Академический Документы
Профессиональный Документы
Культура Документы
WARNING! This text is printed for personal use of PEPWEB GENERIC. It is copyright to the journal in which it originally appeared. It is illegal to redistribute it in any form.
- 149 -
well-known fact that there are no childhood alternatives to the adult's efficiency or failure in sex and work, vital factors which are
used in adult psychiatry as indications of intactness or disturbance. Although in what follows efforts will be made to outline some
"age-adequate tasks" for children, these are by no means of similar diagnostic significance.
Since, thus, neither symptomatology nor life tasks can be taken as reliable guides to the assessment of mental health or illness
in childhood, we are left with the alternative idea1 that the capacity to develop progressively, or respectively the damage to that
capacity, are the most significant factors in determining a child's mental future. Accordingly, it becomes the diagnostician's task to
ascertain where a given child stands on the developmental scale, whether his position is age adequate, retarded or precocious, and
in what respect; and to what extent the observable internal and external circumstances and existent symptoms are interfering with
the possibilities of future growth.
But even this more circumscribed task, namely, to place the case of a given child in the correct position on the scale of normal
or pathological development, is admittedly difficult, all the more so since, besides psychoanalysis, several other disciplines such as
descriptive and dynamic psychiatry, psychology, and the social sciences have a stake in it. For the child analyst the appraisal of the
child serves not only practical but also theoretical aims. To the first category belong the decision for and against treatment and the
choice of therapeutic method; to the second, the attempts to formulate clearer pictures of the initial phases of those mental
disorders which are known now principally in their later stages; to distinguish transitory from permanent pathology; and in general
to increase insight into the developmental processes themselves.
The analyst's requirement for the latter purposes is a comprehensive metapsychological picture of the child (i.e., one
containing structural, dynamic, economic, genetic, and adaptive data). This order cannot be filled with the comparatively meager
facts elicited from the children or their parents at their first contact with the Clinic. Therefore, the task of assessment, which begins
with the
1 Suggested by me in "Indications for Child Analysis." This Annual, I, 1946.
WARNING! This text is printed for personal use of PEPWEB GENERIC. It is copyright to the journal in which it originally appeared. It is illegal to redistribute it in any form.
http://www.pep-web.org/document.php?id=psc.017.0149a Page 1 of 6
PEP Web - Assessment of Childhood Disturbances 30/09/15 15:56
- 150 -
diagnostic team, is continued by the child analyst, i.e., it passes from the stage of initial diagnostic procedure into the stage of
therapy. Since in analysis the method of therapy coincides with the method of exploration, the whole bulk of analytic material can
be utilized for the latter purpose or, as happens in analytic teamwork in the Clinic, be handed back to the diagnostician to confirm,
correct, and expand his first impressions of the case.
In what follows we attempt to outline the setting up of a metapsychological framework of this kind, i.e., of a "developmental
profile" in which the result of the analyst's diagnostic thinking is broken up into its component parts. Profiles of this kind can be
drawn up at various junctures, namely, after the first contact between child and Clinic (preliminary diagnostic stage), during
analysis (treatment stage), and after the end of analysis or follow-up (terminal stage). If this is done, the profile serves not only as
a tool for the completion and verification of diagnosis but also as an instrument to measure treatment results, i.e., as a check on the
efficacy of psychoanalytic treatment.
At the diagnostic stage the profile for each case should be initiated by the referral symptoms of the child, his description, his
family background and history, and an enumeration of the possibly significant environmental influences. From these it proceeds to
the internal picture of the child which contains information about the structure of his personality; the dynamic interplay within the
structure; some economic factors concerning drive activity and the relative strength of id and ego forces; his adaptation to reality;
and some genetic assumptions (to be verified during and after treatment). Thus, broken up into items, an individual profile may
look as follows:
http://www.pep-web.org/document.php?id=psc.017.0149a Page 2 of 6
PEP Web - Assessment of Childhood Disturbances 30/09/15 15:56
b. according to their quality, i.e., correspondence with the level of libido development;
c. according to their direction toward either the object world or the self.
immaturity and dependence to the gradual mastery of his own body and its functions, to adaptation to the object world, reality and
the social community, as well as to the building up of an inner structure. Whatever level has been reached by a given child in any
of these respects represents the end point of a historical sequence which can be traced, reconstructed, scrutinized for defects (this
to be done during and after treatment), and in which ego, superego, as well as drive development have played their part. Under the
influence of external and internal factors these lines of development may proceed at a fairly equal rate, i.e., harmoniously, or with
wide divergences of speed, which lead to the many existent imbalances, variations, and incongruities in personality development.
