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TIhis is one of a number of papers prepared
at the request of the Technical Committee on
Fact Finding of the Midcentury White H~ouse
Conference on Cfhildren and Youth. ALddress
inquiries to the Natiornal Mideentury~ Commit-
tee for C7hildren and You~thl, 160 Broadwa;y,
New York 38, N. Y. Th`)ese papers w~er~e re-
viewed by the Colnuittee. for use in its work,
although Conference pr~oei~red n rs er~e not de-
signed to provide for official approval.
This report w7as prepared by Arthur Lesser,
M. D., Chief, Program Planning Branch, Divi-
sion of Health Servcices, Children's Bur~eau,
from papers presented by Greta Bibring, M. D).;
]Franklin PM. Foote, M. D>.; Ben Grayr; William
G. Hardy; Betty ~Huse, M. D.; William G. Len-
nox, M3. D).; MVelyer A.L 1Perlstein, Mil. D>.; HE~elen.
Ross; and ]Eunice Wrilson.
FEDERAL SECURITY AGENCY
Social Security Administration Children's Bureau 1952
For sale by the Superintendent of Documents, U. S. Government Printing Office
Washington 5, D. C. Price 20 cents
CHILDREN'S BUREAU PUBLICATION NO. 336
P ROBLE MS
H ANDICAPPIN G
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]Parent-child relationship __ __ ___
Reactions of the! child who is handicapped ____
Special problems of the handicapped _______
Achieving independence____ _______
Achieving a feeling of adequacy______ _
Adolescence and achieving a sense of iden~ltit~y
Reactions of society to the handicapped _____
AcN UTNDEIRSTANDING of the emotional problems which
may be associated_ withl handlicapping conditions in childhood reqcu i re~Is
some knowledge of the fundansentaleltl r of th~e social andi emotional
growth and dleverlopment of children, for the handicapped child is
first a child and therefore becomes involved in the growth processe~s of
all children. T'he fact that he is handicapped~t usually creates addit-
tionall difficulties in the growing up process, but no one is entirely free
of these difficulties. How adequately these children are help~led to grrowC
up is of vital importance in their Irachling~ the satisfactions of emo-
tio~lnl maturity. There are many emotionally inllnaturet adults who
are not physically handicapped and who exhibit the same kinds of
reactions as the handlicsap-ped. WVe know that some children who have
relatively minor physical defects may have more serious problems
than others with major handicaps. The key to these situa;tion,l,
whether there is a physical handicap or not, lies essenlt idly in the
degree of security the child experiences in infancy and as he grows
older and faces the progressive steps in emotional growth andt de-
Tvelopmen"t. For this 1reasol, it cannlc.t be isaid too often that the most
imnpo~tan~t job parentlt s have is to give their childrentI the feeling~ that
they are genuinerly loved and wanted. All children need this feeling
and handicapped children need it especially.
Thle relationship between the parents and the handicapped child
is frequently just as healthy as that with a physically normal child;
however, the presence of a handicapping condition always imposes
a strain on the parent-child relationship. An understanding of this
relationship is important, not only because having a handicapped
or chronically sick child has a deep effect on th~e parent, but also
because, in the final analysis, the understanding of the child and the
attention given him have a profound influence on the kind of person
hie turns out to be.
Acceptance of the handicap on a realistic basis can be, and often
is, achieved. But parents (and the mother as central figure in all
these problems has to be stressed) do not always respond rationally
to the painful fact of having a handicapped or chronically sick: child.
They may react with a number of unconscious conflicts and emotions
thus playing into the child's fantasies and fears.
There is hardly a mothler who does not respond with deep feelings
of guilt and self-accusations to a congenital defect of the child, a
birth injury or a chronic disease---even operation or accident leading
to in-validism. Parents, in addition to their normal worry and com-
passion for their halndicapped or chronically ill child, frequently feel
personally injured and aIttackedt' by fate, and are inclined to reject
the child to some degree. This reaction and the resulting behavior
might not be understood at all by the mother or a naive observer and
nevertheless be of the greatest significance for the well-being of the
Some mothers can har~dlly disgfuise their publishing attitude and act
it out, often in the rigidity with which they hold their children to a
restricting diet or painful medical schedule. Others, in their attempt
to cope with these tendencies, lean over backwards to a point where,
with the same rigidity, their lives are sazcr~ifieed completely, respond-
ing to an ulnjust~ibbleb degree to th~e slighltest need or demand of the
little patient and to the detr~imnt~lt also of other memliber~s of thne family.
Anothler group exprle~s this conflict by behaving as if they were! cursed
and are determined never to have another child. Some parents--
without comnprehnending thne meaning of their emotions--feel ashnamed
of the child as if the fact that they have a defective child reveals a
shameful weakness of their owFPn, thus beings the counterparts of the
nzeurotically ambitious mothers and fathers who drive their healthy
children, and demand from them outstanding success in, every area as
a, token of their own greatnetss. Other parents cannot bring them-
selves to see what is apparent to everyone else and they deny that
here is a permanent situation they need to learn to live with. Such
parents may go from one ph~ysiciazn to another, to various healing
practitioners and quackts, seeking support in their evasion. of the situa-
tion and the result is usually a postponement of treatment.
