No More Learning

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Effects of a Brief Stay in Hospital
A study by Fagin ( 1966) of the behaviour of two groups of children after return home from a short stay in hospital (varying from one to seven days) casts some light on this problem. The thirty children of one group had had mother staying with them in hospital, the thirty of the other group were there without her, though they were visited daily. The children were matched for age, between eighteen and forty-eight months, but not for sex. Interviews held with the mothers prior to the hospitalization suggested that attitudes towards child-rearing did not differ between mothers in the two groups, nor did the mothers differ in regard to their desire to remain with their child in hospital.
For each child, behaviour at one week and again at one month after his return home, as reported by mother at interview, was compared with what it had been before he entered hospital, as reported by her at that time.
Both at one week and at one month following return home the behaviour of the unaccompanied children was reported as markedly disturbed in comparison with what it had been prior to hospital. Significant differences occur in all the usual fields. In particular, these children were reported as being much more upset by a temporary brief separation than they were before hospital and as more 'dependent'. By contrast, children who had been accompanied in hospital by mother showed none of these adverse changes. Indeed, mothers' reports showed them to have developed favourably in all these respects, which suggests that, as MacCarthy and his colleagues ( 1962) have found, mother's
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presence on a potentially upsetting occasion had given a child additional confidence that she would always be available in emergency. 1
These findings are in keeping with those of similar studies. What is of particular interest in Fagin's study is the differential effect on children in the two groups of having a mother who was rated by the interviewer as being very 'irritable'. Of the accompanied children who had an irritable mother none showed any adverse effects of their stay in hospital; whereas, of the unaccompanied children, those who had an irritable mother were even more affected by their experience than were those whose mother was rated as more equable.
A number of other studies point firmly to the view that a separation has a specially adverse effect on children whose parents are inclined to be hostile or to threaten them with separation as a disciplinary measure, or whose family life is unstable. Indeed, evidence is accruing fast that parent-child relations, both before and after the event, play a very large part in accounting for the differential outcome of a separation.
Effects of Periods of Residential Substitute Care
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Moore ( 1964; 1969a and b) has reported a number of findings of much interest to our thesis. In a longitudinal study of London children, starting at birth with 223 cases and reducing to 167 at the age of six years, Moore was able to investigate the shortterm effects on children of separations and other discontinuities of care, and also differences in the behaviour, at the age of six or seven years, of children who, during their early years, had had different types of experience. Information regarding behaviour was obtained: (a) from interviews with mothers (two before the child was born, five during the child's first year, four
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1 Limitations of Fagin's study are that data were derived entirely from mothers' reports and
that, in regard to ailment and length of stay, the two groups were not matched. Twenty-one of the accompanied children were in hospital for hernia operation or tonsillectomy and were out again within two days. Only nine of the unaccompanied children had a similar experience; thirteen had had respiratory or alimentary infections and had been away for between three and five days. It is therefore possible that these differences of experience might account for some of the reported differences in subsequent behaviour, though the findings of MacCarthy, Lindsay & Morris ( 1962) do not support that interpretation.
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during the next two years, and annually thereafter); (b) from psychological tests and observations of the children carried out regularly at the Study Centre; and (c) from interviews with the heads and staffs of any day nurseries or nursery schools that the children attended. Most of the results are expressed in terms of differences between the average frequencies of behaviour in children in a series of samples differing in regard to previous experience.
A number of the children had spent periods of a week or two with relatives, by way of a holiday for the child or for the parents or both. The commonest behaviour of children under three on reunion with mother was clinging around her, sometimes after initial reserve. Although such clinging often passed off after two or three days, in 30 per cent of cases it persisted for a matter of weeks. Moore ( 1969b) concludes: 'It is clear that for most young children separation from the mother is in itself a stressful experience', and that they are especially vulnerable during their second and third years.
Moore reports much evidence that shows that whether disturbances persist or fade turns in great measure on the stability of the home and the attitudes of the parents. Details are given of three of his comparisons.
(a) There were six children who had experienced one or more stays in a residential nursery between the ages of nine and thirty months. All but one, who was backward, were upset on return home, 'showing it in aggressive behaviour, head banging, fear of strangers and/or increased dependence on their mothers'. Four other children had had a similar experience before the age of nine months; of these, two were similarly upset. When all these ten children had reached the age of eight years, two were found to be 'reasonably well-adjusted' and eight were not. It was noted that, whereas the two who were reasonably well adjusted came from homes in which family relationships were good, the eight who presented difficulties, mainly of an aggressive uncontrolled sort, came from homes which were breaking up (two cases) or where relationships were otherwise disturbed.
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(b) Fifteen children who came from stable homes had experienced episodic separations during their first four years. Separations had been in various settings and of varying lengths. In many cases a child had stayed with relatives; in others he had been in a hospital or nursery. When the lengths of time away were summed for each child, summed lengths ranged from
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five to twenty-three weeks. Not only did these children come. from stable families but, apart from the separations, they had been cared for throughout by mother. At the age of six years their behaviour could be compared with that of two similar groups of children:
those who had been cared for by mother throughout without having experienced any separations;
those who had not only experienced a variety of separations but whose home life had been generally unsettled, including frequent changes of daily caretaker during the pre- school years.
Judged by mothers' reports, the children from stable homes who had experienced these episodic separations were rather less given to attention-seeking than were those who had not been separated. This suggests that, for children cared for as a rule by mother in a stable family, episodic separations of the length and kinds described, although in many cases reported to have been very distressing at the time, do not leave obviously adverse effects on the children's later attachment behaviour. Nevertheless in drawing conclusions it is necessary to be cautious since we do not know how such children would react to a new fear-arousing situation. The findings of Hinde & Spencer-Booth, for example, on the effects two years later of a week's separation on young rhesus monkeys when exposed to a fear-arousing situation (see Chapter 4) are a warning against premature confidence. Whereas the children from stable homes who had experienced episodic separations appeared to have developed favourably, those from unstable homes had not. At the age of six they are reported to have shown many typical signs of insecurity: overdependence, anxiety, sleeping problems, and nailbiting.
