i t a t i n g or r e a c t i v e f a c t o r s w h i c h h a v e b r o u g h t a b o u t s u c h f e e l i n g s . I n fact, t h e c o n c e r n a b o u t t h e d e p r e s s i o n h a s u s u a l l y n o t c o m e f r o m file p a r e n t s , b u t t e a c h e r s or p h y s i c i a n s w h o d e t e c t t h e a p a t h y a n d listlessness of t h e s e c h i l d r e n . T h e p e d i a t r i c i a n o f t e n w o n d e r s i f t h e r e is n o t a v i t a m i n or n u t r i t i o n a l d e f i c i e n c y p r o b l e m w h i c h is o c c a s i o n a l l y , b u t n o t c u s t o m a r i l y , f o u n d . As t h e h i s t o r y a n d c o u r s e u n f o l d , it b e c o m e s a p p a r e n t t h a t t h e p i c t u r e o f h e l p l e s s n e s s , h o p e l e s s n e s s , a n d l a c k o f i n t e r e s t a r e "'just t h e w a y t h e c h i l d is" a c c o r d i n g to t h e p,'u'ents. I n o t h e r w o r d s , tim c h i l d h a s b e e n t h i s w a y f o r m a n ) , y e a r s o v e r t h e c o u r s e o f his d e v e l o p m e n t , so t h a t o n l y a n " o u t s i d e r " w o n d e r s if s o m e t h i n g is w r o n g . T h e c h i l d will g o t h r o u g h t h e m e c h a n i c s of l e a r n i n g in t h a t he a t t e n d s school, b u t t h e c o g n i t i v e p r o c e s s d o e s n o t s e e m to p r o g r e s s m u c h b e y o n d t h e b a r e r u d i m e n t s . T h e h o m e s e e m s to b e a l m o s t u n i v e r s a l l y d e v o i d of r e a d i n g m a t t e r or a n y intell e c t u a l s t i m u l a t i o n . A l t h o u g h t h e tele~dsion is on c o n s t a n t l y , it is t u n e d to t h e s a m e h a c k n e y e d p r o g r a m s a n d r a r e l y to t h e f e w d o c u m e n t a r y or e d u c a tional p r o g r a m s that are available. T h e q u e s t i o n m a y b e a s k e d ff t h e s e c h i l d r e n a r e r e a l l y d e p r e s s e d in t h e clinical, p s y c h i a t r i c sense, or i f t h e y a r e m e r e l y r e v e a l i n g b e h a v i o r w h i c h fulfills t h e n o r m s for t h o s e f r o m this s o e i o - e e o n o m i c s t r a t u m . O n e w r i t e r llas t h u s r e f e r r e d to A D C p a r e n t s as h a v i n g a " ' p s e u d o - d e p r e s s i o n " s y n d r o m e .
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"VVe found a continuation of immobilization w i t h r e g a r d to effective activity,
isolation from social relationsllips, depressed appearance, :~weigllt loss, poor appetite and chronic health problems. ''* The - p s e u d o , : i s n o t t o distinguish affected poses, b u t to r a t h e r differentiate these behavioral manifestations from the specific clinica ! diagnosi s of depression. Tt!is c o n c e p t of pseud0idepression in adults from the A D C population a c t u a l l y describes a situational depression, not in the specific sense of a current failure, or a series of Critical:rebuffs, leading t o a fall in self-esteem, b u t in the b r o a d e r cultural sense. It iS felt that t h e s e people are reacting to t i l e situation of marginal living with a l l its implications, a n d living a hand-to-mouth existence in:a Consumption~oriented society whose values d e m a n d that they lmve money a n d s p e n d it on m a t e r i a l possessions. The situation t h e y / a r o r e a c t i n g t o is a feeling of being itlie v u l ' n e r a b l e pawns of c o m m u n i t y agencies and t h e p e o p l e who i a d m i n i s t e r these services; ` such as the welfare agencies, c o u n t y hospitals, social workers, doctors, courts, etc. T h i s viewpoint is still focused on the reactive :process, but in a broader sense; T h e implication is t h a t if these environmental factors were altered, tile clinical picture p r e s e n t e d b y these parents w 0 u i d : t h e n clmnge: This is a t p r e s e n t difficult to establish as a Xalid generalization. Tile.proposal is not to o p p o s e efforts to i m p r o v e t h e living conditions and respect long due to these p e o p l e , b u t t o question it? the : issue i s n o t m o r e complicated: Thus, when a few of t h e s e m o t h e r s are fortunate enougl a t o : r e m o v e themselves from the situation of A D C p a y m e n t s a n d t h e never-ending w a i t i n g line for community services, there does not frequently s e e m to b e a d r a m a t i c change w i t h i n the Family structure. Perhaps, the cultural and psyclxologieal forces h a v e produced ego alterations a n d family disorganizations t o an extent where the processes have effected sufficient injury So t h a t environmental and situational elmnges are no longer adequate to allow the ego of the child in these settings t o ;'catchup'" a n d cope with w h a t is a p p r o p r i a t e for the given stage o f