Recognition of emotional disturbance among school children

R E C O G N I T I O N OF E M O T I O N A L D I S T U R B A N C E AMONG SCHOOL CHILDREN* SULA WOLFF M.A., M . R . C . P . , D . P . M . , I).C.H.

C~msultant P.~3'chiatrist, Royal tto.wital for Sick ~Ttildren, Edinburgh ! ,',: a paper entitled Some Notes on the htcidence of Neurotic Dijficuhies hl Young Chihh'en, Susan Isaacs in t932 described an attempt at estimating the frequency of childhood behaviour disorders. The material consisted of nearly 600 letters from middle class mothers and nannies sent to a correspondence column in a xveekly magazine. The children described came from comfortable homes and most of them "enjoyed modern methods of upbringing". The sample was thus a curiously biased one and the method of reporting quite unstandardized. One third of the letters described educational problems: the rest dealt with neurotic disorders. Among these, difficulties in relation to authority occurred most often, fears were next in frequency. While rebellious behaviour occurred more often in boys, fears predominated among girls. Studies subsequent to this pioneering one have always shown that parents and teachers worry most about their children's aggressive and anti-social behaviour and that boys are more openly aggressive :lnd anti-social, girls more fearful and inhibited. Since the publication of this paper considerable progress has been made, especially in the past fifteen years. in refining methods for identifying disturbed children and in discovering the medical, social and educational causes for behaviour disorders in childhood. It is no longer true to say, as Cyril Burt did in 1952: "'Most writers on child psychiatry apparently hold that any attempt at statistical confirmation is not merely invalid but actually impossible" (Burt and Howard, 1952). But despite the refinements in research methods and despite increasing factual knowledge some questions, though asked repeatedly, remain unanswered and issues which once seemed clear and straightforward are now recognized as much more complex. The Underwood Committee on Maladjusted Children (Ministry of Education, 1955), was still seriously struggling to answer the question: " H o w common is maladjustment in school children ?" in order that psychiatric services for school children could be properly planned. For this purpose three surveys of school children were carried out in different parts of the country, but the interpretation of the findings as they applied to service needs was so complex that the Committee finally reported as follows: "'We first attempted to make an estimate of the incidence of maladjustment, expressed as a percentage of the child population : from that we hoped to be able to deduce approximately the staff and facilities *Paper read at a Day Conference of the National Association for Mental Health on the Mental Health of the Schoolchild. York, March, 1967.

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likely to bc rcquircd. Wc had to abandon this attempt, h o w e v e r , . . . w e dccided that, in the present state of knowledge, we should be performing a more useful service if we made a purely practical cstimate of wh~t should be attempted in the next deep,de." IlOW PSYCIIIATRIC

1)|SORI)I!I,', IS I I ) E N T I F | E D

IN C I I I L I ) [ [ O O I )

q-he question "'Flow common is maladjustment?", assumes that we know what maladjustment is and can recongize it when we see it. There are several approaches to the problem of defining emotional disorder. Each is v~llid in its own way: each has its limitaiions. None is perfect, and none c~l~ ever give us a !inal a~aswer.

I. ,~lvuptom cottttts We can make a list of all possible zypes of beha~!iour commonly rcgzlrded :is problem behaviour in children, e.g. bed wetti~g, temper tantrums, fears, shyness, stealing, truanting et,:. We can then ask people who know a child well, his parents or his te~/cher, whcther he has any of these symptoms and if so to what degree of severity. Research has shown that symptoms can be reliably estimated and counted. But are symptoms the same as illness? A number of recent surveys of school children (Rutter and Graham, 1966: Shepherd et cd., 1966; Lapouse ~md Monk, 1958) have given us estimates of the prevalence of bchaviour disordcrs. For cxample, in the primary school age group nail biting occurs in about 30 per cent., enuresis in t5 per cent. and stealing in 5-per cent. of children. We now know what types of behaviour are statistically normal and abnorm~d for boys and girls at difli:rent ages, but because a boy of eight still wets his bed at night when most boys of his age do not, does this mean that he is maladjusted or needs to see a psychiatrist ? A number of other factors must be known ~bout ~ child before he can be identified as sick and in need of treatment. Some of these factors relate less to his symptoms, but instead are associated with his life situation. For example, if the 8-year-old comes from a stable family in which other members have also been enuretic and if his mother conlidently expects him to "outgrow" his symptom as the other children have done, the problem is entirely different from that of a boy, previously dry, who began to wet his bed during a hospital admission for a burn and whose mother finds the symptom more than she can tolerate. Although symptoms can be reliably measured and counted, as an index of illness they have their limitations. 2. Psychiatric referral A second method of identifying tile psychiatrically disturbed children in a community is to select for study those who have actually been referred to a psychiatrist: but so long as the services provided fall short of the manifest needs for them, this can give one little idea of the actual prevalence of disturbances in the community.