Effects of Daily Substitute Care
Moore ( 1969a) deals in some detail with the effects on a child's behaviour at the age of six years of different types of daily substitute care experienced before the age of five. About half the mothers of his sample had worked outside their homes for at least three months before the child was five, but patterns both of mother's work and of child care while mother worked varied enormously. At one extreme were mothers who, during their child's fourth and fifth years, did part-time work while the child
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attended nursery school; at the other were women who were doing full-time or near full-time work from early in their child's life while the child attended day nursery or a childminder. Inevitably variables were much confounded. In most cases in which daily substitute care had started early in a child's life, care had been unstable, so that the child had been looked after first by one set of people and then by another. Conversely, when care began after the third birthday, often at nursery school, it had tended to be stable. Another complication, not surprisingly, is that instability in arrangements for care tended to be correlated with instability of parental personality.
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Despite these problems, Moore is able to identify two samples, each of about fifteen children, matched for sex and reasonably well matched in other respects, all of whom had received some daily substitute care before the age of five years. In one sample substitute care had been stable and in the other unstable. For each sample the age at which the children first received daily substitute care varied from a few weeks to about three years.
Sample with unstable daily substitute care: The fifteen children who had experienced unstable and changing daily substitute care, in most cases starting before the second birthday, were conspicuously insecure and anxious in later years. Judged by mothers' reports when the children were six, they showed
far more dependent clinging behaviour -- wanting to sit on mother's knee, hating her to leave, being very upset if she was cross and demanding attention at bedtime. . . . This behaviour was obvious at the Centre, where the group received higher ratings for dependence and nervousness and lower for initial adjustment to the situation. They showed more fears, especially of doctors and hospitals and the dark . . . ( Moore 1969a).
In addition to unstable daily substitute care, these fifteen children had experienced more periods in hospital and elsewhere than had children in the other sample. Moreover, some of their anxious attachment, though not all of it, was probably attributable to the treatment they received from their parents, many of whom were rated as 'unstable personalities'.
Sample with stable daily substitute care: There were only a few cases in which daily substitute care had begun before the second birthday and had also been stable. At the age of six or seven years, these children tended to seek extra attention from mother;
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and some of the mothers had failed to establish a close relationship with their child.
The children whose daily and stable substitute care had not begun before their third birthday, by contrast, showed no evident emotional difficulties at the age of six. This finding is in keeping, of course, with common everyday experience. During their time away from mother these three- and four-year-olds had either been attending nursery school or else been cared for in another family, both of them arrangements that are not only widespread at that age but are usually enjoyed by the children and have never seemed to give rise to any difficulty. 1
Yet a further finding, from a subsequent study by Moore ( 1971), is that some of the children who had remained with mother until the age of five and had never attended nursery school or play group were apt in later years to be over-sensitive to criticism and timid with peers. This finding, if confirmed, supports the commonly held view that, from about their third birthday, children benefit from play with peers within an ordered environment, and this especially when the alternative is confinement within limited living space in an urban environment, and in many cases with a rather controlling and possessive mother, as in Moore's sample.
The findings of Moore's study thus strongly support the theory that anxious attachment develops not because a child has been excessively gratified, as is sometimes held (see next chapter), but because his experiences have led him to build a model of an attachment figure who is likely to be inaccessible and/or unresponsive to him when he desires her. The more
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stable and predictable the re? gime the more secure a child's attachment tends to be; the more discontinuous and unpredictable the re? gime the more anxious his attachment.
To this conclusion one major proviso must be added. Some children subjected to an unpredictable re? gime seem to despair. Instead of developing anxious attachment, they become more or less detached, apparently neither trusting nor caring for others. Often their behaviour becomes aggressive and disobedient and they are quick to retaliate. This type of development occurs much more frequently in boys than in girls; whereas anxious clinging is commoner in girls than in boys.
That separations and instabilities of maternal care should
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1 Compare the case of Lottie who began attendance at nursery school when she was two
years and three months old (see Chapter 3). -225-
lead to responses of two opposed types, anxious attachment and aggressive detachment, and sometimes a mixture of the two, is a little confusing. So also, perhaps, is the finding that in respect of these responses the sexes differ. Nevertheless, that finding is in keeping with the differential incidence between the sexes of certain types of personality disorder in adult life. Anxiety is commoner as a neurotic symptom in women than in men; conversely, delinquency is commoner in men than in women.
Follow-up inquiries when the children were eleven and fifteen years old showed that whatever pattern of attachment behaviour had become established during the first five years tended to persist, whether it was secure attachment, anxious attachment, or some degree of detachment ( Moore 1971). ?
Anxious attachment following threats of abandonment or suicide
Already in previous chapters reference is made to the effects on a child of being threatened by his parents that they will not love him or even will abandon him if he is not good. Clinical experience suggests that threats of these kinds, especially threats to abandon, including threats of suicide, play a far larger part in promoting anxious attachment than has usually been assigned to them.
Threats by parents that, if a child is not good, they will not love him any more have, of course, frequently been referred to as playing a part in the genesis of anxiety. In Inhibitions, Symptoms and Anxiety ( 1926a) Freud discusses them. Yet, although a threat of loss of love is far from being of negligible importance, the threat actually to abandon a child plainly carries immensely greater weight. Reference to such threats rarely appears in case reports, and suggestions in the literature that they play a significant, let alone a key, role are few and scattered. Nowhere do they seem to have been the subject of systematic study and discussion. The reason for their comparative neglect is almost certainly that parents are loth to talk about them.