de~,elopment. T h e obsern.ations m a d e above o n A D C families h a v e b e e n n o t e d by t h e a u t h o r in children of A D C m°thers, a n d those £-rornl the lower socio-economic groups. T h e same c o n t r o v e r s i a l issue a r i s e s as to whether altering, the: environment, after y e a r s of exposure t o the monotony a n d stultification o f t h e i r culturally deprived setting, w i t lead to the hoped-for enrichment and elinieal alteration in the majority: of e a s e s . A t this p o i n t , even~ if positiv0 proof i s lacking, it would s e e m praginatically justifiable to p r o c e e d as though tim result rnight be positive for the c h i l d r e n . Once engaged in t!aerapy, these c h i l d r e n often verbalize the same resentments a n d hostilities t o / a u t h o r i t y figures that their p a r e n t s do. C o u p l e d l w i t h this is the external a p a t l l y and indiffer~ence which i s so frequently observed, Except f o r t h o s e whose intelligence is in the moderately-retarded category or below, t h e r e rarely: seems t o be a quiescent acceptance o f their s t a t u s when their t r u s t w i t h the therapist has been :established; t h e whole ~problem of their difficulties regarding trust and mistrust with adults, peers and therapists is a major one with theist c[~ildren, as it seems to take them m u c h l o n g e r to work through these feelings with repetitive testings. This m a y b e due to their distrust not
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CARL P. ,XlAL~XIQU.IST
b e i n g solely, o r p o s s i b l y even p r i m a r i l y d u e to f a m i l i a l inte r a c tions b u t d u e to the suspicions of their cultural m i l i e u toward the "have's?" T h e o u t w a r d " m o l d i n g in" to the c u l t u r a l m i l i e u i s not as t r a n q u i l as m i g h t a ppe a r . T h e b e h a v i o r of these c h i l d r e n s e e m s to be the result of d e f e c t i v e ego d e v e l o p m e n t a n d organization d u e to a c u l m i n a t i o n of factors, suc h as maternal d e p r i v a t i o n , used in the b r o a d s e n s e of not o n l y death, desertion or a b a n d o n m e n t , b u t also tile p s y c h o l o g i c a l d e p r i v a t i o n that c o m e s from th e p r e s e n c e of a m o t h e r figure w h o is h e r s e l f i n a d e q u a t e , depressed, r e s e n t f u l a n d o v e r w h e l m e d w i t h e.xcessive pe r sona l a n d f a m i l y responsibilities. W h e n t h e s e f a m i l i e s arc s t u d i e d l o n g i t u d i n a l l y , the m o t h e r s t h e m s e l v e s f r e q u e n t l y h a v e e x p e r i e n c e d s i m i l a r Childhoods. Tile " a b s e n t father," or a series of diff e r e n t m a l e s w ho come a n d go out of the f a m i l y setting, also ma ke s a n e g a t i v e c o n t r i b u t i o n to ego d e v e l o p m e n t a n d i d e n t i t y models. W h e n some of th e s e c h i l d r e n b e g i n to s h o w b e h a v i o r p r o b l e m s ot an acting-out nature, a series of foster h o m e p l a c e m e n t s f r e q u e n t l y begins, t u r t h e r c o n t r i b u t i n g to th e f e e l i n g s o f a b a n d o n m e n t a n d de pr iva tion. This has b e e n r e f e r r e d to as the "'foster-home roulette" s y n d r o m e . In some of these ehillren, a true c l i n i c a l n e u r o t i c depression in the p s y c h i a t r i c sense m a y then exist w i t h feelings of a b a n d o n m e n t , worthlessness a n d self-deprecation. O n e 1 3 - y e a r - o l d boy, w h o h a d b e e n raised until 10 w i t h his m o t h e r a n d a series of m e n . w a s finally r e m o v e d on the g r o u n d s of his m o t h e r ' s i m m o r a l c o n d u c t . N o p s y c h i a tric i n v e s t i g a t i o n o f the b o y w a s n o t e d at the t i m e b u t school reports n o t e d h i m to be u n i n t e r e s t e d a n d b a r e l y p a s s i n ~ w o r k in 4 t h g r a d e . W h e n p l a c e d in foster homes, a c t i n g o u t b e h a v i o r b e g a n in a serious vein. w i t h thtr c u s t o m a r y p r o b a t i o n a n d a t t e n t i o n w h e n a p p r e h e n d e d . At 13, a serious s u i c i d e a t t e m p t was m a d e w h e n he took t w e n t y b a r b i t u r a t e t a b l e t s f r o m t h e t h c n - c u r r o n t foster m o t h e r . A f t e r c o i n i n g o u t o f his c o m a . h e v e r b a l i z e d i n t e n s e feelings of w o r t h l e s s n e s s , a n d e v e n t u a l l y m u c h a n g e r t o w a r d s his m o t h e r c o u p l e d w i t h a g r e a t n e e d to g o b a c k a n d r e c a p t u r e a t r u s t i n g r e l a t i o n s h i p w i t h a person, w h i c h he h a d n e v e r h a d . l i e was at t h a t t i m e n o t e d to h a v e an I Q o f 120 on t h e \ V I S E .