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3. Global a.~:~z,.~:~'memof di~'turbance The third and most common method used to estimate psychiatric disorder is a subjective judgement of the overall degree of handicap or impairment of a child's functioning or of his need for psychiatric treatment. The difficulty here is that there are differences in the perception of handicap and in the recognition of treatment needs, not only between one person and another, but between difli~rent groups of people. These differences in tolerance of illness and in attitude to what should be done about it, for example, between school teachers and parents, general practitioners and psychiatrists make a fascinating field of study but they also make it impossible to arrive at any once and for all defintion of illness. The first person to study the differing perceptions of children's behaviour disorders by teachers on the one hand and psychiatrists on the other was Wickman (1928) in America. in this study teachers were asked to rate the children in their c[asses on a checklist of troublesome behaviour. Teachers were also asked to assess the children globally as well adjusted, or as having minor emotional problems, or as having serious problems, Teachers identified 10 per cent. of the boys and 3 per cent. of the girls in their classes as seriously maladjusted. These children were characterized by their acting-out and difficult behaviour. Next teachers and psychiatric clinic staffwere asked to rank a number of hehaviour disorders according to their seriousness, No agreement at all was found between teachers and psychiatric clinic staff in what symptoms were judged to have serious implications for fflture mental health. Teachers singled out sexual behaviour, disobedience and failure to learn as harmful symptoms: psychiatric clinical workers on the other hand stressed the seriousness of withdrawal, anxiety and unsociability. Over the years professional opinions about children's emotional disturbances have changed, so that the views of teachers and psychiatrists have come to be more alike. Several recent studies have shown that teache,rs are more sensitive to the difficulties of shy and withdrawn children, while psychiatrists and psychiatric social workers now regard acting-out and aggressive behaviour as more ominous than they did in the past, no longer believing that uninhibited expression of feelings and impulses is necessarily a healthy reaction to stress. (Ulhnan, 1952). The change in teachers" attitudes can perhaps be credited to more widespread acceptance of psychoanalytic views about the crippling effects of excessive repression and inhibition on personality development. The psychiatrists have learnt perhaps from the failure of their own treatment methods with delinquents and from follow-up studies which showed aggressive and delinquent children to have a worse outcome in adult life than inhibited, neurotic children (Robins and O'Neal, 1958). The attitudes of teachers and psychiatrists to different kinds of behaviour disorders in children are now more similar than before but there are still marked

