EMOTIONAL AND BEHAVIOR PROBLEMS IN CHILDREN: Summary of a Round Table Discussion Hale F.

Shirley Pediatrics 1960;26;700

The online version of this article, along with updated information and services, is located on the World Wide Web at:
http://pediatrics.aappublications.org/content/26/4/700

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright 1960 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

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@ediuIrics
VOLUME 26 OCTOBER 1960 NUMBER 4

AMERICAN

ACADEMY

OF PEDIATRICS

PROCEEDINGS

EMOTIONAL AND BEHAVIOR PROBLEMS IN CHILDREN

Summary of a Round Table Discussion
Hale F. Shirley, M.D.
Departments of Pediatrics and Psychiatry, Stanford University School of Medicine

The fostering of mental health during the

early periods of childhood is an area in which

the pediatrician plays a vital role. There are two parts which have particular relevance for the pediatrician. One has to do with counseling around a particular problem or symptom, and
the other is concerned with helping parents to

are variables among the determinants of most human behavior which are hard to identify and to evaluate, and usually there are some that are unknown. This leads to the necessity of tenta tiveness at first in planning for a child's treat
ment, and uncertainty, often, as to prognosis. For anyone, the effectiveness of what is done

understand the various stages of child develop ment in order to prevent some of the diffi culties which might otherwise be encountered. These two aspects were considered in this presentation.

COUNSELING IN RESPECT TO A
CHILD'S BEHAVIOR
When vestigating a mother complains about her child's

depends greatly upon how adequate an under standing of the child's environmental back ground one is able to acquire. Such aspects of the environmental background as the emotional atmosphere of the home, the personalities and emotional adjustment of the parents, the feel ings of the parents toward the child and his be havior, and the feelings of the child about the people around him, are all important.
The physician, in his attempts to explore this

behavior, how can a pediatrician

it? What

go about in

does one look for? And

if emotional disturbances are uncovered, what can one do about them? In the field of child psychiatry there is no neat answer to every problem. A behavior problem is not a clinical syndrome any more than a symptom like fever or headache is a disease. Furthermore, the
clinical syndromes in the field of child psy

emotional background, may often feel frus trated, and he may feel particularly baffled and
irritated by the resistance which both the

parents and the children display toward reveal ing their real feelings and thoughts. The more profoundly disturbed the family, usually, the
greater is the resistance. Everyone working in

chiatry are not as yet very well defined. There

Presented 21, 1958. at the Annual Meeting of the American

the field of human feelings and interpersonal relationships has to deal with it. In child guid
Academy of Pediatrics, Chicago, October 20 and

Summary prepared by Dr. Robert M. Kugel.

ADDRESS: Clay and Webster Streets,San Francisco15, California. PEDIATRIcs, October 700 1960

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ance work one attempts to deal with this kind of resistance by being patient, tactful and ac cepting. One should be careful not to probe too fast, for too obvious curiosity or aggressiveness
just increases the patient's anxiety and resist ance. Sometimes, it is many weeks or even

which a psychiatrically oriented pediatrician could handle. There is no implication that a pediatrician should do so, because each physi cian has to decide whether he has the capabil
ity and can afford to devote sufficient time to

months before patients will become really com

fortable with the physician.

Besides giving parents the factual data they need to arrive at correct conclusions, one of the most helpful things which the pediatrician can do is to give parents and children an oppor tunity to explore and clarify their problems,
thoughts, feelings and desires, if they wish. He, like the psychiatrist, can listen sympathetically

and uncritically, postponing advice until he can be fairly sure of the wisdom of it, and also until he can feel that the parent or child can make constructive use of it. If the difficulties can soon be brought out into the open, and if
the parents, with the advice and support of the physician, can come to constructive de cisions and carry them out, the pediatrician

such problems; but in this case no psychiatric techniques were used which are not appropri ate to pediatric practice. The case illustrates how the development and dynamics of a behavior problem gradually unfold, how ever deeper layers of the etiology and ever more obscure maladjustments of the past have entered into the picture. At first, one is struck by the immediate emotional upheaval with which one must promptly deal. Then, one probes for the situations and incidents which have led up to the difficulty, first in the back ground of the child, and then in the back ground of the parents. As one goes on, one attempts to put the material together in such
a way that it makes sense and provides a formu

may be able to handle the situation to the satis faction of everyone. Some of the points can be further illustrated in a case (to be presented and discussed at
length later) where there is not extensive family psychopathology and sociopathology: The patient herself was a little 3-year-old

lation on which plans for treatment can be based. Furthermore, the case illustrates the fact that one never learns everything one might like to know about a situation, but ordinarily one attempts to uncover only what is necessary for satisfactory treatment.
Finally, the case well illustrates, when

girl, who was the first and only child in the

family at the time; physically healthy, intelli

gent and attractive. The mother was an attrac tive, energetic, well-educated and conscientious
young woman who was not handicapped in the

least bit by an inability to verbalize. The father

was not seen, but there was no reason for be lieving that he was not a very capable and

promising young man. It is usually helpful to have both parents come into the interview, but this case illustrates that this is not always
necessary.

The mother was seen 10 times and the child was also seen enough to obtain a good idea of what she was like. Altogether about 12 hours
were spent with the family. From the practical

viewed retrospectively, how much could have been done from the standpoint of prevention before the child was ever brought to the guid ance clinic: what, for instance, could have been done to help the mother in her childhood; what could have been done during the prenatal period and in the infancy and earlier childhood of the little girl. The problem which finally brought the mother of this 3-year-old girl to the clinic was that for about 2 months the youngster had been running away from home. She had run away from home six times. The mother was really in an anxiety state about it. There was no ques tion here that there was sufficient motive for getting help. The first time Mary ran away, she went to the railroad tracks to see the trains and was
gone about 2 hours. Her mother was upset and

standpoint, if one were charging $25 an hour, the treatment would have cost the family $300, not much more than any acute illness with a few days hospitalization would have cost. In a period of 3 or 4 months, results were obtained which were satisfying to the mother, and the
family was helped over a crisis.