N o t all cases i l l u s t r a t i n g some of the f e e l i n g s of these c u l t u r a l l y d e p r i v e d c h i l d r e n are so d e e p l y conflicted. Some of t h e m can v e r b a l i z e their resentm e n t s a b o u t " s c u m m y li,,~ing. " A n l 1 - y e a r - o l d girl living w i t h h e r p a r e n t s a n d e i g h t siblings in a h o u s i n g p r o j e c t rel a t e d h e r f e e l i n g s o f rejection w i t h r e s p e c t to h e r r e a d i n g . p r o b l e m a n d n o t b e i n g a b l e to o b t a i n a n y h e l p for it. She h a d initially b e e n r e f e r r e d for p s y c h i a t r i c h e l p w i t h an e n u r e s i s p r o b l e m , a n d in a r o u t i n e p s y c h o l o g i c a l e x a m i n a t i o n h a d b e e n f o u n d to be r e a d i n g at a 2.3 g r a d e level w h i l e in sixth g r a d e . C o n u n u n i c a t i o n w i t h t h e s c h o o l s y s t e m w a s u n a b l e to s e c u r e a n y .special r e n d i n g i n s t r u c t i o n d u e to t h e girl's r e p o r t e d l y b e i n g in t h e u p p e r h a l f o f h e r class in r e a d i n g ability. T h e r e m a i n d e r o f h e r i n t e | l i g e n c e t e s t i n g d i d n o t r e v e a l m e n t a l d e f i c i e n c y or a b r a i n d a m a g e p r o b l e m , n o r d i d t h e clinical i n v e s t i g a t i o n . H e r i n d i f f e r e n c e to s c h o o l w a s ' n o t e d as p a r t o f t h e n o r m s p r e v a i l i n g a t school.
T i l e e n t i r e r a n g e of b e h a v i o r p r o b l e m s seems to a p p e a r in these c h i l d r e n , b u t there is a p r e d o m i n a n c e of p r o b l e m s with an acting-out basis, such as stealing, r u n n i n g aw ay, promisc uity, g a n g a n d i n d i v i d u a l overt p h y s i c a l .,ggression, r a t h e r than tile more restricted n e u r o t i c b e h a v i o r such as phol)ias
]'lie
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and obsessive-compulsive reactions. In m a n y of these children, tlae acting-out behavior appears to b e a defense against underlying painful, depressive feelings which riley are warding off. '~ N,lany o f these families operate on the primacy of the pleasure principle as a way of l i f e w h i c h has been witnessed and internalized. They, consequently, oiten have difficulties :in ' tolerating tension and frustration and are consequently impaired in this a r e a o f psychological functioning. Their impulsivity a n d hyperactivity will often manifest itself in a motorized quality to their behavior. Such belmvior is often incorrect],y diagnosed as "'brain damage" on the assumption that l llyperactivity is equivalent to brain d a m a g e : Thus, t h e s e inner conflicts and difllculties in impulse control accentuate the culturally-given situation of the baseline of: minimal intellectual stimulation: A self-concept of being personally inadequate and unable to master n e w s k i l l s is r e i n f o r c e d b y the unrewarding milieu in which the child is Supposed to, learn and I mature, a reinforcement f r o m t h e family and culture combined. I n some of the earliest school years, these c h i l d r e n will verbalize and express through various therapeutic m e d i a t h e i r unworthiness t o achieve suc~ cess and competence. One 8-year-old with m a j o r learning problems w o u l d repetitively Verbalize tiis depreciated self-image by lstating, " I ' m a : n u t t i n . , I n s o m e of these children, a defense of w i t h d r a w a l may be noted in their peer relationships and in any competitive venture, where ~not t a k i n g any risks avoids the chance of failure, an example of ego reStriction. T h e stage is thus set for the t:uture development of multiple learning problems, e v e n apart from any organic deficiencies that may happen to b e present r It is believed that, without the ability to trust, the ability to learn must b e d a m a g e d t o some extent. Learning will also require delay o f gratification a n d the ability to alternate beha~dor, from being active to passive; such a s s p e a k i n g or sitting, and compl>dng with others" wishes.C" I n t e r m s of ego psychologTi learning is a function of the conflict-free eg0, and i n a ettild with internal conflicts with respect to handling