Professional Documents
Culture Documents
Psychologic Aspects of Pediatrics
Psychologic Aspects of Pediatrics
Psychologic Aspects of Pediatrics
SOME I N T E R V I E W T E C H N I Q U E S IN C H I L D P S Y C H I A T R Y
HYIVIAN CAPLAN, M.D.
NEW Y O R K , N. Y.
ONDUCTING a psychiatric inter- The attitude of the physician dur-
c view, like taking a medical his- ing the interview is important. He
tory and doing a physical examina- must show a genuine interest in the
tion, requires a thorough knowledge patient. Every effort should be made
of the subject in hand. Nevertheless, through facial expression, tone of
the physician, without special training voice, and physical contact to establish
in psychiatry, can carry on a reveal- a friendly and secure relationship with
ing interview if he is cognizant of eer- the child.
tan facts and techniques and is will- An interview is therapeutic as well
ing to tr y to utilize them. Too often as diagnostic and can do harm as well
the pediatrician considers this aspect as good. If improperly conducted, it
of his examination as too subjective may provide some diagnostic material
and nonscientific and outside of his but it may harm or prolong future
domain. therapeutic efforts. After the infor-
mation has been obtained, the findings
"AI~VIS OF THE INTERVIEW
must be interpreted so that they can
The purpose of tile interview is to be fitted into a diagnostic and thera-
discover the nature of the child's prob- peutic scheme.
lems and preoccupations, the sources The interview may be regarded as
of his worries and anxieties, and the a test situation to which the patient
manner in which he deals with them. is expected to respond or react. This
The interview should provide informa- is the basic principle of all psychologic
tion regarding two large areas of the testing. Thus the interview may be
child's personality: First is a study formal and systematic with specific
of the child's interpersonal relation- questions being asked. The replies
ships, his attitudes and feelings toward may be compared with norms arrived
members of the society in which he at statistically and evaluated accord-
lives. Second is a study of the child's ingly. Or, the interview may be flex-
fantasy and unconscious life. The ible, the patient talking about any-
child should be helped to give this in- thing at will without the physician
formation without creating undue attempting to channel ideas, concepts,
anxiety, pain, or fear. or thoughts. This is the so-called
From the Psychiatric Division, Bellevue "free-association" technique. In deal-
H o s p i t a l , a n d t h e 1 ) e p a r t m e n t of P s y c h i a t r y
College of Medicine, New York University- ing with children at the first inter-
Bellevue Medical Center.
Present address: The Children's ]V~emoriai view, it is usually advisable to steer
HosoitaL Department o f ] P s y c h i a t r y , lVs
25, Q u e b e c . between the above extremes. Each
128
PSYCHOLOGIC A S P E C T S OF P E D I A T R I C S 129
be? The child's attitude to the ex- "bad, s c a r y " dream, a "good, h a p p y "
aminer should also be noted. Is he dream should be asked for. I f he re-
shy, meek, and introverted? Does he peatedly denies dreams, one can ask
cry and shun the examiner or is his him to make it up out of his head.
attitude aggressive or hostile ? Despert 1 has recently indicated that
these invented dreams are as valid as
INQUIRY INTO UNCONSCIOUS AND
real ones especially in children of pre-
FAINTASY LIFE
school age. Children having night-
The next area for investigation is mares or night terrors are only too
the child's unconscious and fantasy h a p p y to share them.
life. IIere we often make use of some Another device is to postulate a
special techniques. Essentially each deserted island upon which the child
strives to tell us what the child is in a magical way is stranded and then
thinking about. The child remains to proceed to find out whom in order
unaware that he is imparting to us of preference he would like to take
highly relevant, emotional material. along with him and whom he would
Whereas the child's verbalizations re- p r e f e r to exclude if he had his own
garding his interpersonal relationships way colnplete]y.
can be readily interpreted, this intra- Still another, is to have the child
personal or unconscious material is make up a story, good or bad, or have
more difficult to evaluate, and requires him complete a story you have started.
clinical experience and some knowl- In this story, the information already
edge of psychopathology. obtained can be used to procure more.
