The Long-Term Hospitalization of Asthmatic Children

Symposium on Pediatric Allergy

The Long-Term Hospitalization of Asthmatic Children

John E. Sadler, Jr., M.D.*

It is with reluctance that most physicians would consider long-term hospitalization of their patients, even those children who have severely chronic asthma. As in all medical treatments, the physician must weigh the potential harmful effects, or risks, of a given treatment method against the potential therapeutic gains for the child. The hazards of hospitalization of children are not unfamiliar to pediatricians. Spitz27 • 28 • 29 has clearly documented the most extreme effects of long-term separation. Cooke,9 Bergman, 1 and Blom2 have shown the problems of short-term hospitalization of children. Senn 24 • 25 and Jackson 12 have contributed towards humanizing hospital experiences for children and their families. Prugh et al.,t 8 in a controlled study divided 200 children into two groups. One group of 100 children received the usual nursing, medical, and psychologic assistance available in that hospital. They showed that the control group had problems of adaptation 3 months after hospitalization, a number of these reactions being quite severe. They show conclusively the beneficial effects of having special nursing care, consistent human relationships for children, and ward patient staff meetings available to the experimental group. Robertson21 emphasized the importance of the special problems of the "long stay ward." He particularly refutes the arguments that rationalize restricted parental visiting and he supports strongly the concept that "a firm obligation rests upon the hospital to compensate as fully as possible for the loss of maternal care." He emphasizes the importance of giving consistent care from the same nurse, which cannot be provided by student nurses or other trainees. He feels the only solution is that the care of the inpatients should be done entirely by permanent staff. The Robertsons,22 along with Bowlby,a-o have documented studies of the effects of maternal deprivation and separation experienced by children through even brief hospitalization. *Coordinator, Pediatric Behavioral Sciences Service, National Jewish Hospital and Research Center, Denver, Colorado; Assistant Professor of Psychiatry and Pediatrics, University of Colorado Medical Center, Denver.

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On the other hand, Solnit26 has emphasized the adaptive nature of human experience and has emphasized that hospitalization can be approached as a fact of life which children can learn to master as one of life'~· experiences. This adaptive viewpoint helps counteract the potential traumatic experiences. If, with proper care to potential risks of hospitalization, one can develop preventive mental health approaches, what is the evidence in favor of long-term hospitalization as a specific treatment tool for asthmatic children? With childhood asthma specifically, Long et al. 13 have shown the improvement of children's asthma by the simultaneous impact of environmental, emotional, and allergic factors occasioned by hospitalization. Purcell 19 • 20 describes two subgroups of asthmatic children-one called rapid remitters, who contrasted with another group, steroiddependent children. The rapid remitters showed very few symptoms of asthma after separation from their parents. By returning the children to their homes under the care of child care workers, Purcell showed in this short-term study, that such beneficial effects were not simply due to change in the physical environment. In the absence of their parents in their own homes the children still showed improvement in their asthma. In developing the "parentectomy" concept, Peshkin 17 initially meant to show how separation could be exercised as a therapeutic tool in itself. A very unfortunate side effect of the term "parentectomy" has been an attitudinal problem whereby professional people have used this term in a pejorative manner, criticizing parents, particularly mothers of asthmatic children. Out of their own frustrations with the difficulties presented to them by a child suffering from severe chronic asthma, physicians may take their frustrations out upon families and parents of these children with little empathy for the long, anxious nights that the parents have remained up with the child breathing laboriously. Reports of convalescent homes and residential treatment centers have attested to the constructive use of separation in the treatment and rehabilitation of severely ill asthmatic children. However, none of the reports adequately describes the role of behavioral sciences staff in the psychologic care of asthmatic children separated from their families for extensive periods of time. 7 • 14 • 15 In contrast to the previous optimistic reports, Falliers 10 reported a 15year study of changing statistics at CARIH which showed that the number of patients improving dramatically upon admission to that residential center had dropped from a reported 98 per cent in 1953-55 to 12 per cent in 1968-69. He also noted that potentially the most important variable, namely the child's physical and psychologic home environment, could not be fully assessed in the residential setting. A primary role of such institutions must be to provide experienced staff for the investigation of a multiplicity of physical and psychologic factors likely to precipitate or aggravate asthma. Such facilities must train personnel in various related fields and in interdisciplinary cooperation. This report is an attempt to describe the current Pediatrics Behav-