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differences ill assessments by parents and leachers of the children they both know. These discrepancies are probably at least in part due to real differences in the behaviour of children at home and in the school setting in a recent survey of all 10- and l l-year-old children living on the isle of Wight (Rutter and G r a h a m , 1966) teachers and parents were asked to rate the children on inventories of behaviour disorders. Two psychiatrists independently examined each child who scored above a certain point on one or other inventory. Agreement between lhe psychiatrists on the severity of psychiatric disturbance was very good. Agreement was also good between the psychiatric assessments and the behaviour scores obtained on the parent and the teacher scales. But while the psychiatrists agreed both with the parents and the teacher ratings there was very little agreement indeed between the rating accorded each child by parent and teacher. Children were identified as disturbed either in the school setting or by their mothers at home, but rarely in both situations. The same was found in a recent study of Edinburgh primary school children (Wolff, 1967a). There was no associalion between symptom counts based on teachers' rating scales and symptom counts based on mothers' reports. Mothers and teachers agreed on the presence ot" easily recognized symptoms like slammering, other speech dilticulties, nail bitilg and tics, school refusal, stealing and lying. They also agreed on whether the~child had p o o r concentration or attention and on whether he fought a lot. Presumably these are behaviour characteristics occurring al home and at school to which teachers and mothers are equally sensitive. Mothers and teachers did not agree in their estimate of the presence of sadness, withdrawal, solitariness, obsessionality, over-activity, disobedience and bullying. This means either that mothers and teachers differ in their sensitivity to these particular types ot" behaviour or that these symptoms are situationally determined, some children being unhappy and inhibited at home but not at school some being obedient and easy to manage at home, but rebellious and ditticult in the school setting. What conclusions can we draw from these findings? First, there is no universally applicable definition of emotional disturbance or psychiatric illness in children. Such an ideal concept of illness is e r r o n e o u s - and it is erroneous not merely in the case of childhood emotional disorders. In general medicine too, the question o f " w h a t is a case ?" does not always have a clear-cut answer. One person tolerates a chronic cough for years without considering himself ill; another with the same symptom presents himself to the doctor, is diagnosed as having chronic bronchitis and receives treatment for this condition. There is no ideal definition of psychiatric illness in childhood. But this does not mean that we cannot assess the presence o f illness in a commonsense way. It merely means that we must be critical of the measures we use, that we must know their limitations and that we must be aware of the biases that exist in our judgement about illness. The second point is that if we want to find out how c o m m o n psychiatric

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disturbances are in children, it is no good asking only teachers or only mothers. We must ask both. In view of all the dit~cutties it is perhaps surprising 1.hat there is so much uniformity in the numerical estimates of psychiatric disturbances among school children. Surveys invariably show that between 5 per cent. and 10 per cent. of school children have serious psychiatric disturbances. This is about ten times the number of children who actually get referred to a psychiatrist.

IDENTIFICATION TO \VHAT END All recognition of emotional disturbances in children is for a purpose and the methods used must fit the purpose. This may be research to test a particular casual theory or, of more obvious usefulness, research designed for immediate administrative action. The answers provided by research benefit all children, but the methods used to identi~, disturbed children for research purposes are not generally useful for the better management of the individual child. The argument for ever earlier and more sensitive identification of psychiatric disorders in school children requires to be seriously questioned. In particular. ~e must be clear what, under e\;eryday circumstances, we are identifving children for. If it is to improve parents" and teachers' understanding of children so that the child's apparently senseless and aggravating behaviour becomes meaningful and if it leads to more sensitive and helpful handling of children at home and in the school, then the recognition of problems is beneficial. If', on the other hand, it leads in parents and teachers to an anxious giving up of responsibility and a feeling that only experts in special settings can cope, if it leads to the exclusion of more and more children from ordinary care in the home and at school, then deliberate efforts to recognize emotionally disturbed children are of doubtful value. Emotionally disturbed children are not handicapped in the usual sense. Most of them l'm\e no permanent psychological defect for which allowances must be made. They are, as a rule, children reacting with normal psychological mechanisms to excessive stresses in their lives and their behaviour disorders require to be understood in the light of these stresses. To treat emotionally disturbed children as if they were essentially different from other children may be harmful. When adults fear for a child's future these fears are transmitted to the child and may actually contribute to bring about the feared consequences. The recognition of emotional disturbances for research purposes is quite a different matter. If we can find out how to improve the environment for children as a whole so that fewer emotional disturbances occur and if we can learn how to help children in stressful circumstances in order to prevent psychological difficulties arising, we shall achieve more than if we expend our enegries identi~'ing children as problem children or even trying to predict who might develop problem behaviour in the future.