This, it would seem, is the kind of a situation

scolded her, vividly explaining the dangers in volved, and finally spanked the child soundly in an effort, the mother stated, to impress her with the importance of what she said and to prevent further episodes. However, before 2 weeks had elapsed, she ran away again. This time, the mother, uncertain as to whether

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702
S@)a11king was the best technique,

BEHAVIOR
just scolded

PROBLEMS and she added, she didn't want anyone to her that she could handle it, because couldn't; experience having shown that couldn't! It would only be natural for a physician experienced in the psychologic aspects
pediatric practice to believe

her. After that, the mother tried to prevent the running away by just clamping down on her and not letting her out of her sight, but under this regimen Mary was able to give her mother the slip 3 more times. One time when Mary threatened to run
away, her mother tried a different tactic. She

tell she she in of

that his first task

said, Okay, run away,and so Mary packed her bag, went to the neighbors, and stayed for an hour or so. Meanwhile, the father came home from work. The neighbors invited the
parents over and they had some cookies and

in a situation of this kind would be to tell the mother that what she was doing was wrong and how she should manage her child. It is true that mothers sometimes come to the
physician expecting criticism, if not a scolding.

chocolate. After a while the parents invited Mary to go home with them, whereupon she repacked her bag and returned, and nothing
further was said about it.

However, running away was only one of several complaints about Mary. For about 2 months, also, she had been wetting her clothes in the daytime, something she had not done for about a year. There were also times when she would revert to infantile speech. But the thing which her mother said concerned her most was that Mary was constantly disobedient and de fiant. The defiance was in all areas: eating, the use of the toilet and at bedtime. Before going to sleep at bedtime, Mary would get up at least 10 times so that it was almost midnight before she would go to sleep. It is often helpful in a situation like this, which seems to be getting more and more com plicated, to ask the mother to describe a typical day. This mother, in response to such a request, started at the noon feeding. Mary, she said, let the food run down her chin. Then she threw her vegetables on the floor. The mother, in anger, stopped the meal and sent Mary to her room. In her own room Mary took all of her
freshly scattered ironed some dresses dress off their patterns hangers on which and her

Some attempt to avoid the criticism by with holding information. Some attempt to forestall a scolding by promptly admitting their errors. Others are prepared to withstand the criticism, and occasionally one sees a mother whose feel ings of guilt and need for punishment is so
great that she seems to seek criticism. This

mother early expressed her concern about her loss of temper and her inability to carry through with a line which she believed was the proper one. Moreover, by emphasizing and attempting to prove the point that she had tried everything and nothing had worked, she was saying two things: first, that it could
hardly be all her fault; and second, that she

stuffed them into a small doll house. She then mother was working all over the room. She next stuffed toilet paper down the toilet bowl. Finally, she got some scissors and cut the bottoms off the shower curtains. By this time the mother said she had a beautiful case of indigestion and she could scarcely refrain from resorting to physical violence. The mother wound up her story by saying that she felt that what her child needed was discipline, but that she had tried everything and nothing had worked. She had tried reasoning, she had tried punishment; she just didn't know what to do,

would have no confidence in an@' quick solu tions which might be proposed. What this mother wanted and needed, her physician soon decided, was acceptance, sym pathetic understanding, and relief from emo tional tensions which were fast building up to a level beyond her capacity for tolerance. Un til she could obtain some emotional relief, it was felt she could neither deal with her child's difficulties objectively nor make effective use of suggestions in regard to her child's manage ment. So the mother was just encouraged to talk. By his comments, her physician attempted to convey to her his appreciation of the difficul ties she faced without emphasizing the serious ness of her child's behavior. His responses to her statements implied that he felt she was sincere and doing her best to be a good mother. The week following the first interview some thing happened which not infrequently does; when the mother came in again, she was more relaxed. She said that during the past week she had felt like a great load had been lifted from her shoulders, that Mary had re sponded to her change of feeling remarkably, and that she had had almost no trouble at all

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with Mary. Now it's pleasant to be told a thing like this, and the physician should enjoy it when it happens, but he shouldn't assume that such prompt improvement can be lasting. In this case it wasn't; when the mother returned the next time, she said that things were as bad or worse than they had ever been. At the same time that the physician was
giving his attention to the emotional reactions

After this, Mary began to talk disparagingly about babies. She stole a nursing bottle from a

neighbor's baby, hid it under her own bed, and the mother later caught her drinking from it. It was at about this time that she began to wet her clothes and to speak with baby talk. Some times, when she became angry, she would threaten to cut the baby's head off.
Here then was a second group of facts which

of the mother and attempting to lessen the emo tional tension between the mother and Mary, he was attempting to unravel the history of the development of the present difficulties. This mother, as is true of most mothers, was willing to talk freely of the development of her child. As she gained confidence in her status with the physician, she began to show more and more of a willingness to talk about herself and her own background.
Mary's mother and father were married soon

might be clinically significant. The history sug gested that the pregnancy was unwanted at first, and was the source of considerable emo
tional turmoil early in the marriage. Could it

be that Mary was really an unwanted child, and that her mother's present solicitude merely covered up a feeling of rejection, which broke
out in anger and excessive punishment during

episodes of stress? Could it be that Mary felt this rejection, was reacting to it with resent ment and defiance, and was playing for atten
tion by resorting to behavior inappropriately

after their graduation from college. Neither of them felt ready for the pregnancy when it oc curred, largely because of economic reasons. The father was quite upset about it. The mother said that she was shocked, but that she recovered more quickly than her husband did, and eventually she came to look forward to the coming of the baby with pleasure. However,
throughout her pregnancy she felt continuously

ill in one way or another. She was hurt by the fact that her husband and friends, for some
time, thought that her complaints were on a

neurotic basis. However, when her baby was about 8 months old, it was established that she was physically ill, and she was placed in a hos pital until her child was 18 months old. While the mother was in the hospital, the maternal grandmother cared for the child and, according to the mother, this grandmother was very strict and demanding. When the mother returned home she felt that her little girl was terribly spoiled, and she was very much hurt because the child showed her no affection. At this time, the maternal grandmother left and the paternal grandmother moved into the home. She was extremely lenient and tolerant; what is more, she criticized every effort of the mother to discipline her child. The mother felt that she overdominated the household and finally forced her to leave. After the mother took over her role as a mother, the situation gradually im proved until 2 months before she came to the clinic, when Mary discovered that her mother was pregnant.

infantile for her age? And then there was the matter of Mary's separation from her mother from the age of 8 to 18 months. What did this do to the feelings of the mother and child toward each other? The mother said that when she was in the hospital, she longed intensively for her child, and she was deeply hurt when she returned home to find that Mary was per sistently indifferent to her. There was also to be considered the fact that Mary was exposed to two types of discipline by her two grand mothers. Would this have been confusing to Mary? And finally, there was the matter of the mother's present pregnancy. Obviously, Mary was already concerned about her position in the family and was jealous of the coming baby. All of these possibilities were brought into discussions with the mother. She came to the conclusion that although she was very irritated
by Mary's misbehavior and became very angry

with her at times, she really was very fond of the child and was deeply concerned for her happiness. She recognized that the current pregnancy had put her under increased tension. She could also understand Mary's feeling of apprehension in regard to the coming baby, and she decided that what Mary most needed, perhaps, was not so much discipline as re assurance in regard to her mother's affection, even if this required some more babying for a time. The mother admitted that she had be come more and more demanding of Mary be cause she was driven by her own feelings of

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704 uncertainty and inadequacy.

