Normality and Pathology in Childhood: Assessments of Development
The problem of prediction in child development was once put succinctly by an eight-year-old patient I knew. At the beginning of her treatment she was under the impression that an analyst was a fortune teller, and she was very reluctant to give up her gaudy vision for the mundane truth I taught her. Months later I had to ask her, “Do you still think I am a fortune teller?” “No,” she said, “I know better now. You can tell fortunes backwards but not frontwards.”
Prediction in psychoanalytic study of the child is one of a number of clinical and theoretical problems which Anna Freud takes up in her new book. Dr. Freud, the daughter of Sigmund Freud, is a child psychoanalyst of great distinction, and her contributions to psychoanalytic theory are counted among the most original and far-reaching of our time. In this work she applies her extensive critical research at Hampstead clinic in London to the discussion of normality and pathology in childhood. These problems, which are mainly of interest to clinicians, are linked to some of the most fascinating problems in contemporary psychoanalytis theory. While the achievements of psychoanalytic child psychology are considerable, this book can be read as a sober statement of the unknowns that still exist, and uncertainties that testify to the complexity of personality even in its formative stages, and to the variety of adaptive solutions to conflict which are manifest throughout a child’s development.
The analyst can, as the eight-year-old observed, tell fortunes backwards. In the case of the adult neurotic patient the analytic method can achieve a reconstruction of the unremembered past which Freud likened to an archeological investigation. The significant experiences of the past are revealed through their residues in personality, preserved by repression which, like a clumsy forger, erases the surface and covers over, but marks the place where the original text lies buried but intact. The uncovering of the work of repression led Freud beyond the borders of the adult neurosis as he first encountered it. The threads led back in time to childhood. In every case the illness told the story of an earlier disorder, a childhood edition of the adult neurosis. It was in this way that Freud was led to discover the extraordinary power of childhood longings.
The discovery of a childhood prototype for the adult neurosis brought new dimensions to the study of the neuroses and, at the same time, introduced problems that have not yet been resolved by psychoanalytic research. For the childhood conflicts of the neurotic patients were not distinctively different from those of men and women who were not neurotic. The night terrors and animal phobias, the rituals to ward off dangers, the fears of mutilation and annihilation were among the common experiences of childhood. There were, it appeared, typical conflicts and even typical symptoms in the course of child development. If these conflicts were ubiquitous, what constituted “normality” in childhood and what constituted “pathology”? What factors in child development favored resolution of conflict and insured against an adult neurosis? What were the factors that set the stage for an adult neurosis? Could one predict from the childhood neurosis the form or the type of the neurosis in later life?
These are the problems which Anna Freud examines in her current work. Studies of this kind have been greatly facilitated by developments in psychoanalytic ego psychology to which Anna Freud herself has brought great gifts, among them, a notable lucidity. Until the Twenties psychoanalysis was mainly a “drive” psychology; its theory of child development was cast in the framework of drives and their vicissitudes. Implicit in the early theories was a human environment that gave form and purpose to biological tendencies, but the reciprocal relations between a child and his needs and the human partners who satisfied these needs were considered only in a general sense. An “ego” was also implicit in the earlier theory, in the idea of control and modification of drives through processes that were closely allied with consciousness. But the concept of a psychic organization that regulated the internal needs in accordance with the requirements of objective conditions, and of a moral agency within the personality, did not emerge until the Twenties when Freud himself made flexible turn in his theory of neurosis. The shift involved new formulations regarding psychic agencies (id, ego, superego) and their relations to each other, and a radical change in the theory of anxiety in which the functions of perceiving danger (receiving the signal) and defending against danger were given over to the ego. Anna Freud’s own work, The Ego and the Mechanisms of Defense (1936) led the way to new investigations in the nature of defense mechanisms, the study of ego functions, and the relations between id and ego in normal development and in the neuroses. The new theoretical framework opened up the study of the adaptive functions of the ego and the mutual influences of ego and id in child development. (Here one should mention especially the important contributions by Heinz Hartmann, Ernst Kris, Rudolph Loewenstein, David Rapaport, and Erik Erikson.)