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T t t F CAUSES OF E M O T I O N A L DISORDERS IN C H I L D H O O D

The causes for childhood emotional disorder have been sought and found in three main areas" 1. parental attitudes and parental behaviour; 2. the child's innate personality characteristics; and 3. environmental circumstances and events. From a public health point of view tile third area is the most important. If conditions under which psychiatric disorders occur most often can be identified then perhaps these conditions can be remedied. Likewise if there are publicly re, .... nizable events in a child's life that commonly produce emotional disturban, en we can identify children experiencing such events as vulnerable and can coJ ..... ntrate our prophylactic eflbrts on these particular children at these special times.

I.

Family disruption

Some quite early studies have pointed to family disruption as a frequent forerunner of emotional disorder in childhood. During the war, for example. a study was done in Cambridge in which Child Guidance Clinic attenders were compared with a control group of non-referred children from similar schools (Banister and Ravden, 1944). It was found that many more among the disturbed children came from broken homes than among the controls and this was particularly so for children who presented 'with delinquent and aggressive behaviour. Inhibited, neurotic children, in contrast, generally came from united families. The Cambridge findings have been confirmed repeatedly. In the Edinburgh study of school children a hundred children referred to a psychiatric clinic were compared with a hundred non-referred children matched for sex, age and social background, who came from the same school classes. Among clinic attenders 28 per cent. were currently not living with both their own parents. In the control group only 6 per cent. were deprived in this way. Of course, families do not usually break up suddenly. Death accounts for only a minority of broken homes. More often the child is illegitimate or his parents have separated, so it is clear that the parents themselves had difficulties in their inter-personal relationships; these difficulties as they affect the handling of their children, rather than the actual disruption of the family, may well be the important factors causing the child's emotional disorder. Nevertheless, i!legitimacy and the break-up of a family are public events in the sense that they are generally known to profiessionals who can be helpful. Such events also represent points of crisis in the lives of the people affected and it is now commonly held that psychologically skilled intervention at times of crisis is more effective than intervention at other times in helping people with their inter-personal difficulties (Caplan, 1964).

2. Parental ill health and death In an important recent study (Rutter, 1966) in which disturbed children

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referred to the Maudsley Hospital were compared with children attending p~ediatric and dental clinics it was found that chronic physical illness of parents was twice as common among disturbed children than in the control groups, and that parental psychiatric illness, especially personality disorder, was three times as common. The incidence of bereavement in the disturbed children was compared with the expected frequencies of parental death calculated from the Registrar General's mortality tables. It was found that death of either or both parents was signilicantly more common in disturbed children, especially in their third and fourth years. However, the onset of behaviour disorder and the psychiatric referral often occurred long alter the bereavement, indicating that the death itselfwas tess important than theabsence of'the parent. In addition, an association was found between the gex of the dead parent and the sex of the affected child, so that the really damaging ,~-,pect of bereavement in early childhood appeared to be, the loss of the parent as a figure for identification during those years when it is known that identitication with parents is one of the crucial developmental experiences. Interestingly, grief reactions proper, i.e. disturbances occurring within six months ot" bereavement, were contined to adolescents, especially to boys, and then took the form either of depression or of delinquent behaviour. in the comparative study of Edinburgh primary school children (Wolff, 1967c) psychiatric disorder of the mother, especially psychoneurosis and personality disorder, was significantly more common in tire children referred to a psychiatric clinic than in their matched controls. Moreover, while 58 per cent. of the clinic tnothers said they were "'suffering fl'om their nerves", only 25 per cent. of control mothers said this. Seventy-seven per cent. of clinic mothers had been to their family doctor with a psychological problem compared with 43 per cent. in the control group. 3.

]l]~wss il~ dw ch&! As for the children themselves, the referred children had experienced more and longer hospital admissions than tire controls (19 per cent. had been adn)itted three or more times, compared with 5 per cent. of the controls). They had also had more frequent and more serious accidents. 4.