BEHAVIOR Throughout the

PROBLEMS feeling that her mother. was always right, and

yet she resented it. She also expressed a great deal of disrespect and hate for her father, emphasizing particularly her feelings toward

early interviews, she was reassured that Mary was a healthy girl of normal intelligence, who

was reacting in a very understandable way to her present situation, and that with her co operation there was no reason to believe that the situation needed to remain so uncomfor table. She discussed what was said in her inter
views with her husband and was pleased at his

him in her early childhood when he was an alcoholic. In her childhood she blamed him for all the family difficulties, siding with her mother in that view.
Here, then, was the third collection of infor

interest and willingness to share the problems by devoting more time to Mary. The mother,
at our suggestion, enrolled Mary in a nursery

school. The social worker who had seen Mary felt that she was ready for it, needed it, and would react to it satisfactorily, which she did. Now what did helping this mother consist of
during this period? Probably just teffing about

mation which might contribute to a more corn plete understanding of the problem and which also needed evaluation. It now appeared that the mother in her childhood felt unloved and rejected. One began to wonder just how capa ble this mother was of warm, loving feelings, and it soon became clear that she was still
struggling (though she was still able to keep

these things released a great deal of emotional tension which the mother no longer directed toward the child. Probably the mother got some insight into the reasons the child was be having as she did, and she was able, therefore, to decide what it was this little girl needed.
Also, the early experience that the child's be

them pretty well hidden) with neurotic con flicts extending back to all of the early stages of her childhood. She told at considerable length of her jealousy toward her younger sistcr, which was so severe that at one time, in
a fit of jealousy, she ran away from home and

havior could improve increased her confidence in her ability to be a good mother. There were a number of aspects of the situation which were explored at considerable length. One was what the mother could do to prevent the increase of the jealousy, particularly after the baby was born. Another one was what the mother could tell the child about the matters of sex that were coming up. The subject was rather embarras sing to the mother, although she wanted to do the right thing. And finally, one bit of advice was given: that she be enrolled in a nursery school. After seven interviews, the mother suddenly asked her physician whether, now that Mary's problems seemed to be pretty well settled, he
would be interested in helping her and her

had to be brought back from a neighboring city 200 or 300 miles away. At the beginning of the tenth interview she asked if it were all right to discontinue inter views, temporarily at least. She said that the
interviews had served the purpose of breaking

husband,

principally

herself.

She

then

dis

cussed her lack of satisfaction in the marital relationship with her husband. She said that she had been troubled with this ever since their marriage. She felt that it was not fair to her husband, who was really a very fine husband, father and person. She said she felt very guilty about it, hated herself because of it, and wished it were different. She said that she had always harbored a great deal of hate towards her own mother, describing her mother as a cold fish and a
strict disciplinarian. She had always had the

the iceas far as her sexual difficulties were concerned. She had been talking these things over with her husband and had been quite surprised at his reaction. Although she had ex pected him to be hurt and angry, he was kind, sympathetic and interested. She and her hus band decided that they wanted to see if they could work it out together. She was assured that this was their privilege, and that if her physician could be of any further help to them, he would most certainly want to be so. There was no further contact with this family for several months. It was learned that Mary was doing very well in the nursery school and that a baby brother had arrived. After a few months, though, there was another emergency call. The mother came in looking worried and said that Mary had again threatened to run away, was wetting her clothes, and had again become obstreperous. She went on to say that until recently Mary had been behaving per fectly well at home and had seemed quite happy. What had happened was that when
Mary and her mother were bathing together,

Mary had commented

on the size of the

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mother's abdomen. The mother told her that she was going to have another baby. We asked the mother what it was that she wanted of us this time, and she said that all she wanted was assurance that she should handle the problems as she did the previous time. We told her that, as far as we could see, this was the thing to do.

COUNSELING PARENTS
This case described illustrates many points. From the standpoint of the functions of the
pediatrician attempting to deal with behavior

parents' anxiety to the point where they no longer seek the help which they really need; such measures usually only backfire. More over, as most pediatricians have learned by repeated experience, merely telling parents not to worry about something does not always allay their worries and is often anything but helpful to them. Nevertheless, by his own self
assurance, his sympathetic interest, his willing

problems of children, some points in regard to the parents are worth further elaboration and
emphasis.

First, while the physician is attempting to determine from the parents' complaints the nature, extent and seriousness of the child's behavioral difficulties, he should also be at tempting to evaluate the emotional components of the situation of which he has become a part. When parents seek help in regard to the be havior problems of their children, it is usually because they are driven to do so by their own anxieties. The anxiety may be quite obvious, even disconcertingly so, or it may be covered up with rigid formality, poise or display of a keen sense of humor; but it is wise for the physician to expect it, to be alert to the extent of it, and to be prepared to deal with it con structively.
In all probability, in addition to being

ness to listen, his sharing of responsibility for the solution of the problems, and his contribu tion of information, the pediatrician may be able to ameliorate emotional tensions which in themselves are a source of disturbance in the parent-child relationship. Even though such a measure does not entirely solve the problem, or at least for long, it lays the groundwork for, and encourages the mother to continue with, further therapeutic efforts. The pediatrician can do more than this. By
assuming the importance of the mother in the

resolution of the difficulties, by respecting her ideas and efforts, and by supporting her in whatever remedial steps she feels she can take (when he feels that they are appropriate), he builds up the morther's confidence in herself as a mother. This is of fundamental importance.
In the case that was presented, the mother, in

working through a complicated situation, ap parently obtained enough feeling of self-confi dence as well as guidance that later when she
was faced with a similar situation
a minimum of reassurance, that

she felt, with

she could

anxious, the mother, in particular, feels guilty. She likely feels that she must be to blame for her child's trouble, that she must be doing something wrong, or that she is inadequate as a parent. She may, in addition, feel frustrated and angryangry at her child because he will
not respond to her efforts, and angry with her self because she cannot make him behave; she

tackle it on her own.