(See, for example, excessive speech and thought development combined with infantilism of needs, fantasies and wishes; good
achievement of object constancy combined with low frustration tolerance and primitive defense system; or complete dependence
for feeding, defection, etc., combined with fairly mature intellectual and moral standards.)
At the time of diagnosis, the status of these developmental lines can be investigated by using for the purpose of examination
any one of the many situations in life which pose for the child an immediate problem of mastery. Although such tasks may seem
simple and harmless when viewed from the outside, the demands made by them on the personality show up clearly when they are
translated into terms of psychic reality. Such translations are the indispensable prerequisites for assessing the meaning of
successful mastery as well as for understanding failure and for alloting it correctly to the right sources in either the drives or the
ego agencies.
Examples of such situations as they may occur in the life of every child are the following:
separation from the mother;
birth of sibling;
illness and surgical intervention;
hospitalization;
http://www.pep-web.org/document.php?id=psc.017.0149a Page 3 of 6
PEP Web - Assessment of Childhood Disturbances 30/09/15 15:56
symptoms of the obsessional neurosis with their known fixation points. In contrast, symptoms such as lying, stealing, bed
wetting, etc., with their multiple causation, convey no genetic information at the diagnostic stage.
For the diagnostician trained in the assessment of adult disturbances, it is important to note that infantile regression differs in
various respects from regression in the adult; it does not always require fixation points and it does not need to be permanent. As
"temporary regression" it takes place along the developmental lines mentioned before, and forms part of normal development as an
attempt at adaptation and response to frustration. Such temporary regression may give rise to pathology, but the latter will be
short-lived and reversible. For purposes of assessment the two types of regression (temporary or permanent, spontaneously
reversible or irreversible) have to be distinguished from each other, only the former type justifying therapy.
http://www.pep-web.org/document.php?id=psc.017.0149a Page 4 of 6
PEP Web - Assessment of Childhood Disturbances 30/09/15 15:56
1. the level of maturity, i.e., the relative independence of the child's personality structure;
2. the severity of his disturbance;
3. the intensity of therapy needed for alleviation or removal of the disturbance.
WARNING! This text is printed for personal use of PEPWEB GENERIC. It is copyright to the journal in which it originally appeared. It is illegal to redistribute it in any form.
- 156 -
IX. DIAGNOSIS
Finally, it is the diagnostician's task to reassemble the items mentioned above and to combine them in a clinically meaningful
assessment. He will have to decide between a number of categorizations such as the following:
1. that, in spite of current manifest behavior disturbances, the personality growth of the child is essentially healthy and
falls within the wide range of "variations of normality";
2. that existent pathological formations (symptoms) are of a transitory nature and can be classed as by-products of
developmental strain;
3. that there are permanent regressions which, on the one hand, cause more permanent symptom formation and, on the
other hand, have impoverishing effects on libido progression and crippling effects on ego growth. According to the
location of the fixation points and the amount of ego-superego damage, the character structure or symptoms produced
will be of a neurotic, psychotic, or delinquent nature;
4. that there are primary deficiencies of an organic nature or early deprivations which distort development and
structuralization and produce retarded, defective, and nontypical personalities;
5. that there are destructive processes at work (of organic, toxic, or psychic, known or unknown origin) which have
effected, or are on the point of effecting, a disruption of mental growth.
WARNING! This text is printed for personal use of PEPWEB GENERIC. It is copyright to the journal in which it originally appeared. It is illegal to redistribute it in any form.
- 158 -
http://www.pep-web.org/document.php?id=psc.017.0149a Page 5 of 6
PEP Web - Assessment of Childhood Disturbances 30/09/15 15:56
Copyright 2015, Psychoanalytic Electronic Publishing. Help | About | Download PEP Bibliography | Report a Problem
WARNING! This text is printed for personal use of PEPWEB GENERIC. It is copyright to the journal in which it originally appeared. It is
illegal to redistribute it in any form.
http://www.pep-web.org/document.php?id=psc.017.0149a Page 6 of 6