A threat to abandon a child can be expressed in a variety of ways. One is that if a child is not good he will be sent away, for example, to a reformatory or to a school for bad boys, or that
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he will be taken off by a policeman. A second, made also in a disciplinary context, is that mother or father will go away and leave him. A third, which plays on the same anxiety, is that if a child is not good his mother or father will be made ill, or even die. A fourth, probably of great importance, is an impulsive
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angry threat to desert the family, made usually by a parent in a state of despair and coupled often with a threat to commit suicide. Finally, there is the anxiety engendered in a child when he overhears his parents quarrelling and fears, not unnaturally, that one or other of them is going to leave.
Evidence suggests that threats of these kinds, whether punitive or incidental, are not infrequent and that they almost always have an extremely frightening effect upon a child.
Let us start with threats that are used as part of disciplinary policy. The proportion of parents who use such threats no doubt varies greatly from culture to culture and subculture to subculture. In their study of 700 children and parents in Nottingham, Newson & Newson ( 1968) report that no less than 27 per cent of all the parents interviewed admitted using threats of abandonment as a means of discipline. The incidence was lowest in social classes I and II, the professional and managerial, in which it is reported as 10 per cent. In parents from the remaining social classes it is in the region of 30 per cent. The Newsons are particularly struck that white-collar workers of the shop and clerical groups should show an incidence (34 percent) at least as high as skilled, semi-skilled, and unskilled manual workers, and perhaps higher.
Naturally enough, threats of these kinds can vary in the seriousness with which they are made and believed. Some are plainly no more than teasing. But probably to interviewers like the Newsons, who are inquiring about techniques of discipline, parents would hardly refer to such threats unless they used them seriously and believed in their efficacy. In any case the children concerned in the study were only four years old and to a young child a threat needs very little elaboration to be taken in deadly earnest. Nevertheless, some parents, intent on teaching their children a lesson, clothe their threats in impressive playacting, as the following examples from the Newsons' records show.
In reply to inquiries regarding the techniques of discipline she employed with her four-year- old son, a packet's wife replied:
I used to threaten him with the Hartley Road Boys' Home, which isn't a Home any more; and since then, I haven't been able to do it; but I can always say I shall go down town and see about it, you know. And Ian says, 'Well, if I'm going with Stuart (7) it won't matter'; so I say, 'Well, you'll go to
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different ones -- you'll go to one Home, and you'll go to another'. But it really got him worried, you know, and I really got him ready one day and I thought I'll take him a walk round, as if I was going, you know, and he really was worried. In fact, I had to bring him home, he started to cry. He saw I was in earnest about it -- he thought I was, anyway. And now I've only got to threaten him. I say 'It won't take me long to get you ready'.
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To the same question a miner's wife first denied using such threats to her small girl and then corrected herself:
No -- oh, I tell a lie, I once did -- and upset her that much that I've never said it any more. (What did you say? ) Well, she was having an argument with me, and she says to me 'You don't live here! Hop it! ' So I says, 'Oh, well, I can do that! Where's my coat? I'm moving! ' So I got my coat from the back, and I was gone. I just stood outside the door, and she cried so bitter, she did. As soon as I came in, she got hold of my leg and wouldn't let go, sort of thing, I'll never say it no more.
Another miner's wife also had qualms about using such methods with a four-year-old:
I have said that if he makes me poorly when he's naughty I shall have to go away, and then he'll have no Mummy to look after him, and he'll have to live with someone else, I know that's all wrong, but I do. His Daddy'll say to him 'Pack his bags -- get that bag out, and get his toys, he's going! ' And he has one time put some of his clothes and toys in the bag; and it made him nearly demented -- it upset me, but I didn't like to interfere, you see. And I asked him after, I, said 'Don't do that again, I don't like it, it'll make him feel unsafe, and he belongs here as much as we do. Find another way to punish him, I don't like him to think that. ' I thought it was going too far.
In the last case, although mother drew the line at father's packing the child's bag, she was prepared to threaten that she might become ill and have to go away.
Since the most complete information about the use of threats to abandon a child comes from the Newsons'study conducted in England there may be danger that citizens of other countries will shrug off its findings. Any tendency to complacency is not
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encouraged by some, more limited, findings reported for parents in New England.
When interviewing some hundreds of mothers regarding their child-care practices, Sears, Maccoby & Levin ( 1957) found that such was the reluctance of mothers to acknowledge that they used threats to withdraw love or to abandon a child that information was inadequate in half their cases. In the other half, for which information was believed to be adequate, two out of every ten mothers were assessed as making considerable use of threats to withdraw love and/or to abandon the child, and a further three out of every ten as making moderate use of them. Taken together that makes half of all cases that could be assessed. Examples given in which five-year-old children are described by mothers as becoming 'hysterical' or as weeping 'a rain of tears' when threatened with being sent away from home -- e. g. back to the hospital where he was born -- differ in no way from those reported by the Newsons.
The fact that in a representative sample of lower-middle- and working-class homes in midland Britain today 30 per cent of mothers admit to using threats of abandonment, and another 12 per cent to threatening that they won't love a child any more if he is naughty (and that New England figures appear comparable), may come as a surprise to those brought up in professional-class homes in which such threats are much less common. 1 Yet, once the frequency and effects of such threats are firmly grasped, a great many cases of separation anxiety and anxious attachment that otherwise appear inexplicable become intelligible.
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Furthermore, it becomes easy to understand why so many children who have to go to hospital or residential nursery should suppose that they are being sent there as a punishment.
It is of course true that a majority of parents do not threaten to abandon their children and, as the Newsons found, refrain from doing so as a matter of principle. As a publican's wife remarked: 'It takes the child's security away. You're the whole of their security, and you must not take that away. ' Yet the Newsons also came across mothers who, though sure that such threats were wrong, admitted that none the less they occasionally used them when they were upset.