has tried and tried, and nothing has worked. The mother may early reveal these feelings
directly or indirectly, or she may hide them,

perhaps displaying a more or less disguised, defensive attitude. But as long as such feelings are intense and dominating, it will be difficult for her to consider her child's problems ob jectively, to accept suggestions which may be contrary to her feelings, or to change her methods of handling the child when this seems indicated. It would, of course, be unrealistic
and futile to attempt to allay anxieties which

are warranted by a dangerous situation or to overdo the act of reassurance by allaying the

Another point concerning the pediatrician's role which is worth discussing pertains to his use of his position of authority. The authority of the physician in his field is an inherent com ponent and a therapeutically useful aspect of the doctor-patient relationship. Parents come to the physician for help with their children because of their faith or hope in the adequacy of his knowledge and experience, if not of his magic when they feel desperate. His words, in our present society, are likely to carry more weight than those of most other sources of authority. But aside from the unbecomingness of assuming either an authoritarianism which present knowledge does not warrant or a back ground training which has not been obtained, it is usually wiser for the physician to define, at least by implication, the limitations of his role in the diagnostic and therapeutic process. More specifically, work with the mother may be

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BEHAVIOR

PROBLEMS an extreme
which

facilitated if she can be made to feel that the physician-parent relationship is a collaborative one. The physician, because of his objectivity, as well as his knowledge and understanding, may be a catalytic factor in the resolution of the difficulties, but what the mother and father have to contribute is of no less importance. The mother, after all, is usually the one who has most closely observed the child's development, and she is most familiar with the child's reac lions. She and her husband are also most aware of the characteristics of their home atmosphere and of their feelings toward each other and the children. More likely than not, the parent has some pretty good theories or even considerable understanding of what is wrong. Moreover, they, better than anyone else, usually can de cide what they can or cannot do to change the
emotional atmosphere of the home and their attitudes toward the child or their child-rearing

and unreasonable
with periodic

oversolicitude
outbursts of

alternates

rage against the child, the physician may sus pect that the mother's basic feeling is one of rejection, which may vary in degree from one of intense dislike to one of mere preoccupation with unacceptable behavior. The physician may further gain some impression as to whether the mother values the child as an ex pression of her own maternal feelings, either because of his accomplishments or because he serves her neurotic needs; also, whether she underrates or overrates his capacities. And,
finally he may gain some idea as to the amount

of dominance which she exerts upon the child: whether she is indifferent, overpermissive, over submissive, or is unable to be positive and firm or is overdemanding and overcontrolling. Along with the evaluation of the parental
attitudes the physician must appraise the ex

practices. So what the physician can accom plish depends greatly upon the co-operative attitude he can inspire in the parents and upon the assets and positive resources which they can bring into the therapeutic process. As the physician, indirectly through history taking and more directly through his encourage ment of the parents to discuss freely their ideas and feelings, attempts to acquire an under standing of the etiology of the presenting prob lem and the dynamics of the home background, he obtains some insight into the feelings of the parents toward the child and his behavior. Child-rearing practices and philosophies, whether inherited by tradition or acquired by conscious effort, are of significance in the analysis of the disturbed situation; but in the long run, child-management techniques are likely to reflect parental feelings; and, more over, they are likely to be permanently effective only as they do reflect broad, pervasive and reasonably consistent parental attitudes. As conversation with the mother (or father) proceeds the physician begins to form an im pression as to her (or his) attitude toward the child and his behavior. Thus, he may soon come to feel that the mother is a warm person, basically accepting of her child and profoundly interested in the child's welfare, even though she may be confused and upset. In this case, he may properly feel that there is a sound basis for entertaining much therapeutic hopefulness. Or, because of the extent and nature of the complaints against the child, the criticalness and vindictiveness of the mother's attitude, or

tent and nature of both the psychopathology in the personality of the parents, if any, and the sociopathology in the home. Frank mental ill ness in the parents and grossly inadequate or disturbed home environments are usually easy to uncover, but much more commonly to be dealt with in a pediatric practice are the ubiquitous and more or less normal frailties of human personality and the ordinary and extra ordinary stresses of daily living, complicated frequently with marked degrees of personality deviations and neurotic conflicts which are often difficult to define and evaluate without skilled and sometimes prolonged study. From these impressions the pediatrician
must decide what he feelshe can do to be

helpful. There is no simple answer as to what a pediatrician should and should not, or can and cannot, do. It depends, in addition to the extent and depth of the psychopathology and sociopathology in the case, upon the training which he has obtained in the psychologic aspects of medical practice, upon the interest
which he has in working with the behavior

problems of children, upon whether or not he has or can afford the time, and also, upon whether he has learned to make use of child guidance personnel for help with the diagnos tic and treatment procedures which need special training. The ability to deal adequately with the emotional and social difficulties of parents and the emotional and behavioral disorders of children is not easily or quickly obtained. While some knowledge, experience, and skill

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can be acquired through practice, nonpsychia

trically-oriented pediatric training will leave

many young pediatricians feeling confused, inadequate and frustrated when dealing with emotional disturbances. It is the author's ex perience that it takes the equivalent of about a year of training and work with the emotional and behavior problems of childhood before the pediatric resident can integrate basic psychi atric concepts into pediatric practice, and deal with the rank and file of the behavior problems with a satisfying degree of self-confidence and effectiveness. However, the pediatrician, and the general practitioner who engages in pediatrics, have an area and function in the field of mental health which is peculiarly their own. They are in the best position to educate parents in regard to the nature and needs of their children and to provide guidance and support to the parents in the appropriate management of the common emotional disturbances and behavior problems associated with normal social development that are inherent in the ordinary stresses of home, school and community living. They are in the best position to forestall or to minimize the emotional trauma resulting from illness. Fur thermore, in their assumption of responsibility for the health of children, mental as well as physical, they can play a fundamentally im
portant role in their support of the develop ment of adequately staffed and qualified psy chiatric facilities for children, which are no