A study of any phobias or fears is The routine psychiatric interview in
important. Often these may be in- an adult includes the investigation of
dicated by asking" the child to describe d~lusions and hallucinations. Chil-
the worst thing that could possibly dren rarely object to being asked if
happen to him. This m a y be so they ever hear noises or voices in their
frightening that he may be unwilling heads or elsewhere. The more direct
to talk about it, yet he m a y suggest and straightforward the question, the
drawing it and of course this should more clear-cut the answer. Children
be permitted. who are asked about their "imagina-
In the three wishes we say to the t i o n s " are glad to talk about them.
child, "Suppose you had three magic They will eagerly discuss imaginary
wishes and could wish for anything companions and playmates, etc. This
at all that you want, what would you is a normal developmental phase and
wish for ? " This may give an idea of is most frequently found about age 3
secret desires, suppressed wishes and or 4 years. It has pathologic signifi-
cravings and m a y even indicate basic cance only if it persists (fixation) or
dynamics as is shown in one of the is reverted to at an older age ]eve]
cases cited below. Dreams provide an (regression). Even at the 3-year-old
important source of information. The level, the child shows in many ways
child should be encouraged by re- that he distinguishes between his real
marks such as " s u r e l y you can tell world and his imaginary one. In ab~
me only one d r e a m . " I f he offers a normal cases, this distinction between
PSYCHOLOGIC ASPECTS OF PEDIATRICS 131
the fifth grade now. The teacher is she is on the phone, " H e is always
too strict. calling up and bothering me."
(Your teacher is too s t r i c t ? ) (You mean your mother g e t s
What? Yes. You know if yon fall cranky ?) Yes.
asleep she picks up your head and (She seems a little more mad?)
hits you. Nobody was ever hit in the When she sees my father go out with
lower grades; but in this grade, if another girl, she is happy. She is
you fall on the floor, you get hit. glad she saw it.
(Is this trouble only with you?) (You mean otherwise she doesn't
The best ones get it too if they don't know where he is all the time?) Yes.
know their lessons. (You have no other troubles beside
(Do you think your teacher is the the ones you mention?) Not that I
reason you are not so good in school ?) can remember.
No. I daydream. (How do you get along with your
(Did you used to daydream before ?) sisters and brothers?) I don't have
No. I just close my eyes. At night I brothers, just two sisters.
never sleep. I cannot sleep at night. (How old?) One is 12 in the sev-
I go to bed late and get up early. I enth grade and one is 6 in the first
fall asleep about 10 or 11 o'clock. grade.
(How early do you get up?) About (How do you get along with them?)
6 o'clock. I get along. I argue with them but
(Do you feel that you have to day- we don't really fight. I am spiteful.
dream?) I don't have to. (How are you spiteful?) I get mad.
(Do you daydream?) Yes. I just I send away for things on the radio
go to sleep. and television. I hardly ever get
(That's not daydreaming.) I don't chem. I get mad.
know. (What does spiteful mean ?) Being
(What other troubles do you have ?) mean. When my sister gets things
My mother is always mad. that I don't, she never shows me.
(What makes her mad?) My (How much do you play with other
father. My father calls up and my children in the street?) I don't go
mother starts yelling. They have a in the street. I go in the park.
legal separation. (What games do you play?) Base-
(How long have they been sepa- ball, football, and swimming.
rated?) From January. (You were telling me about night-
(What does it mean "separa- mares.) The worse one was in Oc-
t i o n " ? ) They cannot see each other. tober, two or three years ago.