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ioral Sciences Program at the National Jewish Hospital and Research Center (NJHRC). Hospital Setting NJHRC in Denver provides for the long-term medical and psychologic treatment of children from infancy to adulthood who suffer from chronic intractable asthma. The Pediatrics Department is responsible for the diagnosis and medical management of approximately 100 children at any one time from infancy to age 15. The majority of children stay for approximately 1 year, with admissions as short as 12 hours, and occasionally as long as 2 years. The children are referred from throughout the United States, Canada, and South America. A child psychiatrist is Coordinator of the Pediatrics Behavioral Sciences Liaison Service and is responsible for the supervision of the large staff of child care and social workers whose mission is to counteract the potential traumatic and deprivational problems of long-term care away from parents and families. The Pediatrics Behavioral Sciences section operates as a liaison service to the Department of Pediatrics. Consultation is provided upon request from the Pediatric Allergy Fellow who acts as the primary physician.

Goals The Pediatric Behavioral Sciences section mission is to make the hospital experience nontraumatic psychologically. Another important goal is to support the medical and nursing programs in a way that helps the child come to grips with the nature of its illness. Depending upon the child's cognitive capacities, he or she is helped to learn as much as possible about asthma and begins to have a "living education" regarding asthma. Admissions After referral by a physician for admission to NJHRC, an evaluation of the medical and psychosocial history of the child and family is made. Rarely is a child's admission rejected because of medical or psychosocial reasons. Costs of hospitalization are borne by third party payers, the institution itself, or the parents, if they are able to do so. Team Concepts The essence of our working with asthmatic children is and has to be a team effort involving many disciplines. The team to which a child is assigned consists of from eil~ht to 13 children and a staff which includes five child care workers, a team social worker, an occupational therapist, a nurse, a physician, a physical therapist, a teacher, and a psychiatric consultant. Since January 1973, children have been grouped randomly according to age and sex on teams and not in accord with the traditional ward assignments of children according to ages, such as the babies ward, toddlers ward, adolescent ward, etc. This method of assignment is

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an attempt to provide a family setting and the continuity of stable, consistent, warm people with whom the children relate throughout the course of their hospitalization. Clinical observational studies in our hospital have shown that the benefits of this kind of assignment outweigh the disadvantages. 16 The children benefit from the "family" groupings. Adolescents respond well to infants and toddlers. The babies and younger children seem to benefit from the emotional relationships provided by older children on a regular basis. The staff members meet at least once weekly for approximately 2 hours to discuss their group of patients. In this team meeting, the physician keeps the rest of the staff informed as to current diagnostic and therapeutic procedures. The other staff members bring to the meeting their clinical behavioral observations of the child in a variety of settings so that the physician can get a total picture of his patient. He may get special school information, knowledge regarding night time asthma patterns, and effects of exercise. The exciting potential that a long-term hospital stay affords is the possibility of making systematic observations regarding a child's daily life to ascertain the interplay of emotions with his asthma on an ongoing basis through several seasons of the year. The team can assess the child's ability to use expanding privileges and assess the anxiety the child shows, e.g., in not wanting to leave the hospital for activities. Specific behavioral or psychologic problems can be addressed through the team meetings and a collaborative group approach can be developed. The social worker can bring the staff up to date on current family situations as well as on current contacts with the child through case work or more formal psychotherapeutic encounters.

Group Living Program The largest group working with children at NJHRC is the child care workers (counselors). They have the major impact on the daily life of the child. As hospitals are recognizing the importance of these nontraditional professionals, child care work is developing its own professional identity through such national associations as the American Association for the Care of Children in Hospitals and the Association for Child Care Workers, Inc. The four or five counselors per team are supervised by a team leader who reports to the Director of Group Living. The team leaders are in turn supervised by senior Behavioral Sciences staff or psychiatric consultants. The counselors are responsible not only for helping with dayto-day living tasks but also for making daily observations which are so important in defining the various psychologic parameters and interplay between the child's activities, his emotions, and his asthma. The counselors help conduct community type meetings between the ward staff and the children to help foster good staff-child relationships. The children meet with food services personnel to become involved in menu planning, not only for their in-hospital stay, but also for camping trips and picnics outside the hospital. A great deal of the group living activities would be considered recre-