Such shamefaced admissions by parents may well include
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1 Nevertheless, sanctions of professional ostracism to coerce younger and weaker members
of a profession to accept the theories held by their seniors are not unknown. -229-
the most frightening threats of all. There is certainly a minority of parents who, in fits of exasperation and temper, say the most horrifying things which they later greatly regret. Threats to abandon the home and/or to commit suicide, made perhaps only at rare intervals but with an angry vehemence, are likely to have an effect entirely out of proportion to their frequency. Their effect, moreover, is magnified should the parent, father or mother, subsequently be so ashamed of having made such a threat that he or she cannot acknowledge either what was said or how frightening it must have been to the child. In such families the child has no opportunity to check his inevitable fears against the real risks, whatever they may be.
Furthermore, when families of this sort reach a psychiatric clinic, there is small likelihood that the true facts will be divulged. It is then very easy to attribute the child's fears either to his own guilty phantasies or to his having projected onto others his own guilty wishes. Long familiarity with how easy it is even for experienced clinicians to be misled in such cases suggests that, whenever a child or adult is inexplicably afraid, it is always wise to assume that there is no smoke without fire.
Since the way a parent treats a child is usually modelled on the way his (or her) parents treated him (or her) as a child, it is almost inevitable that the use of such threats should run in families. This was made dramatically clear during the treatment of an acutely anxious and depressed mother and her young son.
An Illustrative Case
Mrs Q and her son, Stephen, were referred originally when Stephen was eighteen months old, because he refused to eat and was seriously underweight. It was soon apparent that Mrs Q was in a chronic state of anxiety and depression which had begun at the time of Stephen's birth. Mrs Q was taken into once-a-week analytically oriented treatment and made good progress. Once Stephen's mother was able to refrain from constantly pressing him to eat, Stephen began to do so, and after a month or two was putting on weight satisfactorily.
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In view of the severity of Mrs Q's condition, she remained in once-a-week treatment for some years. Her father was a skilled artisan, now retired, and her husband a ticket collector on the railway. She herself was an intelligent woman who had had to leave school early in order to earn but who had later become a successful technician. The account she gave of her childhood was
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lucid and consistent, though for many months, indeed years, she had the utmost difficulty in divulging its more distressing and frightening aspects.
Pieced together the following picture emerged. Mrs Q's father had fought in the 1914-18 war and had been invalided on account of 'shell shock'. His neurosis appeared to have developed after his section had been blown up on a bridge, leaving him the sole survivor. Thereafter, he had been subject to long phases of depression and ill temper during which he could treat his family very badly. Mrs Q's mother was an active capable woman of strong opinions, whose own mother had been a chronic alcoholic for many years. Throughout Mrs Q's childhood her parents had had violent quarrels, during which dreadful things were not only said but often done. Crockery was smashed, knives drawn, and furniture set alight. Mrs Q recalled long sleepless nights listening to the battles and dreading the outcome. Yet by breakfast next morning all was quiet. Putting all the horrors of the night behind her, Mrs Q's mother went out to her daily domestic work the picture of peaceful respectability. On no account was any of the trouble at home to be divulged to outsiders; and it was deeply impressed on Mrs Q that she must whisper it to no one -- neighbours, teachers, or schoolfriends. This explained why she hid its full horror from her therapist for so long.
There were a number of occasions when Mrs Q's mother had attempted suicide, and many more when she had threatened it. Twice Mrs Q had returned home to find her mother with her head in the gas oven and once she had found her collapsed after having drunk household disinfectant. Not infrequently her mother, after having threatened to desert the family or to commit suicide, would disappear. On some occasions she would leave the house and not return until after midnight. On others she would hide, perhaps, in a cupboard. In view of all this it is hardly surprising that Mrs Q grew up an acutely anxious girl, constantly afraid to go far from home, and that she experienced spasms of violent anger. 1
Although it seemed evident that the anger was aroused by her parents', mainly her mother's, violent behaviour, Mrs Q
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1 In her relationships both with her mother and with her son Mrs Q. showed all the features
found by Melges ( 1968) to be typical in cases of post-partum disturbance. They include intense conflict with own mother, and repudiation of own mother as someone to be imitated, together with a strong tendency nevertheless to behave like her.
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during treatment found it very difficult to accept this possibility.
Instead, she claimed for a long while not only that her feelings for her mother were of love, which was true since her mother had many good qualities, but that that must exclude hatred. But, as she gained confidence, Mrs Q recalled how, as a child, after a bad row with her mother, she would
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sometimes go to her room and wreak violence on her dolls, throwing them at the walls and trampling them underfoot.
It was in this context that Mrs Q's problems with Stephen became intelligible. After Stephen's birth, Mrs Q had experienced strong impulses to throw the baby out of the window and, not unexpectedly, had become acutely anxious lest Stephen should die. Her frantic and ineffective efforts to make him eat were a direct result. It seemed evident that Mrs Q's hostility, still often aroused by her mother, had become redirected (displaced) towards Stephen. Even during the period of treatment, Mrs Q admitted shamefacedly, she still had occasional outbursts of violence, when crockery was smashed, saucepans dented, and Stephen's pram damaged. It was not always clear what precipitated these outbursts because Mrs Q was eager to forget about them as soon as possible and for long she hardly referred to them during treatment.
When Stephen was seven and a half Mrs Q reported that he sometimes expressed fear that she might die, and was afraid to go to school. For some months the origin of this fear remained obscure. Then the solution became clear. Having herself grown up in such deeply distressing circumstances, Mrs Q had been determined that her own son should fare better. She had therefore done everything she could to make Stephen's life secure and happy, and had in many respects succeeded. Yet, during her outbursts of violence, her good resolutions vanished. On those occasions, she now admitted, she said the most dreadful things, the very same things, in fact, that her mother had said to her when she was a girl. Stephen's fear that his mother might die was a direct reflection of his mother's threats of suicide, made during comparatively rare outbursts but with an intensity that might alarm anyone.