Studies of the elements that make for helpful parental attitudes
shzow that these are simply the qualities usually found in well-adjusted,
emotionally secure people. Parents whose attitudes toward their
handicapped children are not constructive are found to be either
poorly informed about disease and the needs of children or emot-
tionallyy unstable or immature. Such parents are in need of help in
order that they m~ayr have a better understanding of their children
and their needs.
Disturbances in the parent-child relationship may, under some
circumstances, create physical disease as well as emotional problems.
Examples of this are asthma and "'hospitalism." It has been observed
that there is a high degree of sensitivity in the allergic child of both
a physiological and a psychological nature. Thne allergic child is
found to be "'touchy" in disposition, emotionally insecure, and given
to anxiety, especially in relation to any change of condition in his
environment. Given the constitutional sensitivity, t~he child is likely
to react to certain emotional situations with. an outbreak of physio-
Togical symptoms. To what extent the child "uses" the atta~ck2 to
express his emotions is a highly individual matter.
In all the asthma cases studied at the Institute for Psychoanalysis
in Chicago there was found to be a disturbance between mother and
child at an early age, for example, an event threatening to. the! child's
physical nearness to the mother such as an actual separation; or a
psychological estrangement such. as a change in mother's attitude with
the birth of a new child. This fear of losing the mother is believed
to be characteristic of children who are asthmatic. In the study it
wFpas found that the attack did not always occur when the patient was
exposed to the allergens, and that conversely attacks would occur when
t~he patient was thrown into an emotional conflict, even though the
allergens were not present. The conclusion was that removal of the
emotional conflict would help the child to be less sensitive to the
allergens. In the children studied this proved to be true.
T~he m~oth~er is usually over-anxious and often contributes to the
child's emotional upsets. She is flrequenltly a hovering mother and
at the same time her strength and pantienlce have often been drawn
upon so much, especially in the case of the asthmatic child, that she
is both angry with the child for not improving and angry with herself
beca;u-e her own m i nistrant ions have had such poor result. This pro-
duces a clinging on both sides.
These observat;~ ions, made by many allergists as well as psychiatrists,
should be useful in planning medication for the child and in. helping
the mother to be more patient and less anxious. For the very little
child, some psychiatrists advise that the scratch tests not be given in.
the presence of the mother, partly because the mother is likely to
over react, and partly because the child may unconsciously hold the
mother responsible for the hurt and feel more est ra nged from her.
There is a considerable amount of "secondary gain" in allergic
attacks. T'he allergic child gets a great deal of extra attention; he
learns that uItineks~~ can completely dominate the family and that they
are a w~ay of escaping things h1e does not like. Some children may
give up t~he athmalrl~ but develop other symptoms. F'or these reasons
it is advanltageouc, ls for the allergist to work: with thne psychiatrist in
gajlining an understanding of the child and his psychologic response
Thle word "hospitalismn" was applied years ago in lieu of a more
specific diagnostic term. to infants in hospitals and institutions who
did poorly without known cause and usually died. It was soon
learned that the absence of "Lmotherillg" resulted in loss of appetite,
diarr~heat, and loss of interest., which. usually was not the result of con-
taminated milk or parenterazl infections. It was noted that those babies
whlo were thle pets of the nurses or attendanllts got along much better
than the others. Recognition of thle basis of "~hos~pitalism," the need of
infants for the mother or a mother figure, hlas resulted in a great
reduction in the number of infants cared for in. institutions and the
provision of home care whenever possible, foster home care, and
mothering in hospitals by nurses andi attendants.
The prevalence of "hnospitalism" a generation or more ago and its
revival in Europe during the last war when children were evacuatedl
from large cities serves to emphasize the tenusua I~t ic e effect s upon young
children of long .epara;tionl from th-e parents, of which '"hosp~italisml"
is the extreme example among infants. It is important to consider
this since childrenil frequently need to be taken. to a hospital or con-
S~eparation from the p~alrents mnayr be very tratumatic for the pre-
school child aznd may seriously interfere with his ability to form satis-
factory emotional relationships with people. Infants and preschool
child In need their mothers, or a mother subst i tute who should be one
person and not a s~uc~essionl of people. TChe infant under 6i months,
since he has not yet iden~ltified his m~other,, adapts himnself mluch more
readily to a, mother~ substitute thain does the older childi, and such
attac~hmentss do take place with older children under good circum.-
Stalnces. If a child under 6 years needs hospital car~e, t~he care should
be given in small~1 units so that a mnotherl figure can be providedi. Inlsti-
t~utional carle, except for nccessa~~ly brief periods of acute illness, is
definitely untles-ilnh-le for youngII children. Whent~ l\ounglb children' n azre
kept too long in institutions or have a swee ~c-ion of mothrers, they
often revert to infantile habits--bed weltting, nighltmares~, mutism,
failure to respond, failure to smile, etc.--andl their mnenltal and emo-
ticona;l gr'owth is seriously delayed~.
Separa~tionl is usual~lly less trainall~tic for the child from 6 years to
adolescence, but maly be serious for some children of this agert. Usua~lly
at. this time, the mentnI~l horizon. is brander.t~l anld t~he child has anl
inlc~reaing~ capaneity to do th~ings' for himcclf. Because of the im-
p~ortanlce to thle young child of thle family retla~tionship, particularly
w~ith the~ mothler, e~verly effort should be mal~dc- to ma~intazin this rclatf innl-
shlip. The implications of separation for the adolescent are different
and group care is usuallly a satisfatctory situation for hlim,? as he is
already beginning to form attacllnents1~ outside the family and eking~il:
independence from his parents.