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ational therapy or activity therapy by some professional groups. What may be considered simply an excursion to go bowling, may tum out to be very enlightening as to peer interreactions and staff-patient relationships. For the children who have been so restricted by the medical aspects of their asthma prior to admission to NJHRC, these activities form the nucleus of a program which helps them to become desensitized to the anxieties, fears and disappointments of the past. Some children may have their first experience of crossing the street alone when they come to NJHRC, so extreme have been their restrictions in the past because of parental over-concem. Because the child care workers are assigned to a small group of children and since they do not rotate among different teams, they can know their assigned children very well. The child care workers become either the parent surrogates or often the "older brother or sister" for the children who remain at the hospital for a significant period of time. The child care workers many times become the confidantes for the children in their struggles with nurses and doctors regarding their attitudes towards their illness. They become the resource people for the children as they struggle with the usual developmental crises accompanying childhood and the whole process of growing up as well as the special crises related to asthma. In addition, the child care workers receive special medical training regarding asthma and other illnesses treated at NJHRC, such as cystic fibrosis and juvenile rheumatoid arthritis. The counselors along with the nurses are quick to pick up any errors in dietary management. They will know the child's specific allergies and will be able to mobilize the child in developing his own responsibilities and awareness regarding his limitations along with his privileges. The need for assignment of staff on a consistent basis with a consistent group of children cannot be overstated. This type of assignment is particularly necessary and helpful for the infants and toddler population of the hospital. We encourage the formation of close relationships to try to foster an emotional climate which encourages ego development in all ages, but particularly rapid is the progression in the development of the children under age six. The use of cross-age group assignments facilitates this process.

Camping Program Several years ago a camping program was initiated at NJHRC. This program is a medically well monitored set of activities which takes advantage of the Colorado Rocky Mountains to encourage outdoor activities and to support the development of group skills among the children hospitalized at NJHRC. This situation provides a unique opportunity for groups of child care workers, nurses, and doctors to take small groups of children camping at moderate altitudes. Through this living, learning exercise, the children develop new feelings about their own identity and own capacities to live and play despite their asthma. Children who may have exercise-induced asthma find that they can appropriately test their own limits and respond adaptively while hiking and camping. This program gives the children a chance to see their nurses and doctors out

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of uniforms, relating to them more as the human beings they are and without the usual hospital-imposed structures. Foster Grandparents The foster grandparents are another group who are utilized as supportive personnel particularly with the younger age group of children. They develop loving attitudes towards their "own" grandchildren in the hospital and remain consistently important to these children. With the new arrangement of children's groups crossing over age boundaries, we now find older children gather around the grandparents as they tend to some of the infants and toddlers. It is not uncommon now to see them reading stories to the older children as well as tending to the younger ones. Pediatric Occupational Therapy The occupational therapists are involved in the initial developmental assessment of all children under age six and make successive reports concerning developmental progress or remediation of any developmental delays, including emotional and social skills. This staff is particularly helpful in working with children with perceptual cognitive motor dysfunctions and does special testing and individual or group therapy where indicated for these problems. The degree and quality of a child's ability to work in groups are noted for team meetings and provide observations for the remainder of the staff working with the children at other times in the day and on the weekends. The therapeutic value for children in mastery of projects and the development of abilities to choose and individualize projects according to individual needs cannot be underestimated in a children's unit.

NJHRC Educational Services One of the most exciting aspects of treating children in a long-term facility is the amount of progress that one can see in correcting educational deficits. Many of the children are several academic years behind their chronological school age. At the present time there are six fulltime teachers plus a Coordinator of Educational Activities who occasionally augments classroom teaching time. The key to this program is not only that education is one of the psychologically most important avenues of adaptation for children in our age group hospitalized at NJHRC, but that the teachers are quite interested and challenged by the educational opportunities for these children. All of the teachers are beyond the M.A. level in training and experience. A great variety of special educational problems is seen in the classrooms at NJHRC. A new Learning and Therapy Center is being planned in recognition and furtherance of these kinds of activities. Appropriate classrooms are available from nursery school to junior high school, plus a physical education program and music program. The music program is geared to innovative concepts of using body movements and rhythm and learning not only about music but also about concepts of body awareness which are so important in helping asthmatic children.