provide the cues which signify these strategic points in his development. His interest in the new behavior can then be encouraged and he can be shown how to do it. Failures and errors, which are inevitable at times in the learning process, can best be ignored and successes should be approved. The thrill of achievement and of exercising his newfound powers, coupled with the social approval which success affords him, provides the child with the satisfaction necessary for the continuance of the more mature behavior.
It should be emphasized that personality de velopment is not always continuously advanc

ing. Within every child there are three ten dencies competing with each other in regard to the direction of emotional and behavioral de velopment. First, there is the drive toward maturity; in the over-all picture this is nor mally predominant. Second, there is the need at times to remain static in order to enjoy the satisfactions of a resting point and to consoli date the gains already made. Third, there is the desire, at times, especially when the going gets tough, to revert to the satisfactions of the more immature stages. Such fixations and re gressions are usually quite temporary and should be no cause for alarm. If, however, the child fails to make a comeback, the cause for such failure should be investigated.
Only the first four of the following periods will be considered.
Periods 1) Early infancy 2) Late infancy Age Range

six age

where adequate in number or size to meet the

recognized need.

The

first year

or

15

months 3) Early childhood

(preschool)

CRUCIAL STAGES IN THE EMOTIONAL AND SOCIAL DEVELOPMENT OF CHILDHOOD

From the standpoint of personality develop

15 months to 3 years :3to 6 years

4) Late

childhood

6 years to puberty

ment, childhood can be divided into six de velopmental stages. The child's personality in each period is built upon the foundations acquired in the previous periods. No child can
skip a stage, nor can any child be successfully hurried from one stage to the next. Each child

(school age) 5) Early adolescence 6) Late adolescence

Puberty to 17 or 18 years
17 or 18 years to matur
ity (21 to 23 years)

Early Infancy and the Sense of Trust

One of the most important developmental

has his own individual rate of emotional and social, as well as physical and intellectual, de velopment. One of the most helpful services a physician can perform for a child is to help the parents understand the kind of behavior for which the child is ready. The child who is ready to adopt a more
mature way of behaving can be expected to

tasks of infancy and early childhood is to acquire a basic feeling of confidence in the
self and in the world in which the child finds himself, which has also been called a sense of trust.In the first years of life this feeling
comes
0 Erikson,

from

the
Erik

establishment
H.: Childhood

of a satisfying
and Society. New

York, Norton, 1950.

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BEHAVIOR

PROBLEMS
human, and being human means that there are infantile experiences and needs at the core of their personalities.

dependency upon the mother. The mother child relationship, especially the first year or two, is a symbiotic one, and the infant, if
necessary, will struggle desperately to maintain

There are three situations

in infancy and

a close, satisfying and supportive relationship with the person who plays the mother role. From the mother-child relationship, pri manly, comes the foundation for the develop ment of the child's feelings about himself, about people and about the world in general. The first year or two is the decisive stage for the acquisition of this feeling. If the mother child relationship is a satisfying one, the child
acquires a feeling of his own worth and ade

early childhood which may undermine the child's sense of security and which are worthy of special consideration. The most common of these is the anxiety and resentment which the small child feels when he discovers that he must share his parents' love with a newly arrived sibling. Such feelings of jealousy probably cannot be entirely prevented, but if

the parents
symptoms

can be helped
and to accept

to recognize
the feelings,

the
even

quacy and a feeling that his world is a pleasant, giving and rewarding place. To the extent that the mother-child relationship is not a satisfying one, however, the infant feels a discomfort. He becomes anxious and angry. His emotional tension may become manifest in such symptoms as tenseness, restlessness, fretfulness, whining,
crying, havior, clinging, substitute persistence of infantile be satisfactions, loss of interest

though they may have to restrain some hostile behavior, the seriousness of the emotional dis
turbance may be minimized. Another important factor in the normal
sonality development and socialization

per

of the

child is a continuous relationship with one per sonthe mother figurein infancy. Deprivation of mothering or prolonged separation from

in people, and visceral dysfunctions. He begins to view the world as hostile and he becomes defensive. Resentment may be expressed in negativistic, resistive, overly-aggressive or hos tile behavior. The physician's task, therefore, is to help the mother and infantand the father tooto be as comfortable with each other as possible. It is becoming increasingly recognized that the emotional state of the mother and her feelings toward the child are more important in the development of a healthy mother-child relation ship than are the methods and techniques of infant care. From the standpoint of the child, in the de velopment of a healthy relationship with his mother, the pediatrician plays a primary role in his fostering of the physical health of the
child. Illnesses are likely to undermine a com

the mother in certain instances interferes with both mental and emotional development. This ma produce what has been called an affec tionless character. Such a child is lacking in
capacity for feelings of affection and thus lacks motivation for socialization. According to Dr. Bowlby, a baby or small child separated from his mother goes through

three stages of reaction. The first he designates

a fretting stage or a stage of protest. Dur ing this period the child is very unhappy and

miserable; he cries, fusses, and makes every effort to get his parents to be with him. Then comes a transitional period of varying length, which he terms the period of despair.And
finally there develops a period which he calls (probably

the settled-in period,which is characterized

by the defense mechanism of denial

really repression) and in which the child ad

justs to the new situation, but he loses interest

fortable parent-child relationship without the understanding help of the physician. The rela tionship is also facilitated when feeding sched ules are kept flexible to meet the individual and changing hunger rhythms and nutritional needs of the infant. The prevention of un necessary conflict over eating is one area iii which pediatricians in recent years have been
highly successful.

in his own parents. The seriousness

type of reaction

and permanency
from the

of this
mother

to separation

apparently depends upon a number of factors. An attempt is being made to clarify the rela tive importance of these factors. One, quite
clearly is the age of the child.
M. D., amid Bowlby,

Probably
J.: Heseardi

it

o Ainsworth,

It should not be lost sight of, in one's con cern for the infant's welfare, that parents also have needs and schedules. Parents are also

Strategy in the Study of Mother-Child

ter International de l'Enfance, Chateau

Separation.
dc Long

Extrait du Courrier, Vol. IV, No. 3. Paris, Cemi champ, 1954.