hiss;repulses, o r in a social environment where he is not free to use his energies for l e a r n i n g a n d creative activities, he will be prone to emotional and educational p r o b l e m s . Freud once rendered a dicl/um t h a t t h e p o o r will be l e s s willing t o part with their neuroses t h a n the rich, as f i l e life t h a t awaitsl them w h e n : t h e y recover has even less attraction. One wonders how itruei: t h i s may !with respect to the cul[urally disadvantaged child, for whom the therapist ex-peets t o work t h r o u g h painful e m o t i o n a l :feelings a n d •experiences. Y e t , it is believed that, unless some of these cliildren a r e g i v e n the opportuniby i~o:form a trusting re]ationship ~fit,h an a d u l t person, and t o c l a r i f y ; m a n y of: t h e painful feelings of anger, rage a n d resentment,: t h e y will continue:t0 b e : cultural 'Or emotional misfits e v e n if they later get a el~ance t o be exposed to culturally-stimulating events and activities. In psychological terms, the ego of the child must be freed so that h e b e c o m e s capable of enjo)dng and appreciating the world about him. As simple a s it appears, there seems t o b e a correlation between the child's being given a chance to t a l k a b o u t h i s or her feelings, as in therapy, and his capacity to delay action and make,
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b e l i e v e , which are both crucial f o r ego development, interpersonal relations and learning ability. T h e r e is one final point to mention about the "'natural history" of such Children. This pertains to w h a t happens to some of the exceptional, culturally d e p r i v e d children who seem to rise out of the morass fi'om which they have c o m e and becorne "affluent.'" Thd.~e are u n d o u b t e d l y a minority, with most of them s e e m i n g to p e r p e t u a t e themseh,es and their children in the same type of existence from which they have come. H o w e v e r , different therapists have had the o c c a s i o n to later see some of t h e s e "'exceptional children," as late adolescents or adults who a p p e a r to be functioning adequately in several spheres. A s one works with these p a t i e n t s in their 20"s and 30's, an unresolved depression s e e m s to be one of the m o s t prominent dynamic a n d m o t i v a t i n g factors in their personality makeup. In some of these cases, their need to achieve appears to be contingent upon anxiety as the stimulus which prevents them from regressing to the life they o n c e knew as a child and which haunts them by d a y and by d r e a m s at night. In some of these people, a " W h a t Makes S a m m y Run" character structure seems to develop, where other people a r e used as disposable ~tepping stones in their own drive for s u c c e s s a n d aelaievement. In some, the recognition that there really is no "'Room At the Top" b r i n g s on an acute depressive episode which leads thein to s e e k therapy. I m p a i r m e n t in interpersonal relations, with difficul~" in gett i n g close and trusting others and maintenance of social distance is also evident. Ambivalence algout their successes may .also be noted in that they feel t h a t they have thus, in turn, "'abandoned" their parents as they themselves were once abandone& This m a y engender guilt over rejecting theh" familv's w a y of life. In some cases, "success phobias" are present. The emergence of these conflicts can aJso be s e e n in aspiring adolescents from such conflicted or deprived families. -In most of the cases like these, the scars from their early experiences still seem operative in their d a i l y , adult motivational patterns. An interesting project would involve a tollow-up comparison stud)" of those w h o have also escaped from such a childhood background, but who have n o t subsequently felt the need for psychotherapy. A l t h o u g h often going tlarough the motions of u p p e r middle class living, these individuals w l i o have later become "'successful" seem plagued b y their past as though t h e y had never resolved this hangover from their childhood. A p r o f e s s i o n a l l~r-':on w h o h a d l o n g since left " t h e o t h e r A m e r i"c a "" w a s p l a g u e d b y c h r