They could see each other but they (You still remember it?) Yes. I
cannot sleep together. I don't know was asleep--dreaming of something--
what it is. They don~t have to sleep I don't know what about. Then I
together. It is just like--They don't heard a noise and I woke up right
have to. I don't mind my mother's away and I looked at the closet and I
business. saw a door opening and a man hits me
(How does this problem worry over the head. Later I asked for my
you?) She says to the children after bed to be moved and changed after
]34 THE JOURNAL OF PEDIATRICS
that. My big sister got the same (Suppose that you had three magic
dream when she slept in the same wishes and you could have anything
place. She heard me talking about it you want ?) One, I would like to have
so she dreamed about it. my mother happy, two, a house for
(What did this man look like?) A my dog, and my third one is about
rough man. With a big nose. sports--to be strong. I am not strong
(Can you tell me another dream?) in baseball--the most I can do is pitch.
About my small sister. These are the I get tired.
ones I am having now. I am always (Have you got a dog?) A fox
telling her not to go places and she terrier.
gets in trouble. She goes in the yard (Have you always had a dog?) Not
and I hear her yelling and then I always. I had one four months ago.
wake up. I never complete any of I had two dogs.
my dreams. (What happened to the dog?) He
(Do you wake up frightened?) Yes. was poisoned. Someone in my build-
(Do you ever cry?) Yes. ing. They didn't like his barking.
(Who comes to you?) I run to my He was out in the yard. I cried to
mother. myself.
(Do you sleep with her?) No. My (How often do you cry to your-
small sister is there. I make sure my self ?) About once a month.
sister is in my mother's room, when I (Do you feel better after?) I feel
go there. the same. Not worse.
(Do you have any happy dreams?) (Did you try to get even with the
Sometimes. man for poisoning your dog?) I
(What would be a happy, pleasant imagined I was a secret investigator.
dream to have ?) I don't know. (What sort of imaginary games do
(Make it up.) That I am a movie you play?) My friend plays the
star. I would like to be a psychiatrist games. We play pirates. For pirates
or a policeman. we hide several things.
(Is that your ambition ?) Yes. (Suppose you were marooned on a
(What do you think a psychiatrist deserted island. Whom do you wish
does?) He tests your blood. He asks you could take along with you?) My
questions like you are doing. dog.
(Why does he ask questions?) To (Anybody else?) No.
make you happy. I get a lot of things (Suppose you had to get somebody
off my chest. I feel better. else ?) My mother.
(Can you remember all the things (Somebody else still?) My smaller
you got off .your chest today?) Yes. sister. My smaller sister could come
Dreams, about my father, in school. through things easier. She is very
My troubles. good at digging. She showed me how
(Do you ever tell anyone else about to swim. She is always teaching me.
these things ?) No. Next my big sister.
(What sort of things don't you tell (How about your father?) I would
your mother ?) My dreams. take him.
(You don't fee] free to tell her?) (Would you be very anxious to take
No. him ?) No.
PSYCHOLOGIC ASPECTS OF PEDIATRICS 135
(I take it t h a t you d o n ' t like your I d o n ' t know, my mother just told me-
f a t h e r as much as the others?) No. from the stomach.
I t ' s not true. (How do dogs get puppies?) Same
(Maybe you are worried how y o u r as human beings only they d o n ' t have
mother would feel about it?) No. to take long. I go to sleep one night.
(What sort of man is y o u r father ?) The next day you look, you see
H e works as an electrician. puppies--that is what happened to my
(Is he good?) Yes. I used to help uncle's dog.
him work sometimes. (Do you think you are nervous?)
(Did you enjoy working for him?) Yes I think so.
Yes. I got $21. (How do you feel?) My mother
(How often do you see him?) I see wrote you a note about it.
him once in a while. Three times a (Do you want me to read it to you?)
week. He meets me outside of school. I don't care.
I d o n ' t go any place with him. (I see you bite your nails?) Yes.
(Did you ever visit his girl friend?) (Does it make you feel better ?) No.
I saw her once. I feel worse when I bite them too far
(Did you like her?) No. She liked down. I bit it too f a r down and it
me. IIer husband ran away. hurts, whenever I press my finger.
( W h y d i d n ' t you like her?) I (What do you think is inside your
would like my family to be together. head ?) Brains.