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OF PEDIATRICSPROCEEDINGS

709

doesn't matter who takes care of the child or whether he is separated from his mother before the age of 3 months or possibly 6 months, but
by 9 months the child's dependence upon his

months of age, when a child begins to cry at night he may need soothing, but he may need to cry it out,which will probably not be in
jurious to him. By 2 years of age, he may have

mother is becoming a profound one, reaching its peak at about the age of 2 years. After that,
it gradually decreases, and the effect of separa

trouble getting to sleep, and here the parents should be helped to realize that the anxiety is real. Frequently, if the mother will sit in the

tion from the mother (or the person playing the room with the child until he falls asleep, the mother role) after 5 or 6 years becomes of less problem may be over in 1 to 2 weeks. The separation that occurs in the case of importance from the standpoint of the distor working mothers need not be a problem, if the tion of basic personality development. mother assumes the role of a mother when at Another factor determining the child's reac home. Sometimes there is a conffict between tion to separation is the quality of the relation ship that existed between the child and the grandmother and mother and here the physi. mother before the separation. If this has beencian may need to help the mother to tesolve the very satisfactory to the child, deprivation of problem. A child will be confused, however, by the mother's care is felt as a great loss. If the confficting and changing philosophies. Although relationship has been highly unsatisfying to the it is generally preferable to have the mother child, separation causes little additional dep with the child until he is 4 to 5 years old, it rivation. may be that the mother has great need to be The length of the separation is also an im out of the home sooner. portant factor. If the separation is for only a A third situation which may adversely affect few days or during the period of protest, al the socialization of the child, is that in which though the emotional upheaval may be great, the mother is unable to feel affection for her the process is quite reversible. If the child child. In the attempt to understand a mother's returns to the parent during the transitional reactions to her child, one must investigate period, the result may or may not be reversible, such factors as: the emotional relationship depending much upon the parent's reaction. If she had with her own parents and how after the separation, the mother is understand they managed her as a child; the development ing and accepting and permits the child with of her feelings toward her own siblings; the out censure to be clinging and overly dependent degree to which she accepts or rejects her for awhile, the condition seems to be reversible; own femininity; the satisfaction she experiences if the mother is coldly rejecting of the child's in her marriage relationship; the motives she emotional distrubance, it may not be. After a has or does not have for wanting a child; her year or two of separation, the child may not be conscious and unconscious expectations for the able to recover. Dr. Bowlby has stated that he child; the experience she has had in taking care followed some of these children for several of infants and small children; and the quality years and the emotional defect persists. of help she can obtain during the ambivalent The completeness of the separation is an feelings and anxieties she experiences in her other factor determining the seriousness of the new role in life. child's reaction. If the child is in a hospital and of Autonomy his parents visit him frequently, there is less Late Infancy and the Sense likelihood of emotional harm. The availability From about 1 to 3 years of age is the crucial and quality of a substitute relationship may be period in the child's life for the development of another crucial factor. A warm mother-figure what has been termed a sense of autonomy. may eventually be a satisfying substitute for He becomes aware of himself as an individual. the absence of the mother. If a child must be He is inclined to be uninhibited and curious in a hospital for a long time, it may be better and to be into everything. His judgment is poor, for one person to have a close relationship yet he resists limitation and domination. So with him than for many to give him relatively this is the decisive stage in the development in impersonal care, even though their attitudes the child's feelings of being an independent in are kindly. dividual, on the one hand, and of being able to A special separation situation often develops accept the guidance and help of others, on the around waking and crying at night. At 3 to 4 other.

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710

BEHAVIOR
toward authority are

PROBLEMS when the child is angry, there is some reason for it. If he is chronically angry, he and his par ents are probably headed for trouble, and the emotional atmosphere of the home needs inves
tigation. In any case, causes may be found

It is to a great extent during this period that

the child's basic attitudes
normal judgment aggressiveness in the child

acquired. The wise parent wants to encourage

and curiosity of this age, and yet, be and for his

cause of the lack of knowledge, experience and own protection as well as for tolerable home living, limits of acceptable behavior must be
set.

that are unnecessary

and removable.

Second,
anger dissi

the parents should know that when once has become mobilized, it must

pate itself in one way or another. It may be that when the anger has accumulated to The limitations that the parents set in early the limit of the child's tolerance it is healthier childhood, and the attitudes which they display for the energy to become discharged in a fit of toward different kinds of behavior, eventually become a part of the child's personality and anger than to let it seethe within at the expense of normal visceral functioning. Third, the par later, more or less automatically, restrain un ents should be supported in their effort to teach desirable behavior from within. When limits the child that he cannot utilize his anger to get are not set, the child does not learn the basic his way or to dominate the household. Often it elements of self-discipline and continues to step is best to ignore the temper. When this cannot frequently over the bounds of the socially toler be done, it may be best, at times, to send the able; this keeps the child in trouble, confused child to some appropriate place where he can and anxious, and eventually results in parental explosions or frustration and resentment. But have it out. Then, when he has gotten over his if the limits which the parents set are to be anger, he is received back promptly into the effective and are to result in a healthy, well good graces of the family. Fourth, the child socialized conscience, they must be appro should not be made to feel that he is inhuman, priate to the age and stage of maturity of the abnormal, bad or criminally inclined because child. To attempt to hold children of all ages he becomes angry at times. It is better for him to be able to look upon his feelings as normal rigidly to adult standards, can result in nothing but constant friction between the parents and and human even though one cannot approve of them or leave them uncurbed, for otherwise the child, emotional upheaval in the child, and the child has to deal with feelings of guilt and frustration for the parents. In the socialization of the child during this periodwhen his inner anxiety superimposed upon his resentment; when intense such feelings may lead to patho drives are powerful, when he has little control over his feelings, and when his ability to rea logic symptoms. son is very rudimentaryit is hardly possible During this age period the question of pun for parents to avoid all friction and heat or out ishment often first comes up, and when it does bursts of anger at times. Fortunately, when the question is usually the simple one of they make mistakes (as all parents must at whether or not the parents should spank the times) serious harm will not result, if the parent child. Ordinarily, it is wisest not to give an child relationship is basically a healthy one. answer to such a question off-hand, for if the Parents frequently ask the physician how to physician replies in the negative to a parent handle temper tantrums. In homes in which all who knows of no better method of maintaining family members frequently and freely give vent order, all he will be likely to accomplish is to to their hostilities, temper tantrums in the small force the parent into an anxiety state. If, on the child may not be considered a problem; he is other hand, he advises a rejecting, hostile par merely fitting into the pattern of family living ent to traumatize the child more severely than which is held up to him. In most families, how has probably already been done, he only in ever, even if the parents cannot handle their creases the parent-child conflict and thus the own hostilities well, violent temper outbursts emotional disturbance within the child that was on the part of the child undermine the confi at the bottom of the misbehavior in the first dence of the parents. place. If he tells a parent to punish (who emo The physician may be able to help the par tionally cannot) or if he tells a parent not to ents handle such episodes in a constructive punish (who cannot refrain from doing so), he manner. First, the parents must realize that is not only wasting his breath, but he is add

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AMERICAN
ing to the parent's emotional

ACADEMY
burden.