o n i c d i s c o n t e n t a n d feelings o f dissatisfaction. D e s p i t e a c h i e v e m e n t professionally a n d financially, his d i f f i c u l t y in i d e n t i f y i n g w i t h those w i t h w h o m he w o r k e d a n d lived c r e a t e d a f e e l i n g o f isolation from his c o n t e m p o r a r i e s . F o l l o w i n g P r e s i d e n t K e n n e d y ' s assassination, h e h a d a d r e a m in w h i c h h e w a s r i d i n g in o n e of t h e processional cars on t h e w a y to A r l i n g t o n N a t i o n a l C e m e t e r y , ms p o r t r a y e d on t h e nation's television screens. H e was p o i n t i n g o u t various n a t i o n a l m o n u m e n t s to his wife, w h o w a s c o m f o r t a b l e a n d c o n t e n t that' t h e y no~" lived in "Washington in a s t i m u l a t i n g e n v i r o n m e n t a n d associated w i t h p e o p l e f r o m t h e i r o w n social class. As t h e procession e r o ~ e d t h e b r i d g e to e n t e r t h e c e m e t e r y , he b e g a n to cry, w h i c h he c o u l d n o t eventl~ally c o n c e a l f r o m his wife. a n d at this p o i n t a w a k e n e d f r o m his d r e a m . l t i s associations to this d r e a m w e r e p r e d o m i n a n t l y a l o n g t h e line of his f e e l i n g t h a t
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TrIE SOCIALLY-DISADVANTAGEDCHILD
he could never reach the goals h e set out for himself anymore than the late d e a d President now could. Though he is still alive mad materially prosperous, h e is inwardly still deprived. The return to t h e "'emptiness and poverty of the earth" are inescapable for him and "'one's background remains ever present:" The disiUusionment which is present when he realizes the frailities and foibles of his professional achievements leaves/a gap in his attempt to escape the iinp0verishment and depression accompanying his own past life exl)eriences. This is a laighly condensed and abstracted selection from a fascinating case. Tlaere are innumerable individual neurotic components which have led this individual to these feelings and conflicts, but the point to be stressed here is how often this same theme seems to occur repetitively with this type of patient.
In summar); the author wislms to stress tlmt there does seem t o b e individualized emotional scars from culturally deprived backgrounds which are added to the conflicts with which all claildren: in dae course 0t? their psycho-social-sexual development~ Some c.fthese :problems would~n0t be a l tered by changing the cultural milieu. Yet, it would seem hard to deny tlmtl t o the extent tlmt any form of disadvantageous social or emotional deprivation can b e eliminated, a step has been taken to preyent some future social or emotional prt)blems for children and families. Within this framework. adequate mental llealtll facilities for childrenandfamilies with c0mpetently "trained psychiatrists should play a role, along xsdthsuch ifaetors as improved educational programs, medical care, youth employment and training, housing developments and slum clearance, as o n e p a r t of a preventive psychiat~% program for the culturally deprived child~ 1. 2.
3.
REFERENCES diagnostic groups among juvenile deCohen. J.: Soq!al XVork and the Culture of Poverty. Social Work 9:3-11, 1964. linquents: The schizophrenic and t h e Riessman: F.: The CultuarHy Deprived impulse ridden Ch,-u'aeter disorder. J. Child. New York, Harper & Row, inc. , : Am. Acad) Child Psychiat. 2:292--,318; 1962, pp. 47--48. 1963. Visotsky, H, M . : Social-psychiat~, ra6. Sperry, B., et. aI.: Renunciation and: de, tionale: Administrative and planning nial in learning : difficulties.- Am. J, approaches~ AJn. J. PsychiaL 121:433Orthopsychiat. 28:98-111;Jau.,: 1958. 441~ 1964. "~Viltse, K." Orthopsychiatrie progress for 7. Katan. :A.: Some tli6ilghts about the role o f verbalization i n e a r l y , childhood. socially deprived groups. Am, J. Orthopsai! Sta,dy:;:Of thechild~:i!6:i~8, psYcliiat. 33: 806--813, 1963. 1961. Kaufman, I.~ et. al.: Delineation of t w o ,
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Carl P . Malmquist,:~M.D., DepL:crf PsyChia~ry,: Heunepin County General Hoepital; Minneapolis,: iuinn~
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