Once the facts were known it was possible to arrange some joint sessions with mother and son during which mother, with real regret, acknowledged making the threats and Stephen explained how terrified they made him. Mother assured Stephen that she would never do it really. All was not well thereafter, but recognition that Stephen's fears were well based and an
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opening of communication between mother and son eased the situation.
There can be little doubt that great numbers of parents are extremely reluctant to admit to a professional person that they sometimes threaten their child in the ways described. Many are aware that it is a bad thing to do and are ashamed of it. Others may themselves have mixed feelings about it, but are aware that professional people would disapprove. For these reasons it is probable that parents hardly ever volunteer the information and, until they have gained much confidence, are likely to deny it if questioned. Children, moreover, habitually take their cue from their parents and are similarly reluctant to divulge the truth. Even when she was in her mid-thirties, Mrs Q was still intent on protecting her mother's reputation. Not only is a child afraid of what a parent might say and do should he discover that the child had 'split' on him, but children are deeply reluctant to admit even to themselves that their own mother or their own father can behave in these frightening ways. Thus children are often willing conspirators in silence, even though simultaneously they may be yearning for someone to come to their aid.
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Incidence of 'Attempted' Suicide by Parents
The incidence of completed suicide among parents of children under the age of eighteen years is low because most suicides occur in the older age-groups. By contrast, the incidence of socalled 'attempted' suicide among parents in this category is relatively high because such acts occur most frequently in both sexes between the ages of twenty and thirty years. Since most attempts are not intended to end in death but to frighten or coerce others, the term is placed in quotation marks in the heading of this section. 1
Figures for attempted suicide in the city of Edinburgh are available for the past decade, and from them a number of rough estimates can be made. 2 For all women between the ages of fifteen and thirty-four years there was an average annual
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1 To deal with the difficulty Kreitman and his colleagues ( 1969) have proposed
'parasuicide'; but Walk ( 1972) has raised serious etymological objections.
2 I am indebted to Norman Kreitman, Director of the MRC Unit for Epidemiological Studies in Psychiatry, for making some recent figures available. Owing to rising rates and for other reasons, the estimates given for mothers and fathers over a twenty-year period are
extremely
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incidence of attempted suicide of about 0? 3 per cent and there is reason to think that this figure holds for women with children as well as for those without. Over a twenty-year period, during which children are being born and are reaching mature years, it can be estimated that about 4 per cent of mothers will have attempted suicide and, of these, one-third will have done so more than once. The incidence for men is lower and seems likely, over a similar twenty-year period, to amount to between 2 and 2? 5 per cent. Even allowing for the possibility that in some families both mother and father will have attempted suicide, it seems that not less than one in twenty of all children growing up in Edinburgh during recent years will have had experience of a suicidal attempt by a parent. For most children the attempt will have occurred before they have reached their tenth birthday.
The incidence of attempted suicide is not spread evenly throughout a population, so that in some sectors the rate, with age and sex held constant, may be several times what it is in others. Whereas the incidence in socio-economic classes I, II, and III is below average for the population of Edinburgh, that for class V is much above. Children growing up in certain subcultural groups are therefore at high risk of being exposed to the suicidal attempts of their parents. There is evidence also that in certain family networks a very high rate of attempted suicide may be due to its having become a recognizable mode of social communication. Women below the age of thirty-five years seem especially likely to be influenced by such family patterns ( Kreitman, Smith & Tan 1970).
Since no figures appear to be available to indicate the incidence of threats to commit suicide, we can only speculate. Presumably very many children who are exposed to suicidal attempts by a parent are exposed also to threats. Mrs Q is a case in point. In addition, there must be many others who, like Stephen Q, are exposed to threats but not to attempts. All in all the
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proportion of children who are exposed to threats or attempts, or to both, must be considerable. Both clinical experience and common sense suggest not only that such people will be more than usually prone to anxiety about the availability of attachment figures while they are still children but that they will often continue so long after they are grown up.
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rough. They have been calculated by me, and are given on my sole responsibility, in order to show the order of magnitude of the problem.
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What is so surprising is that, as a source of heightened susceptibility to anxiety, threats of and attempts at suicide by parents should have attracted so little attention, whether from psychoanalysts, psychiatrists, or those engaged in child psychiatry.
Fear of Parental Desertion after a Quarrel
When parents quarrel seriously a risk that one or other will desert is always there. Not infrequently, moreover, it is made explicit. In such conditions children usually hear a great deal more than parents like to believe. Although, therefore, the kind of situation that leads a child to fear abandonment is different from one in which threats to abandon him are directed punitively at him, the effects may still be very unsettling.
Here again it is not unusual for professional workers whom parents may consult about their child's behaviour to be kept in the dark about what is happening at home, and for such workers, ignorant of the true situation, to resort to 'deep' interpretations invoking projection and the inner world to explain a child's symptoms. During the practice of child and family psychiatry and also in work with adolescents and adults it is prudent always to assume that only after some months of work, including joint family interviews, are we likely to have obtained even a reasonably accurate picture of how members of a family behave towards one another and what they say. When after much patience the facts become known, it is usually far less difficult to understand how a child has come to be disturbed and why he fears whatever he does.
Earlier in this chapter it was pointed out that, in studies of the effects on a child of separation, the factors that lead the effects to persist in one child and not to do so in another have in the past been difficult to identify. Review of evidence available today suggests that we may be nearer a solution. We can indeed be confident that when a child is threatened with being abandoned by his parents, either as a disciplinary measure or because of marital discord, the effects on him of any actual separation will not only be magnified but be likely to persist.