In recent y'earls we have seen an increasing appreciation of the fun-
anmn~itnI emo-tional needs of children and underlt ltandcling of their
reactions to separation. from their parents. Somne hospitals are per-
mitting participation by mothers in the care of young children, piedi-
atric units in new hospitals tend to be smaller, a few hospitals permit
the mother to feed her child with food brought flcrom home, the availa-
bility of antibiotics is relaxing the fear of cross infections and liberal-
izing visiting, a few home care demonstration-, ls have beenjl started and
programs are demonstrating that children who are blind or handi-
capped by hearing loss canl make excellent progres'~ls without neces-
sarily being segregated in institutions.
REACTIONS OF THE CHILD
W/HO IS HANDICAPPED
The problem of disability and defectiveness exists in its fundat-
mental form as an ever-present concern in all of us, as a reaction to
illness, accidents, operations, or shortcomningrs in our appearance and
performance. Knowledge of these general psychological problems
should be the background from which we proceed to an uulersl~l~tanding
of the specific problems of handicapped children.
What ar~e the basic concepts centering around disease, accident, andl
disability ? We can observe that our own body, like our own per-
sonality, in its integrity is the center of our normal interest. Usually
this is a wcell-balanced, unobtrusive interest but inner or outer events
may inltenslify' it or upset the equilibrium. For instance, a normal,
well-established interest in ourselves can be shifted to other objects
in case of strong attachment to them, so that thne well-being of a
beloved object eemls more important to us than our own, health or
life. Not only love for a p~erson~, but devotion to our work or to a
cause, a, movement, an idea, may bring about this shift of interest
from ourselves to something outside of us, to such a point that it can
dliminlish our usual concern for self-preservation or self-esteem. On
thet other hand, the normal balance can be upset in the opposite direc-
tion so that interest is centered on one's o~wn personality and body to
such an extent, that it excludes even the usual contact with the world
or interest in the environment.
This happens when a danger from outside threaltenls our security
and inltegrlity, espec~iallyJ if we are troubled b~y inner conflicts w~ihich
demandll~ the normal body and its normal functioning as reassurances
against anxieties of all kinds.
Wha~tever~l the reality of a disease and its cause may be, the child
is usually inclined to link it up with these innrcl appl~~lrehesi ons. He
ilrterpreets it as punllilshlenlt, for whatever he has I;learnedC to call bad
in his thoughts and deed~s; as the result of rejec~tionl or lack of love
from his paltrents; as a sign of his being either an outens~t, or a chlo-se
one; or as a debt owed him by his mother or the world, on which hre
can build his never-enldingl claims and d~emandlc~s.
Accordingr to the different, unconscious m~eaningss thnat d-isease andt
handicap have for thle child, we find dlifferlentl reac~tions and habitual
attitudes which may interfere with the necessary runnagemenll~' t. or some-
times even lead to ~seve\rle personality distortions.
In addition. to these unconscious problems we have to r~emlember~~
that there are sp~ecific frustrations related to diffent~ltlt age groups.
F~or the adolescent patient, interference with the fulfillment of his
interests and realization of his talents, as wocell as disfigruration, have
a much greater effect upon thle feeling of security and courage than
for the younger child. On1 the other hand, thle problem of hospitaili-
za~tionl and separal;tio n from the family or dietary measures and re-
striction of mobility have a mulchl greater illln pnt on the yeningerc1 child.
Our task is to understand the signs and symptoms of thetse~ various
conflicts, to help the child to cope with thleml, and, under favorable
conditions, to eliminated~ their permanenl~lt psychological effect.
The rent ionls of children who are not well adjusted to their handi-
cap var~y. They are usually found to be mixed or overlappiing and
only rarely exist in at clear-c~ut form.
Some children, having a deep conviction that. they are victims of
injustice and that lack of devotion or care must be the cause of thne
condition, may express withdrawal, hostility, atnd, often, aggression
to the more fortunate world. As a rule, the family approaches this
type of child with great warmth but feels hurt and helpless when
friendliness is answered with hostility aind d~isd~in~. Quiet equanim-
ity- and pa;tienlcec, withl unlobtrusive signs of fr'ierllinesst~~ and under-
standing, deprive the child of thne arena of his battle and of the oppo-
nlents whom he wants comlpulsivelly to punish. At the same time, thle
family can dlemlonstrrate by stendcinle~s that true devotion does exist
andc canl lead the childl to a new experience and str~onlg attachment to
the helpful person.
TIhere are other children whose behavior is proud and rather rebel-
lious and who reject pity and excessive demonstrations of kindness.
They (more of tenl boys than girls) ask for respect and are rather
aloof. The only effective waly to be of help is to aIccept the pantien~t
on his conditions. The necessary demands for diet, physioth-erapy,
and adjus~tmentlf to regulations must never be made in a patronizing,
ev-en th~oughl kindly, form. Ins~teadt we must em~phalsize our apprecia-
tion of his courage, patience, reasoning p~o-er, strength, and so forth.