(Who is the t r o u b l e m a k e r ? ) The (Anything else?) No.
woman. (Did you ever think there were
(How can she make trouble?) She noises inside there? Do you imagine
always wants to see my father. She things ?) No. I imagine t h i n g s - - m y
makes my mother mad. There are so dog S k i p p e r - - w h e n e v e r I look at him
m a n y things about her. She is Span- I think of Blackie.
ish. My mother hates the Spanish (Do you know it is not Blackie?)
language even. I know. But I like to imagine it.
(What do you think makes a father (What other things do you imagine?
go away?) I think it is the woman. Do you ever imagine your f a t h e r is
That is why I d o n ' t want to get back home with you ?) No.
married, because if you m a r r y one ~ r l (What do you think is inside y o u r
you always want another. You al- stomach?) Food. Also I am fat
ways get tired of one. I f you see a there.
p r e t t y girl then you see a prettier one. (Do you think you have too much
(What does prettiness have to do fat?) Yes. I look on the scales. If
with it ?) I don't know. you are 5 feet 2 inches, you are sup-
(So you plan never to get married ?) posed to weigh so much. I weigh so
No. much. I weigh 118. Its about right
(What will you do when you grow but I look like I am overweight.
up? How can you have a family?) (Do you think your mother is a
I won't, I don't care at all. nervous woman ?) No.
(How do people get children?) (Would you like to come back and
F r o m the stomach. Like my mother. see me again?) Yes.
136 THE JOURNAL OF P E D I A T R I C S
(Our time is nearly up. Any ques- help cope with his problems. The
tions you would like to ask?) No. physician in his t h e r a p y of the case
can fill this need of someone to turn
Discussion.--This ease illustrates
to for help. Also the daydreaming has
pathology in the field of interpersonal
obviously aggravated his maladjust-
relations in a 10-year-old boy. Thus
ment in school.
we see difficulties in his relationship
to his siblings, in making friends, and In the interview he tells us clearly
in getting along with them both at what his attitudes are to his mother,
home and in school. In addition, he sister, father, and the'm'istress. His
has difficulty in his relationships to dreams are also revealing of his basic
himself. This is indicated in his problems. They are anxious and
marked i n f e r i o r i t y feelings about his frightening. In the dream where he
ability in sports and about his obesi~. is worried about his sister getting into
He tells us in one of his three wishes difficulties, and where he tells her not
that he wants to be strong and good to go to certain places but she persists
in baseball. F u r t h e r we see the diffi- and finds trouble, we see his preoccu-
culties created by the broken home and pation over his sister's welfare. An
the various ambivalent and conflicting understanding of dreams and their
drives with which he is faced in re- meanings and of the workings of the
gard to his mother and father. unconscious reveals to us the possibility
It must be emphasized again that of feelings of hostility and guilt to-
this boy, although u n d e r great tension ward her. We have already seen from
at the time of the interview (his father tile mother's original complaints that
had threatened to take him away from there was an exaggeration of the
his mother that very day), was able normal problems of sibling' rivalry
to talk about extremely troubling per- with regard to his sister. However,
sonal problems to a stranger with rela- the finding' of this problem in a dream
tive ease and openness. is more important than the mother's
statements. How deep this problem
The verbal content of the interview
is and how important it is to the child
and the way in which the boy related
can be discovered only in further in-
and controlled himself revealed that
terviews.
the problem is a neurotic behavior dis-
order. This is usually the case where From the material provided it also
the pathologic findings are in the field seems that the boy shows some block-
of interpersonal relationships. F u r - ing on sexual matters. This may, how-
thermore, on the surface of things it ever, be because of lack of sufficient
appears that the problems have been rapport with the examiner, or it may
created both a t h o m e and in school by reveal problems pertaining to pre-
environmental factors. Faced with a adolescence.
split between his mother and father I t can be seen that some of the
and with nobody near him to whom he questions are quite straightforward
can turn fbr help, he has taken to and pointed, e.g., " I take it, you d o n ' t
daydreaming as a means of escape. like y o u r father as much as the
Thus the daydreaming is a defense others?" Such a question is not
mechanism for him which he hses to necessarily traumatic. I t depends on
PSYCHOLOGIC ~ ASPECTS OF PEDIATRICS 137
how it is put. Sometimes such a stress were always attacking her. She went
situation may help evaluate the child excessively to the bathroom, would
and his reactions. His answer to the not obey, had frequent nightmares, and
question is probably truthful. He does talked to imaginary friends.
like his father. This is the crux of his (Hello there, my name is Dr. Cap-
difficulties. He likes both his f a t h e r lan.) You know what happened last
and mother and they are split up. night ?