When the high incidence of such threats in the lives of children is borne in mind, along with the cumulative effects of actual separations, of threats of separation, of unstable substitute care, and of unstable family life, the fact that many
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children grow up to be anxiously attached becomes explicable. In the light of these findings, moreover, a number of clinical syndromes can be better understood (see Chapters 18 and 19).
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Chapter 16
'Overdependency' and the Theory of Spoiling
The child is all the more clinging the more it has an inner conviction that separation will repeat itself.
BURLINGHAM & FREUD ( 1944)
Some contrasting theories
Following presentation of some of the evidence on which the theoretical position adopted here is based, it is useful to consider briefly the whole array of hypotheses that have been proposed to account for why a particular individual is prone to a high degree of overdependency or separation anxiety, the terms by which anxious attachment is usually known. Hypotheses advanced by psychoanalysts and others working in a psychoanalytic tradition not only give varying weight to constitutional and environmental factors but also inculpate different and in some respects contradictory factors in each class. The five main hypotheses, each of which has adherents, are outlined briefly below. Two lay emphasis on constitutional factors, as follows:
1. Some children have inherently a greater amount of libidinal need in their constitution than others, and so are more sensitive than others to an absence of gratification ( Freud 1917b).
2. Some children have inherently a stronger death instinct than others, which manifests itself in unusually strong persecutory and depressive anxiety ( Klein 1932).
Three lay emphasis on environmental factors:
3. Variations in the birth process and severe traumata occurring during the first weeks of
postnatal life may increase the (organic) anxiety response and heighten the anxiety potential, thereby causing a more severe reaction to later (psychological) dangers met with in life ( Greenacre 1941; 1945).
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Some children are 'spoiled' by excess of early libidinal gratification; they therefore demand more of it and, when not gratified, miss it more ( Freud 1905b; 1917b; 1926a).
Some children are made excessively sensitive to the possibility of separation or loss of love through experiencing either actual separation ( Edelston 1943; Bowlby 1951) or threats of abandonment or loss of love ( Suttie 1935; Fairbairn 1941).
It should be noted that whereas hypotheses 1, 4, and 5 are framed to account for a person's liability to a high degree of anxiety about separation in particular, hypotheses 2 and 3 are intended to account for liability to a high degree of anxiety of any kind.
In regard to the first two of these hypotheses there is no evidence either to support or to refute them since, with present research techniques, there is no way of determining differences of these kinds in constitutional endowment. That heritable differences play some part in determining why some people grow up to be more anxious than others is not unlikely; but
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whether either Freud's or Klein's formulation of the nature of the difference will prove useful seems doubtful.
Clear evidence in support of a hypothesis of the third type comes from the work of Ucko ( 1965) who found that children suffering from neonatal asphyxia are unusually prone to respond to separations and other changes of environment with anxiety. Her findings are described in Chapter 13. While supporting the third hypothesis, they do not conflict with either of the remaining hypotheses.
The fourth and fifth hypotheses, because they raise immediate and practical issues of how to treat children, are perhaps the most controversial of the set, and particularly so since the lessons they hold for how to rear children are of exactly opposite kinds.
The fourth hypothesis, that an excess of parental affection spoils a child by making him exceptionally demanding and intolerant of frustration, is one that was very widely held during the first half of this century and that still dies hard. Freud not only committed himself to it at an early stage of his work but held to it firmly and consistently until the end. Since this view of Freud's has had a deep and lasting influence on psychoanalytic theory and practice, quotations may be useful.
Freud first reference to spoiling is in his Three Essays on theTheory of Sexuality
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Theory of Sexuality, first published in 1905. There, after commending the mother who strokes, rocks, and kisses her child and thereby teaches him to love, he nevertheless warns against excess: '. . . an excess of parental affection does harm by causing precocious sexual maturity and also because, by spoiling the child, it makes him incapable in later life of temporarily doing without love or of being content with a smaller amount of it' ( SE 7: 223). The same theme runs through much of Freud theorizing about 'Little Hans' ( 1909); though, paradoxically, it is in his discussion of this small boy's separation anxiety that he comes nearest the view adopted here. He attributes part of the anxiety to the fact that Little Hans had been separated from his mother at the time of his baby sister's birth ( SE 10: 114 and 132). Nevertheless, both in the Introductory Lectures ( 1917b, SE 16: 408) and in his late work, Inhibitions, Symptoms and Anxiety ( 1926a), Freud makes no reference to such origins and instead explicitly adopts the theory of spoiling:
The undesirable result of 'spoiling' a small child is to magnify the importance of the danger of losing the object (the object being a protection against every situation of helplessness) in comparison with every other danger. It therefore encourages the individual to remain in the state of childhood ( SE 20: 167).
The theoretical context within which Freud advanced these views is referred to in an earlier chapter (Chapter 5) and described rather more fully in Appendix I.
Despite its wide popularity, no evidence of substance has ever been presented to support the theory that anxious attachment is a result of an excess of parental affection. As already indicated, all the evidence points the other way. ? The question arises, therefore, why Freud (and many others also) should have favoured the theory. Possible answers are offered at the
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end of the chapter. Meanwhile, let us consider further the fifth type of theory, the one favoured here.
However cogent the evidence may be that some cases of anxious attachment are a consequence of separation, or of threats of being abandoned, or of risks of losing a parent inherent when parents quarrel, it is still possible that not all cases are to be explained in this way. Are there perhaps other cases that arise from causes other than those so far considered? To answer this question it is necessary to turn to the results of
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studies conceived on different lines from the studies discussed so far. Studies of 'overdependency' and its antecedents
Despite very frequent references to overdependency in the clinical literature there seem to be few studies in which a clinician has selected a sample of adult patients on the criterion of overdependency and then examined the family experiences these individuals have had during their childhood and compared them with the experiences of an appropriately selected contrast group. Some of the literature on agoraphobia is in fact relevant (see Chapter 19) although the criterion for patient selection, namely fear of leaving home without a companion, is ostensibly quite different.