While we acknowledge these procedlures as difficult we stress the
conviction that the patient can fulfill the requirements better than
Otherr children remain, or bec~omle, decpenden~lt and demanding. They
have an excessive need for signs of affection, care, and attention. It
is difficult for them to make independent moves toward progress and,
in fact, being helpless seems to assure them of thne great amount of
considerat ion they want. The demands on the family may become
burdensome and may provoke irritability and defensiveness in. those
providing care. For some of these children particularlyy adolescent
girls) the disability and restrictions may appear to be desirable
gratifications and the prospect of getting well mnay not be welcome.
It is undesirable with such patients to suggest that they could get
better if they wanted to, since this usually results in an increase in
expressions of dependency. The preferable approach is to combine
a grea~terl amount of attention and interest with a friendly but firmn
demand for the child's contributions to our effort. It is a process
of give and take in which we try to teach the child that certain re-
strictions on his demands are una-voidable, not because of our lack of
love but because of a rea~;lit~y situation which makes innumerable de-
mands upon all of us. At the same time we have to direct the child
into a new1 area of relationship which. heretofore he has scarcely
touched, because of his personality structure. Such children usually
have not discovered that striving and achievement are followed by
admiration and affection, and feel that only helplessness generates
kindliness. Work: with these children is slowci7 and cautious.
There are some children, just as there are some adults, who feel
that illness is punlisunent~lt for acts they have been taught to regard
as bad. Their guilt feelings cause the illness to be filled with dis-
proportionate anxlie~tiesi and threaztening connotations. Often there
may result r~esistanlcee to new methods of treatment and the necessity
for an operation may cause great fear. In order to cope with his
deep anxieties, special efforts have to be made to reassure the child
and give him the feeling of our protective strength. For any kind of
patient of whatever age, an essential part of the doct,0r's role is to re-
new in hnim the old, childhood feeling that he has nothing to fear if
the parents stand behind him, but in no other type of patient is this
conviction. of greater importance than in those with anxieties and
guilt feelings. Furthermore, it is advisable to introduce simple and
comprehensible explanat~ionls and information about pending medical
procedures in order to allay the devious and always exragglerated neu-
rotic anxieties and replace then with reality factors which almost
never ha-ve as threatenttlingf connotations as the imagined ones.
We are all aLware of paltienlts who feel tha~t their situa~tionl is becom-
ing hopeless. T1Ihey feel like giving up altogrethner and food and medi-
caltion may be r~efused. Such a situation is most unfavorable since the
wCish. to coop~eralte, the desire and striving for improvement, is neces-
sary for retcoveryl'3 and adjustment. A Inlr.:e amou~nt of attention,
stimulation, and care from the nursing person, and if possible also
from other memberll~~lS of the enlvir~onment, is usual~lly Ilece(-s rly to re-
vrerse this condition and attach the child to thle people around him so
that his inltelres~t in thlen, is alwakrened and hie thus neceptl~, s himself again.
Reactions such as these are conlsideredl by s eelll to be mlore prevalent
among childreni1 with the more serious handlica~ps. It ha:s been o~l srlvedl
however that the basis for thet reaction lies inl the indlividlual perC'L'nallit~y
rather than in the degreec't of hanldice p. Int fact, somle indlividiuals with-
out obvious handicaps suffer mlore than those for whlom a visibly
handicapping condition offers a measure of protection to the egro.
Nror are such behav~\ior reactions chal;ratcIteriti of thle handicappedl.
They are found in all walks of life, among the physically heatlthy3 as
well as the sick and disabled.~l
OF THE HANDICAPPED
All people have problems centered about gaining independence,
overcoming feelings of inadequacy, and establishing themselves as
accepted individuals, These problems are apt to be aggravated among
Dependent~lcy at different periods in varying degrees is a normal
condition for all of us. A handicapped child may have increased
de~pendenlcy needs, or he may have increased dependency imposed
upon1 him by overprotection. Strains within the family and problems
in relations with the siblings may also contribute to prolonging the
Infants, particularly if their handicap is congenital, are likely to
show retardation in social and emotional development. H-andiecaps
in. infants and young children usually create prolonged dependency
needs since the learning rate as well as the ability to do things is
affected. Such dependency is found among children who are blind
from infancy with a resulting tendcyllc~ on the part of the parents to
do so much for the child that he does not develop the skills needed3
in a normal environment. This in turn ninkes it difficult for him to
devlop~l~ emotional mantu~rity. Too0 often we tendzto assume tha~t, a
blind person is dependenlcrt, on us for assistanlce, whnlr l in fact he is not
and aduarllly rejects efforts which tend to make him depenidenit
F~or thie young child who is handicatpp~ed by cerebral palsly the
neuromuscular dysfunlc.tion itself prolong~s thne period of infantile
tlependem-y.~3' While a Ioinorml baby uisua;lly holds his head erect at 3 to
4 months, the spa;stic child's env\ir~olllent continues to be r~estr~ictedl
because he is delayed in this by the spost city of the neck urlls
Similarly, the ability to grasp an object voluntarily at 4 months, a
step in normal decrease in infantile dependc y,~ll- is delayed in spas'-
ticity. The spastic st rectchl reflex causes an opposing mul~sl.lar1 rentl1 lon
to voluntary efforts w~hicht limits the child's ability to learn to wa~lk
and do things for himself and may evenrl produce fear~l of voluntary
In con~t~nst with the spastic, the athletoid does not fear voluntary
effort since he is moving anyway, has more opportunity for achieving
purposeful movement, and therefore is less apt to have continuing
frustrations. Because the cortex is undlamaged, in contrast with thle
spastic, mental defic~iencry is unusual. Like the spas';lt ic child, however,
there is restriction in normal experience. HEe is disabled becaIllzt neof
involuntaryT movements and the necessity of mal~intaiining his balance.