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Social Work Services A comprehensive psychosocial history is obtained through a professional agency prior to acceptance of children to NJHRC, except for emergency admissions. Both parents are encouraged to come with the child at the time of admission and to remain for as long as necessary (from 1 to 5 days) to help with the initial medical evaluation as well as with the child's adjustment and transition to the hospital. The social workers are key personnel involved with working with the parents, not only at the time of admission and discharge, but throughout the hospitalization. They remain the key liaison between the child and his family through long-distance phone calls, letters, progress reports, and report cards. In 1972 outpatient parent asthma discussion groups were initiated by a social worker from the New York regional office. These were developed also on the campus in Denver where the groups are formed of parents within traveling distance whose children either are or have been patients at NJHRC. The group meetings are held monthly in collaboration with a nurse and full-time staff physician to provide ongoing social, medical, and nursing information to the parents. The groups also develop an atmosphere of mutual support given among the parents for problems common to all parents of children with asthma. The discussions run the gamut of practical earthy matters, from getting a baby sitter for an asthmatic child to more complex psychosocial maritalfainily dynamic problems. The nurse and doctor, as well as a social worker, are available for educational counseling. Common themes of those groups have been the parents' difficulties with various professional people and the varieties of problems associated with childhood asthma, e.g., when the parent goes to a strange community where they encounter a new emergency room. The group develops an openness to discuss their disappointments in the help offered for asthma, as well as sharing problem-solving techniques that foster concepts of mastery and adaptation. The social workers on the campus at NJHRC also provide a great deal of casework and psychotherapy time for children needing individual and group psychotherapy. They provide direct clinical resource help to the counseling and nursing staff on a daily basis. They provide the chief liaison between family and staff in helping them to understand the child and promote the development of the child while he is hospitalized. The Chief Pediatric Social Worker as well as her staff are key members in the training of the Allergy Fellows in approaches to parents and family problems as well as in the in-service training of other Behavioral Sciences staff. The staff social workers also, of course, provide the usual medical social work services regarding community agencies, resorces, initiating help in adoptive or foster home selection, child welfare problems, etc. Psychiatric and Psychologic Services Although the hospital is staffed with one full-time child psychiatrist as the Coordinator of the Pediatrics Behavioral Sciences Liaison Service and a full-time child clinical psychologist, we have not attempted to de-

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velop a "psychiatric unit" within the facilities of NJHRC. Psychiatric and psychologic evaluations are not done routinely on all children admitted. The main utilization of these professionals' time .is in staff development, training, and supervision. Children are referred for individual psychotherapy as needed by the primary physician on a consultative basis and a treatment program is worked out with the Behavioral Sciences clinical treatment leader, who is a senior Behavioral Sciences staff member assigned to each floor. Child psychiatrists from the University of Colorado Medical Center are assigned to NJHRC as part of their Fellowship training and offer direct and indirect services. In the rare case when a child is extremely suicidal or his psychotic behavior cannot be managed therapeutically in this setting, a decision is made to transfer the child to a psychiatric unit nearby (Colorado Psychiatric Hospital). We have used this facility only rarely, once for a severely delusional child and once for another child who dealt with stress with fire-setting. Although the family and referring agencies knew about the fire-setting prior to admission, they failed to alert us of this potential hazard, probably for fear that we would not have accepted the child for hospitalization. Special Issues Various problems related to asthma are discussed with the children spontaneously when the occasion arises either individually or in community ward discussions (for example, when a child has died). More formal asthma discussion groups are attended on a voluntary basis by children. Patterned after the parents' discussion groups, these groups are formed with physician and nurse in collaboration with Behavioral Sciences staff to foster an atmosphere where fears and concerns regarding the meaning of asthma to these children can be discussed. It is not uncommon for children to be caught in the family's financial struggles as the parents discuss how costly the medical management of their asthma has been. The children are also quite aware of death and dying, not only from previous experiences in other acute intensive care units, but also from the panic and fears ensuing when they are in status asthmaticus. Other problems can be approached in such discussion groups, such as the type of child who has had rather omnipotent control of his family and manipulation of his parents by his asthma. Some children are depressed and hopeless regarding any future possibilities regarding their asthma and peer groups offer the opportunity of mutual support in discussing common problems encountered in one's lifelong struggle with asthma. Limitations of Long-Term Hospitalization As previously noted, NJHRC's attitudes are against fostering any misunderstanding regarding "parentectomy." The greater reality which the child faces in most situations at N JHRC is that he will return to the same home situation from which he came. Many times we have supported and encouraged parents to become involved in their own therapy to resolve some of their problems while the child is in the hospital.