Sel)araliem e.vl;eriellces Separations from parents, which also occurred more often in the clinic group than in the controls, seemed to be symptomatic of family disorganization and of hospitalization of the child, rather than of primacy importance in itself. The excess of separation experiences in the clinic group was not confined to the early years of childhood when children are known to be particularly vulnerable to maternal deprivation. The explanation for this probably lies in the

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fact that the sample studied included very few children who had experienced institutional care. In the Edinburgh study (Wolff, 1967) three sets of lactors distinguished the disturbed children from their matched controls: I. Family disorganization; 2. Maternal psychiatric illness; and 3. Repeated accidents and admissions to hospital of the child himself. When seeking to identify children who need specially skilled handling from all carctaking people with whom they come into contact, doctors, nurses and teachers, attention must be paid not only to children who actually present with behaviour disorders, but also to those children known to have suffered broken homes, to have psychiatrically ill mothers, or themselves to have had repeated admissions to hospital. THE C O N T R I B U T I O N OF

1.

SOCIAL AND I~r.,UCATIONAI. FAC YORS

Factors relawd to tlle sex o f dw child

All surveys of school children show that boys are more disturbed psychiatrically lhan girls and also that while boys are on the who!e more delinquent and more outwardly aggressive, girls internalize their problems and present more often with fears, anxiety and depression. This is generally attributed not to any inherent differences between the sexes, but to the differing social roles allotted to boys and girls in Western society. How such behavioural differences can be induced even in early infancy has been shown by Caudill and Weinstein (1966)in a comparative study of American and Japanese mothers and their babies. American mothers often ieave their babies on their own, but when with them they stimulate and activate them very much. This is in marked contrast to Japanese mothers who generally have their babies with them but play with them, handle them and talk to them very much less. American babies in turn are more active and more noisy. While the Japanese mother treats her male and female children alike, the American mother is more stimulating to her infant sons than to her daughters. Even at this early age, Western mothers behave differently to children of different sexes. Others have shown that in Western society boys are in more conflict than girls over their aggressive impulses. The reasons are not far to seek. A boy is expected to be assertive, fearless and able to stand up for himself. Dependency is not encouraged after the infant years. Most of his early upbringing~ however, is by women, his mother and his primary school teachers. He cannot use them as role models. They cannot say to him, "be like us". He must be different. Yet this difference is often not at all well tolerated by the very people who try to engender it. Douglas (1964), who followed up a national sample of British children, showed that girls excel in school subjects taught by women such as reading, writing and spelling, while boys excel in subjects generally taught by male teachers such as arithmetic, geography and science. Children did well in subjects

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taught by people who could serve as role models for them. In addition, the teachers' evaluation o f ' t h e children contributes to their progress. Positive evaluation stimulates effort and achievement; negative evaluation has the opposite effects. in the primary schools most teachers are women and Douglas (1964) found that they underestimated boys' abilities and were more critical of boys than of girls, both as regards their work and their behaviour. While intelligence tests showed no difference between tile sexes, boys performed less well than girls on tests of achievement and the performance, especially of working class boys, declined relative to that of girls in the course of their primary school years. Douglas' conclusion is that primary school teachers tend to be out of sympathy with the aggressive behaviour of working class boys and that this unfavourable attitude on the part of women teachers adversely affects the boys" classroom behaviour and also their attitudes to school subjects. In part the teachers' bias against boys may be due to the fact that both physically and socially boys mature more slowly than girls and women teachers may set their standards by the social achievements of girls. Research on a second national cohort of children born in 1958 and examined again in 1~,~64to provide evidence for the Plowden Conamittee (Department of l!ducation and Science, 1967), led to similar conclusions, it was found that streaming in schools favours girls. They get into the upper streams more often than boys and once there they do well. while boys swell the lower streams of classes and tend to deteriorate in their school performance as the years go by. Studies such as these indicate that boys are more susceptible than girls not only, as is well known, to the hazards of birth and to physical illnesses, but also to other environmental influences. It is always found that more boys are referred to psychiatrists than girls, especially during the school years. 2.