Thne disorders of speech and h-earing, common in cerebral palsy,
further retard the process of maturationl. The result is that bsy thle
age of 2 years, when the normal child through his exper~ienlces~- has
been able to accomplish satisfying achievements, the child with m~od-
erate to severe cerebral palsy, e-ven. if he has normal intelligence, is
still excessively dependent and socially retarded.
Another type of handicap which prolongs the normal period of
dependency is any disorder of communication which occurs early in
life. Speech and hearing are the basic elemenrlts of communication
and of language; to-gethler with their derivative forms of readtinlg and
wr~iting,~ theyT provide the foundations for much of human behavior.
Com~munienltionl is not a simple process, however. The learning, the
per~ceiving and the production of Inllguag~e involve a complex rela-
tionship among auditory, visual, and muscular stimuli and Iresponsess~,
and between peripheral and central nervous systems. Inasmuch as
language is chiefly ]el~learne through the hearings mechanl~isml b~y imita-
tion, thle child le~arns to speak not only because but as he hears.
Commnunication begins very earlyr in infancy, as thle baby reacts to
the requirements for food and creature comfort. Soon he begins to
babble, a stage of development which is probably a pleasurable com-
bination of muscular and auditory stimulation and response. Toward
the end of the first year and through the s~c~ond year, the baby exz-
perimentslt freely with sounds, and some combinations b:egiin to reflect
the rhythm, form and structure of the speech that he hears. This is
the onset of language. In the third year thle child usually becomes
sharply aware of himself as a being d~ifferent from others and takes
eno rmnou s st 'i des in. relating this self to the world. Hlis use of language~t
takes a great spurt and moves at an incren fling~ rate until, by the age
of 8 or 9, the basic lanlgua~ge pattern is fairly well established and is
an important aspect of behavior and azdjustmencllt.
This patterln of language does not develop unaided if there is a
considerable hearing impairment. Whether or not special preschool
facilities are atvailab~le, the mother has the major role in. helping the
young child develop language. This requires persistent effort, lots
of attention, encouragement and a centeilrin of her teaching around
the child's needs and interests. Fiirst the diagnostic picture must be
clarified, in both physical and de~velopm-ent terms, and appropriate
medical treatment carried out. Then it is the business of the audio-
logic center to guide and tealch parents the needs of the child; to work
out a program designed to stimulate language and behavioral develop-
ment; to study and carry through the child's needs in amplification
(whether an individual hearing aid or a binaural, training amplifier)
and in the training of residual auditory pathways; to introduce
parents to the facts of speech (lip) reading as a concomitant or adjunct
to the use of residual hear~ing; and to stimulate the development of
normal conversational habits. This is done on an outpatient basis,
and frequently involves multiple consultation and the use of whatever
local facilities are available. The key to audiologic work with pre-
school children--the age of 18 t~o 24 months is the time to begin--is
parental insight and understanding.
Dependency is also fostered by acute or p~rolong~redl illness. Any
sick individual tends to return, at least temporarily, to earlier patterns
and some of these, such as enuresis, t~humb-sulcking, feeding problems,
more intense dependence on the mother, may recur. If previous
levPels of development wciere more satisfooctorly than the present, or if
theyr were not very well dealt with originally, it may be difficult for
the child to move away from them again. Sometimes, on the other
hand, a successful encoulnterl with a physical illness seems to precede
a real spurt of emotional development.
Return to earlier periods of dependency is very likely in a pro-
longed illness like rheumnatic fever. It will help if the child is given
an opportunity to talk about his feelings and to tell as much as he
can about what the experience means to him. Allowing him to tarke
some active part in. managinglb the situation is usually helpful: the
small child may be given a chance to choose whether he gets his medi-
cine straight or in applesnuee and to make similar decisions within
the limits of the medical treatment that is required; an older child
can be given a more decisive role. The child's regressive behavior at
the onset of illness should be accepted, but he should be helped to
regain his former developmental level as soon as feasible through. ch-
couragementt and in~reas~ing~ responsibility. The limits of hnis phy~sica-l
r~e-t rictionsu should be clear to him. He should be treated co~nsistently.3
He should be prepared~': for new exper~ienlces, as far as possible, by
understandable and realistic, exp~~lllanaions. He should be given~ op-
p~or~tunities for playT, schooling, and creative activities consistent with
his physgical stat us and his age.
The parents should have a careful and realistic discussion of the
medical picture and prognosis. TChey should be allowed to talk about
their worries, and they should be helped to see whether they are becing~
unrealistic a~lly indui~let, or restrictive. They should be helped to
undrlllctandl whalt the explerience meanslll to their child andl howr they
can best give himt suppor~t.
Achieving a Feeling of adequacy
Beginning in the early preschool years, we betcomelci aware of our-
selves as individuals and develop a grow~ing consciousness of howc we
are different froml others. Initially, the parents seem to be able to do
every3thing, and the young child in his dl~~lepenenc upon them feels
inferior in complilarison with themrl. Later, as he plays with. other
children, he becomes aware of differences in ability in relation to them.