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However, we realize that the more likely situation is that the child will return to the situation where the parents may have little or no more education regarding their child's asthma, despite our best attempts at providing progress notes or frequent phone calls. Leaves of absence are encouraged for children as a way to facilitate continued engagement between the home and the hospital in collaborative working relationships. Not infrequently, however, parents do divorce while the child is in the hospital, or other situations take place, such as a death in the family. The process of re-integration of the child back into the family still needs to be studied more intensively. It is not infrequent to see a subgroup of our patient population begin to wheeze more frequently as the anxiety of returning home becomes manifest when discharge planning first begins to be discussed. Many parents, for the first time, come face-toface with the reality that NJHRC offers no magic wand. They have to come to grips with the reality of the chronic illness with which they have to cope. Community Resources The problems inherent most clearly at this time are the problems of inappropriate admission in the first place. Many physicians under pressure of the family or the local situation and without adequate community resources at their fingertips, will refer to N JHRC to solve what appears to be primarily a psychosocial problem along with medical aspects of the asthma. The physician who refers to NJHRC with the fantasy that we will somehow be able to change the uncooperative family or get a child so well rehabilitated that he will not need community resources is also doomed to disappointment with the hospitalization. On the other hand NJHRC, through the Department of Behavioral Sciences, has recognized the advantages of community contacts in order to maximize the investment in the child by providing a limited number of funds for Behavioral Sciences staff to visit the referring physician and community resources to help the family and to utilize his community resources better. At the same time, we have also provided special funds for selected indigent parents to visit their child and take an active part in their own educational activities and their own collaboration with the hospital which, without such financial resources, would be impossible. Family Psychiatric Problems In the long run, admitting a child to NJHRC for the resolution of family problems with the feeling that this hospitalization will remove the stress from the family, usually defers the eventual resolution of those problems. Such a lengthy hospitalization may give a family a needed rest, but such families need additional professional help and would perhaps be best served by facing that situation rather than putting off a painful reality which they will necessarily have to face when the child returns anyway. We recognize that in accepting these types of referrals that the child may indeed benefit in the stabilizing growthpromoting experience at N JHRC and so have not refused admissions

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where psychosocial factors have dominated the so-called "purely medical" symptomatology. Perhaps in the future, regional medical centers for the care of children with parents and agencies more closely than is possible at a national referral center such as our own, may help to resolve some of the difficulties encountered in the eventual return of the child to his family. To balance the types of services available to chronically severely ill asthmatic children, I propose that "medicoeducational" day treatment centers be established in regional areas. Such centers could offer special educational services by an educational staff trained regarding asthma and comfortable with the disease process. Properly staffed with nurses and "standby," 11 • 23 i.e., child care staff experienced in the management of asthma and behavioral crises associated with asthma, such day treatment facilities could help correct educational lags inflicted by asthmarelated school absences, prevent unnecessary hospitalization, and maintain close family ties. Such centers could form the research potential to study the difficult problems encountered between parents, teachers, and the asthmatic child. Until such centers are established, NJHRC remains a viable, useful, therapeutic environment for the study and treatment of chronic intractable asthma, as well as for the training of personnel in multidisciplinary cooperation.

ACKNOWLEDGMENTS

The author wishes to express his appreciation for suggestions, comments, and criticism offered by the senior staff of the Department of Behavioral Sciences of the National Jewish Hospital and Research Center and by Dr. Geb Blom, Professor of Psychiatry and Education, University of Colorado Medical Center, Denver, Colorado.

REFERENCES 1. Bergman, T.: Observation of child's reactions to motor restraint: The nervous child. In