Cuhural deprivation The relationship between social class and childhood behaviour disorders has been much investigated. Children attending psychiatric clinics are generally found to resemble children in the community for social class lhctors, but there is also evidence that psychiatric referral is biased in favour of upper working and middle class children. A recent survey in Edinburgh of all adolescents seen by psychiatrists ill one year (McCulloch et at., 1966) has shown tha{ many of the youngsters referred to psychiatric departments in hospitals came from stable, middle class areas of the city, while youngsters seen by psychiatrists in approved schools and in the general hospital after a suicide attempt came from socially disorganized parts of the city where delinquency rates, rent arrears and house evictions were common. While psychiatricdisorders in upper working and middle class children are often identified by the parents themselves who take their child to tile doctor, disturbed children from unskilled working class homes are more often identified by public organization:;: the schools, the police and the

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various child care agencies. The socially well off section of the population gets help for its chi;:tren from those community agencies which rely on a voluntary relationship; the socially deprived section of society gets help from agencies which make use of legal sanctions. The fact that delinquency occurs predominantly in lower working class children from socially disorganized areas of cities requires no emphasis. This is well known. In addition there are subcultural differences both in parental child rearing patterns and "in the behaviour of children. In contrast to the middle classes, unskilled working class parents are less openly affectionate to their children" they tolerate more aggression from their children but they also punish more aggressively. Their children are less independent and also more aggressive than middle class children. The aggressive behaviour of the parents p:,:~vides a model with which ttle children identify (Sears; et al., 1957). The treatment that society provides for disturbed children from socially underprivileged homes under the present legal sy~,tem is on the whole disciplinary and punitive, in contrast to the treatment provided For psychiatrically disturbed children for middle class families. It may be tho.Jght that the disciplinary approach to delinquents and their exclusion from society often serves only to reinforce their anti-social behaviour and that the punitive attitudes of society towards delinquents do n~)thing to counteract the parental punitiveness to which such children have already been exposed. However, the socially under-privileged child is not only at a disadvantage compared with the middle class child when he becomes disturbed and displays delinquent behaviour. Douglas (1964) found that in comparison with middle class children of the same measured intelligence, unskilled working class children entered tov~er streams in their classes and obtained fewer grammar school places. Teachers discriminated negatively against such children and this in turn .affected their school performance which declined over the years relative to that of other children of the same initial level of intelligence. There was a two-way relationship between emotional disturbance and school performance. Disturbed children tlailed more often at school compared with non-disturbed children ofthe same ability and children v+'ho did badly at school were more often disturbed than those who did well. There is thus a tendency for social processes to reinforce both the behaviour difficulties and the educational fai!ures of socially deprived children, ,~specially of boys. In their different +pheres. the Kilbrandon Report on the law relatinu to juvenile offenders (Scottish Home and Health Department, Scottish Education Department, 1964) and the recent report of the Plowden Committee on primary education (Department oF Education and Science, 1967) seek to counteract such damaging social processes. One of the recommendations of the Kilbrandon Committee was that delinquent children should be treated like all other deprived and difficult children and that legal proceedings should be resorted

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to only v, hen there is dispute about the delinquent acts themselves. Apprc, ved school.,, should become rnereb one type of a whole range of residential establishments for children who require c~;re, treatment and education away from home. The Plowden Comrnittee (Department of Education and Science. t967i recommends positive discrimination in favour of children from socially depri',ed hc, rnes in order to halt the progressive educational deterioration of such children under the present school system. Schoolv. they say. "must sup.ply a compen~,ating environrnent.'" They advocate that educational priority schools and educational priority areas should be" identified on the basis of a number of criteria. These include: occupational class, family size. overcrowding, poor ~chool attendance and proportions of retarded, disturbed or handicappe(! pupils. Schools in areas high on these indices should be better and not. as al present, worse than in the country as a ,a hole. The ratio of teachers to chiMren should be increased, teachers" salaries should be raised to keep good quality staff in these areas and social work should be developed in conjunction with the schools. I! ma) ~ be too much to hope that the recommendations of these two progres,,i,,e reports ~itl be implernented in full. They contain the seeds for a social policy that could counteract the current tendencies in our society to reinforce the scholastic and social failures of children, especially those from culturally deprived homes. Both reports contain not only recommendations but a grea~ deal of information, and the Plowden Report (Department of Education and Science. 19671 in particular illustrates how recommendations for administrative action should and can be based on actual research carried out in the community for the purpose.