Studies of the family backgrounds of children selected as being overdependent are also few in number. With regard to these, moreover, a difficulty that has to be borne in mind is the ambiguity of the term overdependent, for it is found to cover two distinct conditions. One comprises children who are exhibiting typically anxious attachment. The other comprises children who are less able than are others of their age to do ordinary little tasks, such as feeding or dressing, for themselves and, instead, ask mother to do them for them.
This distinction emerges clearly in a study undertaken by Stendler ( 1954). A group of twenty six-year-old children, selected by teachers as being markedly overdependent, was found to fall into two subgroups. On the one hand were six children who turned to mother to do everything for them. On the other was a group of fourteen who had no difficulty in doing things for themselves but who were upset by mother's absence and created a scene whenever she went out and left them behind. Not unexpectedly, the family experiences of these two subgroups were radically different.
The six children who constantly turned to mother for help came from stable homes. All six, however, had a mother who was excessively protective and tended to discourage her child from learning to do things for himself.
Of the fourteen children who were anxiously attached eleven had had a very unsettled home life. Changes of caretaker, from mother to grandmother and back again, father constantly coming or going, frequent shifts of residence, and similar instability had been the rule. For the fourteen anxiously attached children taken as a group, the total number of such
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discontinuities that had occurred during the period between nine months of age and the third birthday was fifty-two, an average of nearly four apiece. For a control group of twenty children, picked from the same school classes, the equivalent total was twenty-six, giving an average of 1? 3 apiece.
So far as they go, therefore, the results of this small study are consistent with the view that most, if not all, cases of anxious attachment can be understood as being the consequence of a series of separations and similar experiences. A much larger study, by McCord and others ( 1962), gives strong support to this type of hypothesis.
In their study McCord and his colleagues draw on the detailed case records of some 255 boys aged between nine and seventeen years who constituted the 'treatment group' of the Cambridge-Somerville project. All lived in a high-density industrial area and were mainly from the working classes. Half of these boys had been selected, when between the ages of nine and thirteen, by teachers and others in the community as potential delinquents. The other half were selected similarly as developing in a relatively normal way. All these boys and their families were then given such support and help as could be arranged in order to see whether delinquent development could be averted. Since supportive work continued for five years, a great deal of information was amassed both about the boys themselves and about their families. 1 Some years later the information was rated by independent raters who had taken no part in the study. For purposes of this analysis a sub-sample, of forty-three boys, was identified as showing 'overdependent behaviour' and another, of 105 boys, as showing, in this respect, the normal culturally expected pattern of development.
Three-quarters of the overdependent boys showed markedly dependent behaviour towards adults and can almost certainly be regarded as anxiously attached. A minority (eleven) showed dependent behaviour only towards peers and were rather remote from adults; it is an open question whether that behaviour can be regarded as anxious attachment. In the presentation of the results, however, findings for the majority are not distinguished from those for the minority.
When compared with the control group, the overdependent boys were found to be more likely to express feelings of inferiority
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1 Included in the study also were a comparable pair of samples who were not given support.
Because little information on them and their families became available these cases cannot be used for the present analysis.
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(51 per cent against 12 per cent) and to be more prone to 'abnormal fears' (56 per cent against 36 per cent), though unfortunately details of the fears are not specified.
When the family backgrounds and attitudes of parents of boys in the two groups were compared a set of highly consistent findings was obtained. Nearly twice as many of the dependent boys as of the controls were rated as being rejected by father (51 per cent compared with 28 per cent) and/or by mother (39? 5 per cent and 20 per cent). No less than 56 per cent of the dependent boys were found constantly to be compared unfavourably with their siblings; that proportion compares with only 17 per cent of the controls. No data on
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separations and losses are given. Quarrels between parents and mutual disparagement were reported for almost every home in the overdependent sub-sample; though it must be admitted that in this workingclass neighbourhood a fairly high incidence of such happenings is reported also in the families of the controls. Not unexpectedly, the feelings expressed by some of these overdependent boys towards their mothers were the reverse of warm: one-third of them expressed active dislike, or fear, or contempt of her.
Such other evidence as is available on conditions associated with overdependency, or anxious attachment, is consistent with the findings so far considered. For example, in the previous chapter reference is made to two studies that focus attention on parental behaviour when the children are four or five years old and describe the variety and incidence of different methods of child care used in a particular community; these are the studies by Newson & Newson ( 1968) of families in the English midlands and by Sears, Maccoby & Levin ( 1957) of families in New England. Although in neither study are the effects on the children of different family experiences at the centre of interest, each presents some data relevant to our problem.
The Newsons' findings on overdependency are given in the previous chapter (pp. 213-14). Most of the children who at four years of age were afraid of separation were found to have experienced a separation: either they or their mothers had been hospitalized, or some other separation had taken place.
Sears, Maccoby & Levin ( 1957) report the results of interviewing 379 mothers of five-year- old children attending kindergarten in the suburbs of a large metropolitan area in New England. Among the questions they asked about the children were four designed to give information about 'dependency'.
No evidence was found that separations had played any part in
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the development of those children who, on the basis of mothers' reports, were assessed as most dependent; but the authors point out that the incidence of separation in the sample was very low.
The principle finding of Sears's study in regard to dependency is that the more irritable, scolding, and impatient a mother was when her child was clinging or desirous of attention the more 'dependent' he was likely to be. This significant correlation is appreciably increased in the case of mothers who were initially rejecting but later gave in. The researchers also found a significant correlation between a high degree of dependency and parents who used withdrawal of love as a disciplinary measure, including threats to abandon a child. These findings are consistent with the present hypothesis.
Another of their findings, however, could be taken to support the theory of spoiling. A small group of mothers was assessed as being 'exceptionally demonstrative' of affection, and these were more likely than others to have children rated as 'quite dependent'; the correlation is low but significant.