If there are young~rer children in. the family or among his playma';tes,
his superior abilities afford hnim some compensation. The fal~ntaies
of children, such as their identifientionl with cowboys and Superman
are normal mechanisms in childhood for overcoming the feeling of
inferiority. I~n the process of growing up, most people are able to
make adjustments in relating themselves to other people, although
therzle may be temporary crises such as rivalry for promotions, love,
and so forth.
T1he problems of gaining a feeling; of adequacy~~113 exists in all of us
since we are all inferior to certain powers, whether in ma n11 or nature.
We are more aware of our inferiority at some times than at others.
A~t such times, we are overly sensitive and feel dissatisfied with our
lot, ina~dequat~le and discouraged. TPhese attitudes- have their roots in
our primitive feelings of envy, hate, and guilt.
Although the feeling of inferiority exists in all of u~s, it is apt to be
much more acute in children whlo have physical handicaps and present
obvious defects. TIIhe child with a crippled leg soon becomes aware of
his inability to run and play with hlis agoP-llnoes. Thle disapploinlt-
mnent of the parents in the child hleighltels his sense of inferiority. If
he is disfigured, as by a cleft palate and lip and "talks funny," he is
apt not to be ignored by other children but to be taunted by them and
to be the recipient of cruel pranks. WC1hen these handicaps are obvious
there is little protection from ep~i2;odels which give great mental pain.
Even should the adults in thne nlei ghborhood be enlli ghtenedl there is
always the problem of the attitudes of otherl children.
Where the handllicap is not sevrelly disabling or disfiguring most
children of preschool and school years are able to make a good adjust-
ment and to be readily neccepted. The wearing of glasses is todayZ so
conunllon that other children do not regard it as different. T'he young
w~earer of a leg brace often attrnelcts attentlionl of other children that
is not unwelcome and after the novelty in the classroom wears off he
is not regarded as unusual. Young children take to wearing hearing
aidts with considerable sat is fact ion as a new world of hearing is opened
to thenm. Whleth~er or not the handicapped child can also participate
freely in games with others is a major question for him. 1Even with
acceptance some children may use the wearing of glasses or a brace
as a protective device to avoid the rough and tumble of childhood play.
This, however, usually has its roots in a lack of security and is not
attributable to the handicap itself which is used as a protection.
WT;Then children are frustrated, as by a handicap, their behavior
may not be socially acceptable. 1Behavior which is expected: of all
young children, but which they learn to control as they are influenced
by parental appr~ovatl and disapproval and by accepted social stand-
ards, may persist beyond thne period where it is expected. Or thle
school child or adolescent who acquires a handicap may revert or
regress to enc~lier behavior patterns. Such conduct may include ejx-
cessive agrgressiv~zlenes, lying, stealing, anxiety, excessive demands,
w-ithdlrawal, and so on. This mazy be true, for example, of cross-eyed
children wmho may suffer the gibes of their school-mates and either
r~et Iren(. within themselves or become cocky, swaggering bullies. Treat-
ment where feasible, as in strabismus, may mean thne difference be-
t weencll an adjusted child and a behavior problem.
There are mechanisms in our physiologyr and psychology which
attempt to make up for some deficiencies. All of us are able to read
lips to a limited degree, but this potentiality is much more fully real-
ized by hard of hearings people who can often acquire remarkable
proficiency in lip reading. The sense of touch can be developed to atn
extraordinary degree in blind people and used in reading or in identi-
fyingr objects. Such achievements tend to make up for these percep-
Sometimes the method of complensatinga creates a special problem.
Thus the young child who hears poorly or not at all does not develop
language unnl~ided. He will make his needs known by various signs.
This is regarllded by some as the "'natural" language of the deaf and
speech as the "second" language. As a result, sign language and finger
spelling are taught. But this is conspicuous and accentuates the dif-
ferences between the hard of hearing from the normally hearing child.
Todayll there is inlcrea~Sing~r emphal~ sis on oral communication wh~lich
utilizes the maximum development. of skill in lip reading (or speech
reading, to use the better termm, hlearling aids, auditory training, and
the tea:chl~ingb of speech. Opp-onen~lts of this method qulest ion its genernI; l
applicability and ask whether it may not engender feelings of anxsiety
and inferiority amonc-1g children who have difficulty in learning speech.
Judging from the arompl~lishmelnt~s of the past few years, there is
little reason. to think of speech as aL secondl ];Ll nguge"' sup~er~imposed
on a8 "ha;sio longuage"2~e of sign and gesture to the dtet ri mentf of the child.