SUMMARY

There is no ideal delinition of psychiatric disorders in childhood. For research purposes three indices of illness have been used: symptonl counts, psychiatric referral and overall judgement of severity of disturbance, The vaiidity of this Last measure is influenced by observer bias and by the fact that children beha\e differently in different situations. Certain adverse environmental events are found more often in the life histories of disturbed children than in those of normal controls, These are family disruption, parental ill health, especially psychiatric illness, and repeated accident~ and hospitalization of the child himself. Prophylactic intervention should focus on children caught up in such critical life situations. The risks of developing emotional disorders and of failing educationally arc particularly high for boys and R)r culturally deprived children. Changes in our educational system and in the way we deal with our delinquent children are required to counteract such damaging social processes.

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RElZER ENCES B.,~,~lsrE~,, H., and RAVDEN M. (1944). Brit. J. Psvchol., 34, 60. BtmT, C., and HOWARD, M. (1952). Br. J. Statist. P.~Tchol., 5, 39, CA UDI'.L, W., and WE I NSTE!N, 1-1.(1966). t"earbook o f the International Sociological .,L~sociatiott. Edited by K6nig, R., and Hill, R. Milan: Irrternational Sociological Association. CAPL,~N, G. (1964). Pritlciples o f Preventive P.tvchiato'. New York: Basic Books. DEPARTMENT OF EDUCATION AND SCIENCE. (1967). ChiMren and Their Prhnao' Schools, Vol. 2. London: Her Majesty's Stationery Office. DOUGL,~S, J. W. B. (1964). The ltome and the School. London: MacGibbon and Kcc. IS,',ACS, S. (193-~). Brit. J. PsvchoL, 2, 71. LAPOUSV., R., and MONK, M. A. (1958)..,Inter. J. pub!. tilth, 48, 1134. MCCOLLOCH, J. W., I t~.NI)ERSON, A. S., and PHIL)P, A. E. (1966). &.or. met/. J., I!, 277. MIN)srRYOI: EDLTCA'rtON. (1955). Report o f the (~ommittee on Maladjusted ChiMren. London: Her Majesty's Stationcry Otfice. Rol~)Ns, L. N., and O'NL:AL, P. (1958). diner. J. P&vchiat., !14, 961. R UTTI~R, M. (1966). Chih/ren o f Sick Part'nts--an Environmenta! atul Psychit~tric Stttdy. (Maudsley Mo)~ograph No. 16). London: Oxfora Univcrsity Prc:~s. RUTVer~, M., and Grt,~,HA~,~. P. (1966). Proc. roy. Soc. Med., 59, 382. SEARS, R. R., M~,cconY, E. E,, and LtzvIN, H. (1957L Pattern~" ofChiM Reuring. Evansto)), lllinois: Row-Peterson. SCOTTISIt HOME AND It~AL3"It DEI'AI~, FMt'N1", SCO I FlSI-I l~t)tJ(z.4riON Dt-:I'ARTMIN 1. (1964). Children and Young Pet'~olls, Scotland. Edinburgh: Hcr Majesty's Stationcry Office. SttEr'i-lERD M., OPI'ENHV.t~.I, A. N., and MITC)tELL, S. (1966). J. C/tiM Psychol.Psychiat., 7, 39. ULLMAN, C. A. (1952). hhvltification ofAtaladjusled School Chihtren. U.S. Public t tealth Monographs No. 7. WICtCMAN, E. K. (1928). Chihh'en's Behaviour and Tecwhers" Attitudes. New York: The Commonwealth Fund. WOLFF, S. (1967a). Brit. J. Psychiat., 113, 885. WOLFV, S. (1967b). Brit. J Psychiat., in press.