OF PEDIATRICSPROCEEDINGS
first comes to the child in a highly
way in relationship to toilet training.

711
significant
We live

In clinical experience of dealing with fami

lies, one encounters many conflicting opinions as to the value of punishment. There are par ents who believe that regular spankings, analo gous to daily vitamins, are good for the child's

in a society in which cleanliness is highly valued. The sight and odor of the infant's feces
is disgusting to many parents; they want to get

mental health. Then, there are those parents who believe that there may be better methods of punishment than physical trauma, but they sometimes exhaust all their other resources and
just do not know what else to do. Then there

over the toilet-training period as soon as pos sible, if not sooner. This too often results in a prolonged feud or a knock-down and dragout
fightwhich adversely affects the development

of the child's feelings about cleanliness, elimi native and sexual functions, aggressiveness and
authority in general, parents. or results in defeat for the

are those parents who, whether or not they ap

prove of physical punishment intellectually, find that an occasional spanking is a good outlet for

There are a number of possible solutions to the child's dilemma. The socially desirable re action is for him to adopt the adult behavior it serves the same purpose for the child. There patterns. The healthy child can be expected are also parents who believe that their children eventually to do this, if he feels secure in the need punishment, but they cannot bring them love and approval of his parents; if his satis selves to administer it. Finally, there are par otherwise Un ents who are confident that they are able to factions in living have not been dermined; if too many demands have not al control their children adequately without pun ready been made upon him; if he is not, during ishment. The physician dealing with this matter must the training period, in an emotional crisis over be careful lest his own feelings, rather than an such matters as weaning, the birth of a sibling or starting to nursery school; and if his parents objective evaluation of the situation, determine are patient and tolerant of accidents until he his course of action. For instance, if he identi has acquired reliable control. Sometimes during fies strongly with the parent against the bad this period the child may have a period of fecal child, he may fail to understand the meaning smearing. Here parents need to know that this of the child's behavior. Conversely, if he identi their own accumulated hostility, and they hope
the child,
by

fies with
being

feeling
a hostile,

that

the child
mother

is

is not a catastrophe,

but

the child

must

also be

abused

punitive

(which may or may not be true), there is dan

ger of his not being able to understand the

problems

and difficulties of the mother and

thus, of his not being able to help her and, through her, the child. But physical punish ment, especially if frequently and severely ap plied, is likely to backfire, arousing feelings of anxiety, hostility and guilt in the child, which
only adds to his emotional disturbance. Ordi

narily, in child guidance work, as the parents

gain understanding of their children and of their own emotional relationship to their chil dren, punishment, particularly corporal pun

helped to see that this cannot go on. In addition to conforming, he may take over his parents' feelings in regard to the dirtiness and smelliness of defecation. If parental pres sure has been great, he may become anxious about possible accidents and, sometimes, preoc cupied in regard to matters of cleanliness and overcontrolled to the degree of compulsiveness. Or even though conforming, he may continue to harbor anger and resentment, which often, to the parents' bewilderment, finds expression in negativistic or hostile behavior. Occasionally a child refuses to become broken, continuing to soil to the age when such behavior is labelled
as encopresis.

ishment, becomes less and less of an issue; bet ter and more effective measures can usually be
found. In any case, punishment is never the es sential aspect of discipline. Well-socialized be havior comes piimarily from being loved and learning to love in return. It comes also from the child's need and constant effort, in spite of many failures, to become like his parents.

The impact of discipline in our culture often

Ordinarily, toilet training will not be much, if any, delayed if the parents are willing to wait until the child provides cues in regard to his readiness for it, i.e., interest in his bowel functioning and a desire to do what he sees adults doing, or at least until the child is able to walk and run well, which is a good indica tion of cerebral control over the reflex centers

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712

BEHAVIOR

PROBLEMS
love, and this, as has already been pointed out, is bound up with the development of the

of the lower region of the spinal cord. When parents are unwilling or unable to do this and
want to help hurry things along, the physician

may still be of help to them, lining a procedure of putting of not making cidents. an issue

if, while out the child on and ac

parent-child relationship and the satisfactions which the child obtains from parental care and
training. Frequently, a question is raised about the

the potty, etc., he emphasizes the importance

of failures

best time for doing an elective circumcision.

During the 3 to 6-year-old period is espe cially bad, because the child is apt to view this as punishment and to regard it as an attack

The Preschool Child and the Sense of Initiative The preschool

parent-oriented ingly independent

upon himself. As it is difficult to explain this

dependent to him, it is best to postpone circumcision until after 6 years of age. Some parents may need to be cautioned not to overwhelm their child with facts which he is not yet ready to understand or to use con

child is still self-centered,

and emotionally

upon his parents, but he is becoming increas

physically. At the same time

that the child is learning the rudiments of family living through his relationship with his parents, he is acquiring the capacities and ex pen 3nces necessary to get along with other
children. If he has siblings, he has the oppor tunity at home to work through his social prob lems with them, or if he has none, a nursery

structively, yet if a child is old enough to ask

a question, he is old enough for a factual an swer. Certainly, as soon as children discover the anatomic sex differences, they should be assured of their own normality. Even informa

tion concerning
be withheld formation.

sexual intercourse
the children

should not

school may be of help to him in his social de velopment. This is the period when he needs
to acquire a socially acceptable balance be tween aggressiveness and restraint. One wants

when

seek such in

Perhaps more important than the factual an

swers the child receives to his questions, is the attitude towards sex to which the child is ex posedthe manner in which the parents deal with the sexual material. If the child can learn to feelthe naturalness of sexuality as well as what is socially acceptable and what is not, he will be able to deal with his later thoughts and feelings much more realistically. It is particu

him to acquire and maintain an initiative in

satisfying his basic needs and a confidence in

his ability to do so. At the same time one wants him to learn the value of co-operative activity and the disadvantages of fighting, in spite of
the importance
cessary.