The interview shows how greatly the (What?) I saw a jungle picture on
boy has identified with his father. He the television. People were sailing in
absolves him from blame saying it is a boat and they had a shipwreck and
all the fault of the woman. He even everyone had to sleep in the jungle
says that when he grows up he too and when they woke up there was a
will follow in his f a t h e r ' s footsteps, skeleton and I said " m o t h e r t u r n it
for if he would marry, a prettier girl off" and I was so excited and hollered
would come along and he too would in the night with m y mother.
have to leave his wife. (Was that a dream?) It w a s n ' t a
dream. I saw it on the television and
It is well known from clinical work
then dreamed about it. I d o n ' t know.
with children that animals in the
(Then pointing to a shelf on the wall
child's language and thought often
of the office) W h a t ' s that little thing
represent some member of the family
up there for? Is it for people to talk
circle. The same animal may repre-
through like a window ?
sent to the child a sibling, or a mother,
(Do you ever imagine things?)
or a father at varying times. -Prob-
Yes. Sometimes I imagine I ' m in the
ably the reason that most children take
jungle. My mother saw another skele-
so readily and easily to animal pets
ton there, that was before the natives
as close companions stems from this
came along.
need of the child to be close to a parent
(What is a skeleton ?) The skeleton.
substitute that he can control and
It is some old dead bones that when
direct at will. This fits in intimately
people go and they're dead for a long
with his basic needs and drives. Thus
time they have a skeleton. The na-
in wishing to have a house for his dog'
tives just leave those old things around
the psychiatric interpretation is that
and those old heads are hard.
the child wants a home for his father.
(How do people die?) Because the
Incidentally, the three wishes in this
natives kill them or something. Some-
case are revealing. In essence, they
times they die for no reason.
sum up his basic problems; his worry
(Are you afraid of dying?) I hope
about his mother's unhappiness, his
I don't. I hope I don't. No. No.
desire to have his f a t h e r back in the
(Have you any friends?) Miss Lib-
home with him, and his inferiority
erty. She is a statue, l'm not afraid
feelings about his mild obesity.
of her. No she can't talk because she
CASE 2.--J. H. is a 6-year-old Negro is just a statue hut I can tell when
girl. She was brought by her mother she is around.
because she could not get along in (Who is Alexander?) Did my
school; she continually fought with mother tell you? The one is in my
the other children and felt that they funny paper. The one who is my boy.
138 THE J O U R N A L OF P E D I A T R I C S
(Do you talk to him?) Yes. He (Suppose you had three magic
throws things on the floor and bang wishes?) I ' d wish I had some little
slam. When he chases me upstairs I baby ducklings and a kitty cat and a
hear b]appity, rappity, and rumble doggie. I would play with them and
bumble. let the little black kitten kiss them
(What's in here ?--pointing to her and play together. I would let him
belly) Some bones, blood, and juices. scare the eat and eat the rat. I wish
Its the place where my food goes. I I had some doggies, mules, and all.
imagine that I have two bones and a (Who talks to you outside?) No-
little and some blood and juices and body, I just think something's talking
little things hanging on to me and to me. I don't know how it comes into
little fat meats inside and flesh under me. I guess it's just myself. I look
the skin. all around and I could never find out.
(Anybody ever talk in there?) Ex- I just go to mother and just tell her.
cept when I was talking to myself, I I tell her I hear something inside of
can fee] myself talking back. Iile.