An explanation of this finding that seems not unlikely is that the children assessed by the researchers as overdependent fell, like Stendler's, into two groups, those who showed anxious attachment and those who looked to mother to do everything for them. If this was so and if
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Stendler's findings were confirmed, then a number of the mothers assessed by Sears and his colleagues as exceptionally demonstrative would have been found to be not only affectionate but inclined also to discourage their child from doing things for himself.
Further and substantial evidence that strongly supports the hypothesis favoured here, and equally strongly challenges the theory of spoiling, comes from studies of the family backgrounds of individuals who grow up to be notably self-reliant. This is presented in the penultimate chapter.
How came it, then, that Freud should have adopted the theory of spoiling? Apart from the likelihood that he was more influenced than he realized by the accepted opinion of his day, there is some evidence that he was misled by the show of affection and over-protection that is so frequently present either as an over-compensation for a parent's unconscious hostility to a child or as part of the parent's own desire to cling to the child. This explanation is suggested by a passage in Three Essays, immediately following that quoted earlier, in which he refers to 'neuropathic parents, who are inclined as a rule to display excessive affection, [as] precisely those who are
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most likely by their caresses to arouse the child's disposition to neurotic illness' (SE 7: 223). In fact, when such cases are investigated in a psychoanalytically oriented family clinic, it is found, probably invariably, that the child's heightened anxiety over separation and loss of love is a reaction not to any real 'excess of parental affection' but to experiences of an almost opposite kind. On the one hand are threats by a parent either to withdraw love or to abandon the child, threats that, as already discussed, are apt to be kept very secret. On the other are cases in which a parent demands, either overtly or covertly, that the child act as a caretaker to him (or her), thereby inverting the normal parent-child roles. In such cases it is the parent, not the child, who is overdependent or, to use the better term, anxiously attached. These cases are discussed in Chapters 18 and 19.
To some it may seem a trifle absurd to go to such lengths to demonstrate that uncertainty regarding the availability of an attachment figure commonly results in anxious attachment. Yet, so long as terms such as 'overdependent' and 'spoiled' are in use to describe the individuals in question and a theory is current that attributes their condition to an excess of gratification during their early years, children and especially adults who manifest this type of behaviour will meet with scant sympathy or understanding. Once it is recognized that the condition is one of anxiety over the accessibility and responsiveness of attachment figures, and that it develops as a result of bitter experience, there is good prospect not only of helping those who have grown up insecure but of preventing others from doing so.
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Chapter 17
Anger, Anxiety, and Attachment Anger: a response to separation
Time and again in preceding chapters reference is made to the anger that is engendered towards a parent figure by a separation or a threat of separation. It is time now to consider this response more systematically and in particular how it is related to attachment and fear.
In the first chapter an account is given of the systematic study by Heinicke & Westheimer ( 1966) of ten children aged from thirteen to thirty-two months during and after a stay of two or more weeks in a residential nursery. When comparisons were made between the separated children and a contrast group of children who remained in their own homes the increased tendency of the separated children to respond aggressively was clear. For example, during their stay in the nursery a doll-play test was administered to the separated children on at least two occasions, at an interval of eight days; and the same tests were administered to the children in the contrast group at the same interval at home. On each occasion episodes of hostile behaviour occurred four times as frequently in the doll play of the separated children as they did in the play of the children living at home. Objects attacked tended to be the parent dolls. Of the separated children eight attacked a doll that had already been identified by the child as a mother or father doll; none of the children living at home did so.
Six weeks after the separated children had returned home, and after an equivalent period for the non-separated children, doll-play tests were again administered; and they were repeated ten weeks later. On neither of these occasions, however, were significant differences in hostility found between the children in the two groups. The reason for this was that, six weeks and more after reunion, the children who had been separated were no longer particularly aggressive in their play, a change for the better that was itself significant.
Nevertheless, it was apparent from mothers' reports that
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during the months after return home a number of the separated children were still behaving hostilely in the home, especially towards mother. During the period from the second to the twentieth week after reunion six of the ten separated children behaved towards mother with an intensity of ambivalence reported for none of the children who had remained in their own homes.
Other observers to have reported notably aggressive and/or destructive behaviour during a period of separation are Burlingham & Freud ( 1944), Robertson ( 1958b), Bowlby ( 1953), Ainsworth & Boston ( 1952), and also Heinicke in an earlier study ( 1956) in which he compared the behaviour of a small sample of children during a short stay in a residential nursery with that of a similar group starting to attend a day nursery.
Others to have noted intensely ambivalent behaviour after a child has returned home include Robertson ( 1958b), Robertson & Robertson ( 1971), and Moore ( 1969b; 1971).
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Anger: functional and dysfunctional
Although sometimes the aggressive behaviour of a child who has experienced a separation appears to be directed towards all and sundry, often, as in the doll-play sessions mentioned above, it is plainly directed towards a parent or parentsubstitute and is an expression of anger at the way he has been treated. Sometimes it is the anger of hope; sometimes the anger of despair.
On occasion a child's hostility to a parent takes the form of a reproach for his having been absent when wanted. For example, Robertson ( 1952) describes the angry reproaches of Laura, a child of two years and four months whom he had filmed during an eight-day stay in hospital for a minor operation. Some months after her return home Robertson was showing an early version of his film to her parents for their comments, while Laura was in bed believed asleep. As it happened, she awoke, crept into the room and witnessed the last few minutes of the film, in which she is seen on the day of her return from hospital, at first distressed and calling for her mother, later when her shoes are produced delighted at the prospect of going home and finally departing from hospital with her mother. The film over and the lights switched up, Laura turned away from her mother to be picked up by her father. Then, looking reproachfully at her mother, she demanded 'Where was you, Mummy?