of being willing

to fight if ne

During the preschool period the child not

only continues to develop his concept of him self as an individual, but becomes increasingly aware of his own sexuality. This is the decisive

larly important in the interest of later mental

health that the child (as a result of scoldings, threats, and punishments) does not acquire feel ings of dirtiness, badness and shame in connec tion with his normal sexual feelings. The child, as has been mentioned, must learn what society

stage for acquiring healthy attitudes toward sex. It is quite generally recognized now that the emotional foundations for sexuality are ac quired during the first 6 years of life. However, contrary to popular belief, sex education or training does not consist only of the impart ing of the facts of lifeat the appropriate timeimportant as such teaching is. Sex edu cation begins in early infancy with the de velopment of feelings the individual acquires in regard to his bodily functions, also the feel ings he acquiresand the development of these feelings as he proceeds through infancy and early childhoodtoward his parents and, to a lesser extent, toward his siblings. The impor tant aspect of sex training is the development of the child's capacity for receiving and giving

expects of each individual in regard to sexual

conduct, but he also needs to learn of the con the

structiveness both of love in social living and

the role of sex in family living. By helping

parents to deal more comfortably with these sexual problems, the physician is helping to in culcate into the child sound emotional attitudes for later successful sexual adjustments. Behavior problems and nervous habits abound during the preschool period, but this does not necessarily mean that the child is not developing normally, or that he is being mis managed. Life for the child of this age, even more so than at any other, largely consists of solving one problem after another. There are

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AMERICAN

ACADEMY

OF

PEDIATRICSPROCEEDINGS
duce less cortical sedation. It is important

713

always to be solved the problems

of satisfying

ety of situations, especially because they pro

to

his own needs, of keeping in the good graces

of his family, of avoiding punishment, and of growing up and adjusting to an intriguing, but strange, sometimes threatening, and ever-ex panding world. The point of significance is not
so much
or not,

realize that one is treating a symptom only and

therefore the use of a drug alone is generally not the treatment of choice. If used in conjunc tion with the child guidance approach, there may be considerable benefit.

whether
but rather

there
whether

are

behavior
the child,

problems
with the

help of his parents, is successfully working at their solution. In many children there will be more of less persistence of infantile patterns during this period as well as reversions to in

The School Age and the Sense of Duty and Accomplishment The active interest of the pediatrician in well-child care should continue well into the
school-age period, for developmental tasks es sential to communal socialization now emerge
from the accomplishments in the elementary

fantile behavior at times when there are diffi

culties. There will, also, at times be symptoms of anxiety and signs of frustration and hostility. Usually, patience, tolerance, humor, under standing and sympathy on the part of the par emits will be more helpful to the child in over coming such immature and emotionally driven behavior than criticism, scolding or punish ment, even though the latter may be indicated at times. If, however, in spite of all the physi cian and parents can do, unsolved emotional problems amid the behavior characteristics of one stage of development persist into the later

and domestic socialization of the infantile and preschool periods. The child not only continues to grow up, he grows out, for during this period, on his was' to community living, his interests and activities become centered about school life, both academic and social. During this period, he must free himself from primary emotional dependence upon his parents, join peer groups, give as well as receive love, identify with contemporaries of his own sex, stages, psychiatric study is indicated. learn more social rules and morality, use lan Enuresis is a problem often encountered by guage to exchange ideas and influence people, the pediatrician. Certainly there is no one @va@ and develop a scientific approach in his think to handle it, but it is important to establish ing. that there is no organic basis, as is true in most Starting to school, then, is a crucial point in the social development of the child, although instances. Often this is but one of mans' s\mp nursery and kindergarten experiences help toms which the child has. When this is the case, it is likely that psychiatric help is in order. make the transition easy for many children. Although there is often a familial pattern in For some children this first step into com enuresis, genetic heredity seems difficult to munity living means entering an environment prove. It is perhaps more a question of social in which the expectations, demands and emo inheritance. tional atmosphere, and even the ethical stand Many techniques have been advocated for ards, social values and cultural patterns, are the control of enuresis, such as drugs and wak different from those in the home to which they ing-up devices. In some instances they are suc have learned to adjust. For all children, the cessful, but frequently making a great issue of change means learning to adapt to a group of the matter only rivets the child's attention to children with needs like their own. In an at the problem. In general, bed wetting should mosphere of security and acceptance (which the understanding, kindliness and permissive not be considered pathologic unless it continues beyond 3 to 4 years of age. If parents consider ness that the teacher, as a substitute parent, it a problem at an earlier age, reassurance is at first brings into the situation) the child can usually indicated. gradually learn to satisfy his own needs Although encopresis is only one tenth as through his own efforts and to work and play common as enuresis, the emotional impact is in harmony with others whose needs are en usually greater. It usually indicates a greater titled to the same consideration and satisfaction as his own. degree of disturbance on the part of the child, and will usually require psychiatric help. The child's attitudes toward study and learn ing, and thus success in later schooling, de The question of the use of tranquilizing pends greatly on whether or not he can make drugs is timely. They may be helpful in a van

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714
the adjustment necessary

BEHAVIOR
the first 3 or 4 years

PROBLEMS ready for the tasks which he is given to per

form. Most children, for instance, are ready to

of school life. Successful adjustment depends upon several groups of factors. First, the pre school home care must provide the child with the emotional and social readiness and the ele mentary and domestic socialization which are basic requisites to the developmental tasks of school life. Certainly, behavior problems are inevitable at first if the child brings to the school, for projection upon his teachers and classmates, chronic and dominating anxieties and hostilities which have been unresolved in relationship to his parents and siblings at home. Second, the school atmosphere must be accept ing, understanding, tolerant and flexible, even though firm, until the transition has taken place. Third, the child must be intellectually,
as well as physically, emotionally and socially,

begin to learn to read when they are about

63@ years old. But there are some who are ready

at 5 years and some, quite normal children, who are not ready until they are 7 or 8. To prevent a child from developing his capacity when he is ready for it is likely to result in boredom and the development of poor study habits. In contrast, to put pressure on the child for accomplishment before he is ready for
it or beyond his capacity to achieve, not onI@'

results in inevitable failure, but also may ad versely affect his personality development and cause a variety of behavior problems. It should be noted that it is often difficult to find proper placement and good understanding for the gifted child in our school systems.

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EMOTIONAL AND BEHAVIOR PROBLEMS IN CHILDREN: Summary of a Round Table Discussion Hale F. Shirley Pediatrics 1960;26;700
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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright 1960 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

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