It is most important~ It to take advanltalge~ of the child's langluage potential
which develops raplidly in the preschool years, and. not postpone ther-
apy1 until the school years. B~ut if the impairment is dlilgrnosed early
and clin-ical and guidedc' parental workr is begun by thle age of 2 or 3,
the ];nguagl~le of signs needl~c not develop>. T~he idea tha:t sign-Inguage~rr
or` manlual-]llanguage.~ is the "natural" la~nguager of the child with p~ro-
found hearing impa.~;i Il~rmen can be ma~intained only in. spite of-not
because of--known facts of infant and childhood behavior, the neuro-
phy~siologry of the association centers in the brain, andi the use of com-
pensa~~tory' S adjunelts to the impaired hearing mlchanism~l~ in early
linguistic andl beh~avioral training. TIhis has been demnonstratedl by
the necomilnplishmnent of mal-ny children. It is no rare thing nowadays
for a child of 4, with a severe hearing impairment to be w7pell on, the
way to a good vocabulary and a happy ad~ju.-tmre ntC to the family and
the world around him and t~o be able at, the nonlrl11 period to center a
regular school with or without the nleed~ for special adjunctive edu-
Not all handicap~rs Tend themselves to such a specific mechanism of
compensation.: Some people are helped more genelrally by developing
interests or occupat iotic ns which are within their capabilities. Somne
people pursue hobbies such as reading, gardent~inglb, modeling, and paint-
ing. Others find consllideralble satis~lcfnetio in their religion and in
work with organlizaltions. TIhere is, after all, present in all of us the
need for achieving a ha:~~lla ce in living that will enable us to make a
safi sfalt rjly adjus~tmenrlt to our probclemlls and thne environment.
Adolescence and achievins a sense of identity
Adolescence, w\ithl its ownrl petculliarl anld difficult problems, is prob-
ably the most painful period in growing up. This period involves the
biologic development of sexrual mal~turity,, the further progression. of
the process~~ of me""ntl and emotional growth, and the difficulties in
reconciling the biologic and cultural demands upon the individual.
The adolescent is neither adult nor child although he has something
of each, and in addition thle characteristics of this period. Aclt this
t imIe, thne adcolescent is trying'br to break awmay from close familial dependi-
enlce and establish his own identity and his role in, life as an. adult.
With individuals of this age, glroupl~ ac(tivities become an important
part of life and are being successfully utilizedl in the treatment. of
Physical illness at this time has a somlewvhat different significance
than it has earlier. The adolescent may react to it as though it were
a threat to his prestige. He may, therefore, fear illness and deny its
reality to himself and reject treatment. The considerable concern for
his body may exaggerate the threat to it of even a minor illness. Many
of the psychological and psychosomatic difficulties in adolescence have
their roots in infancy and childhood; the stresses of adolescence bring-
ing; them to the fore. Adolescents who are handicapped are able to
adjust well to this difficult period when they have been fully accepted
by their parents in previous years.
At this time, female attractiveness is of the greatest significance to
the girl, and masculine strength and independence to the bo;y. The
wearing of a leg brace which may not have bothered the 8-year-old
girl much may deeply affect the adolescent. A study of the acceptance
of hearing aids revealed that girls who used them satisfactorily in the
school years began to refuse to wear them in adolescence, with result-
ing increase in problems due to difficulties in communication. Even
though the earpiece can be concealed, the presence of the battery on
the chest seemed to increase their sensitivity regarding the developing
Surgery, in this period, particularly if mutilating, has a more tragic
significance than at any other time. Furthermore, it increases the
primitive fear of mutilation which exists in all of us and may be inter-
preted as punishment for early impulses that are regarded as bad. A
boy of 16 denied to himself for over a year the existence of a sarcoma
of the leg, believing it to be simply a football injury. Even in thre
hospital, he showed no reaction to the decision to amputate the limb.
This was a pathological attempt to protect himself from. his fear of a
future in which his ideal of manliness--to be the captain of the football
team--was threatened. Through psychotherapy it was possible to
help this boy face the reality and at the same time see that he could still
fulfill his role as a man. Regular contact and conversations during
this therapy with a successful war veteran who had lost both legs in
the service was a great help to thne boy. In. this way advantage is
taken of the fact that adolescence is a period of at~ta;chmnents to ideal
adult figures outside the family often amounting to hero worship.
REACTIONS OF SOCIETY
TO THE HANDICAPPED
The reactions of the community toward the handicapped have under-
gone considerable changes in the past generation. Ridicule through
the application of nicknames to individuals on the basis of their handXi-
caps has markedly declined. The work of many individuals and
public and voluntary organizations has contributed a great deal to
the enlightenment of the public and toward an attitude of sympathetic
understanding for the needs of the handicapped and the contribution
they are making to society.
TPhe community's attitude toward some handicaps is frequently no
more rational than that of some parents. A feeling of curiosity is,
of course, common. Pity is so excessive, on thne part of some people,
as to be comparable to maternal over-protection. Such over-solicitous-
ness represents efforts to overcome a deep-seated rejection of the handi-
capped and is an attempt to make up for unconscious hostility, to
appease one's conscience.
Ma ny people are uneasy when they are with. handicapped people.
This may be because they have fears about things which are different
and poorly- understood; or it may be because they are self-conscious
and uncertain how to behave without being patronizing or unnatural.
Disfigurements, such as cleft palate and lip, burn scars and extensive
facial hnemangiomas seen to create feelings of revulsion in some people.
They may, as a result, try to ignore the handicapped altogether and
have nothing to do with them.
Sometimes a handicapping condition has a stigma attached to it.
From antiquity convulsive seizures have been alssc~iaited with. posses-
sion byr devils and even though not many people still believe this, there
seems to be something about the seizure in a normal appearing person
which is deeply repellant. Even though therapy is effective in about
80 percent of the patients, the general public and professional groups
are not greatly inltelrested~ in thne problems presented by this illness
and comlpnlrtively few children have been able to obtain the treatment
they need. The situation is further complicated by a general belief
that seizures are evidence of a tainted family stock and that repeated
convulsions inevitably lead to mental deterioration.