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Bergman, T., and Freud, A. (eds.): Children in the Hospital. New York, International Universities Press, 1965 p. 318. Blom, G. E.: The reactions of hospitalized children to illness. Pediatrics, 22:590, 1958. Bowlby, J.: Maternal Care and Mental Health. World Health Organization Monograph Series, No. 2, Geneva. (U.K., H.M.S.O.; U.S.A., Columbia University Press) 1952. Abridged version: Child Care and the Growth of Love. Baltimore, Pelican Books A271, 1953. Bowlby,].: Separation of mother and child. (Letter) Lancet, I :480, 1958. Bowlby, j., Ainsworth, M., Boston, M., and Rosenbluth, D.: The effects of mother-child separation: A follow-up study. Br. J. Med. Psycho!., 3 and 4:211-247, 1956. Bowlby,]. eta!.: A two-year-old goes to the hospital. Psychoanal. Stud. Child, 7:82-94, 1952. Bukantz, S. C., and Peshkin, M. M.: Institutional treatment of asthmatic children. PED. CLIN. N. AM., 6:755-773, 1959. Care of Children Committee 1946 Report: Presented by the Secretary of State For the Home Department, the Minister of Health, and the Minister of Education (The 'Curtis' Report). London, H.M.S.O., 1946. Cooke, R. E.: Effects of hospitalization upon the child. In Haller, ]. A., Jr., eta!. (eds.): The Hospitalized Child and His Family. Baltimore, The Johns Hopkins Press, 1967. Falliers, C. J.: Treatment of asthma in a residential center: A fifteen-year study. Ann. Allerg., 28:513, 1970.

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11. Farley, G. K., et al.: "Standby": The application of life-space interview techniques to public school settings. Presented at the October 24-27, 1974 Meetings of the American Academy of Child Psychiatry in San Francisco, Calif. 12. Jackson, E. B.: Treatment of the young child in the hospital. Am. J. Orthopsychiat., 12:56, 1942. 13. Long, R. T., Lamont, J. H. Whipple, B., Bandler, L., Blom, G. E., Burgin, L., and Jessner, L.: The psychosomatic study of allergic and emotional factors in children with asthma. Am. J. Psychiat., 115:114-890, 1958. 14. Mascia, A. V.: The role of a residential center in the care of the asthmatic child. Ann. Allerg., 22:191, 1964. 15. Mascia, A. V.: Progress in the treatment of the asthmatic child in a convalescent setting. J. Asthma Res., 3:239, 1966. 16. Matus, 1.: Patterns of Affiliative Behaviors Within a Mixed Grouping Ward in a LongTerm Pediatric Hospital. Pediatrics Behavioral Sciences Liaison Team Report No. 1, August, 1974. 17. Peshkin, M. M.: Asthma in children. IV. Relevant environment in the treatment of a selected group of cases: A plea for a home as a restorative measure. Am. J. Dis. Child., 39:774, 1930. 18. Prugh, D. G., et al.: The study of the emotional reactions of children and families to illness and hospitalization. Am. J. Orthopsychiat., 23:70, 1953. 19. Purcell, K.: Distinction between sub-groups of asthmatic children, psychological tests and behavior rating comparisons. J. Psychosom. Res., 6:283, 1962. 20. Purcell, K.: Distinctions between sub-groups of asthmatic children: Children's perceptions of events associated with asthma. Pediatrics, 1 :486, 1963. 21. Robertson, J.: Young children in Hospital. London, Tavistock Publications, Ltd., 1970, p. 66. 22. Robertson, J., and Bowlby, J.: Recent trends in care of deprived children in the U.K. Bull. World Fed. Ment. Health, 4, No. 3, 1952. 23. Sadler, J. E., and Blom, G. E.: "Standby": A clinical research study of child deviant behavior in the psychoeducational setting. J. Special Education, 4:89-103, 1970. 24. Senn, M. J. E.: Emotional aspects of convalescence. The Child, 10:24, 1945. 25. Senn, M. J. E.: Relationship of pediatrics and psychiatry. Am. J. Diasbil. Child., 71:537, 1946. 26. Solnit, A. J.: Hospitalization, an aid to physical and psychological health in childhood. Am. J. Disabil. Child., 99:155, 1960. 27. Spitz, R. A.: Hospitalism: An inquiry into the genesis of psychiatric conditions in early childhood. In Eissler, R. S., et al. (eds.): The Psychoanalytic Study of the Child. New York, International Universities Press, 1945, p. 53. 28. Spitz, R. A.: Hospitalism: A follow-up report. In Eissler, R. S., et al. (eds.): The Psychoanalytic Study of the Child. New York, International Universities Press, 1945, pp. 113117. 29. Spitz, R. A.: Anaclitic depression. In Eissler, R. S., et al. (eds.): The Psychoanalytic Study of the Child. New York, International Universities Press, 1945, pp. 313-342. National Jewish Hospital and Research Center 3800 E. Colfax Avenue Denver, Colorado 80206