Thus the tragedy for the average epileptic child lies principanlly in
the needless severe restrictions which society places upon him. The
stigma generally attalchedl to epilepsy and the poor utilization of pres-
ent knowledge of the disease have resulted in what appears to be at
conspiracy against him. Dr. Leo K~anner has furnished a most en-
lightening statement about this frustration:
T'he epileptic person, struculing for a place in his community, finds himself
constantly and unremittingly in a position, which does not differ essentially from
Peer Gynt's allegorical dilemma. W7Fherever he turns, in whichever direction he
tries to proceed, there stands menacingly and prohibitingly the massive Borg
of shoulder-shrugging public miscomlprehension. The doors of opportunity are
slammed in his face. He wishes to get an education and most schools either
won't take him in or, if they have done so, send him away when his convulsive
phenomena become a problem in the classroom. He wants to play with other
children and he is chased off the playgrounds, often with deriding epithets ring-
ing painfully in, his ears. He! may not go swimming, ride on a bicycle, or, when he
gets older, drive an automobile. He wants a job and employers have no use
for him; they think of the laws which make them liable for any injury which
a worker sustains while at work. He is excluded from all branches of military
service. He finds himself a social outcast and an economic burden on his family
or on the relief agencies.
It is, therefore, not surprising that the epileptic child reacts, as he
so often does, with behavior that is socially unacceptable. H-e may
become overly aggressive and domineering or, if less assertive, may be
overcome with shame and fear and withldraw from social contacts.
TIhis has been misconstrued so that it w~as formerly believed that there
is an epileptic personality, specific for the disease and a part of it.
This is not warranted since the behavior of the frustrated epileptic
child is not specific but may result from frustrations from any cause.
There is a steadily increasing number of children with treated epilepsy
who are making a good adjustment and are socially accepted. T1he
fact that in the past few months a large national magazine and a widely
circulated Sunday n~ews-paperl supplement devoted articles to two such
individuals indicates that it is still news to most people that a person
with epilepsy can lead an average normal life.
One of the great reasons for the~ neglect of cerebral pnllsy has beenl
the attitude held by many people that a child with this affliction. is evi-
dence of a family taint. Thne proportion. of broken. homes is very high
where cerebral palsied children exist, and quite often one family will
blame the child's condition on some taint in the other family.
Inasmuch as these children are avoided and he~ld in derision by their
playmates and by their neighbors, the parents frequently hide? them
to avoid embarrassment. If well to do, they may hire a. caretaker for
ba~ckl-room. custody. If not well to do, they ma~cy be gladc to colnunit
the child to an institution for the feeb~llem~indiedl r~egnrrdless of his
mental potentialities. The recent activities of public and private
organizations and the workr of parents themselves are helping to over-
come these attitudes of society.
The attitude of the patient's family and of the community to his
handicap are of extreme importance to the child's adjustment, regard-
less of the degree of his handicap. Since both the child and his family
react in a large measure to th~e handicap according to the expectations
of the community, the child, his family and the community need re-
orientation and education simultaneously, as to what can be expected
of him. If the ha ulijcaplped chlild is to have an adequate personality,
he must be able to share in the lives of physically normal individuals.
T1he social en-vironmnent, therefore, should offer opportunities and
services which recognize th~e needs of the handicapped child and yet
not to a degree that interferes wocith the drive of the individual to de-
velop from one emotional level to another. For this reason, we feel
that services which are directed town rd'~ establishing healthy parental
and community attitudes, and toward the social and emotional adjust-
ment of the handicapped individual, should be given equal considera-
tion with the medical, the education, and the training programs. Ob-
jective evaluation of the total adjustment of the handicapped in view
of their degree of disability, their type of education, and their segre-
gation or nonsegregation with simnilar~ly handicapped individuals, are
all of tremendous importance if the handicapped child is to accept his
limitations, make full use of his assets, and relate to normal society
in a mature and realistic way.
Here are some Children's Bureau publications which discuss the
problems of handicapped children.
The Child With Gerebral Palsy--Folder 34
Prepared especially for parents of children with cerebral palsy, this book-
let answers many of the questions parents have about this disease.
The Chlild Wlithe Elpil, /Isy-FIblerl~ 35
A general discussion of epilepsy and what can be done to help the child
with epilepsy, written for parents.
The Chribl7 Who Is Har~d of Heacring-FIolder 36
A parents' bulletin, this booklet tells how children can be helped to use
the hearings ability they have and ways to adjust to the handicap of impaired
Childr~enz With Impatired HEearing-ABn Audciologic Perspective---Publication 326.
A discussion of the steps involved in handling children with impaired
Emotional Problems Associated With Handicapping Conzditions in Childhoo~d-
Designed to help professional workers understand the emotional problems
handicapped children may have.
Services for the Child( Who 18 Hard of Hearlingrr-Publication 334
A guide to the development of programs to benefit children who do not
Single copies of the above publications may be obtained free from
the Children's Bureau, Federal Security Ag~ency, WTashington 25, D. C.
II. S. GOVERNMENT PRINTING OFFICE: 1952
UNIVERSITY OF FLORIDA
3 1262 08484 2227
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