Much of the activity in psychoanalysis today centers in the study of the ego and problems of adaptation. But a clear distinction should be drawn between the psychoanalytic ego psychology of Anna Freud and the ego psychologies of Fromm, Horney, and Sullivan which have lost their connections with psychoanalysis. The ego psychology of Anna Freud and of contemporary psychoanalysis generally is firmly based in psychoanalytic theory and follows tendencies which Freud himself established in the Twenties. Here, the concept of ego is inextricably bound to the theory of drives; the ego is nourished by drives and in its formative stages is progressively differentiated as it achieves distance from biological need and assumes “drive regulation” as one of its executive functions throughout life. Psychoanalytic ego psychology has in common with other psychologies a concern with the relations of the ego to an outer world and with problems of adaptation; but adaptation, in the psychoanalytic view, is given complexity and dimension by taking into account the role of drives, inner mental processes, and the imperatives of conscience. In contrast to other ego psychologies, this is not an adjustment psychology. It grants a generous range to the concepts of health and normality—perhaps because it is the psychology that is most intimate with dreams.
In this view, conflict in childhood is an inevitable condition of growth and development; it is not easy, Anna Freud demonstrates, to judge the shaded area where conflict has moved into the realm of pathology. Each of the stages in child development produce typical conflicts and even transitory symptoms which do not, in themselves, have a morbid significance. In the broad range of development that is called “normal,” conflict, regression, symptoms, inverted sex aims, and sadistic behavior may all be manifest at one time or another without in themselves having prognostic significance for a later neurosis. Typically, these manifestations drop out in the course of the progressive development of the child’s personality: in layman’s language they are “outgrown.” But this process to a psychoanalytic observer is infinitely complex. For while there are strong currents in development that carry the personality forward, the “problem solving” is done by the ego, and even the immature organization of the child ego normally possesses adaptive mechanisms and modes that will work for resolution of conflict.
The most reliable criteria for assessment of normal or pathological development in the child are derived, in Anna Freud’s extensive catalogue, from the study of the child’s ego. So far as anxiety is concerned, she points out:
It is not the presence or absence, the quality, or even the quantity of anxiety which allows predictions as to future mental health or illness; what is significant in this respect is only the ego’s ability to deal with anxiety.
The child who can actively deal with danger through play, intellectual understanding, or appropriate aggressive response, is likely to be a child who can dispense with pathological defense mechanisms and neurotic symptoms. The child who can deal with frustration by finding substitutes and alternatives for wishes that cannot be gratified, that is, who demonstrates a capacity for sublimation, possesses a valuable safeguard for his future development. So it is not the presence of conflict or symptoms that determines the future health or illness of the child, but rather the ego’s capacity for adaptive solution to conflict.
Illness in a child has the effect of constricting and even paralyzing the problem-solving techniques which normally serve the ego in dealing with danger. The ego, helpless in the face of overwhelming anxiety, may then resort to defensive measures against the anxiety itself to keep it from breaking through into consciousness. The original conflict itself undergoes repression and may reveal itself in distorted form through symptoms. Yet, the severity of the illness cannot be judged, even then, without other criteria in the case of the child. In childhood there are progressive currents in development that carry the personality forward. A severe illness in a child has the effect of blocking development in vital areas and even reversing developmental patterns, so that a serious regression in behavior and intellectual functioning may occur. In all these ways the ego reveals to the clinician a breakdown of adaptive capacity, one that is beyond self-healing.
But now to return to the questions which this book raises: What is the relationship between the childhood neurosis and the adult neurosis? If it is demonstrated that every adult neurosis is the later edition of a childhood neurosis, is every childhood neurosis the first edition of an adult neurosis? Can we predict that the five-year-old boy with a severe dog phobia will become an adult who suffers from an agoraphobia or a claustrophobia? If a seven-year-old boy dresses up in girls’ clothes and prefers doll play to boys’ games is he likely to become a homosexual in later life?
Here, Anna Freud cautions strongly against prediction. An illustration from her discussion of homosexuality can demonstrate the complexities of the problem. The adult male homosexual of the passive, feminine type is characterized by a strong tie to his mother, an aversion to sexual intercourse with women, and by sexual activity with men who are sought out for their crudely masculine attributes (great muscular strength, size of genitalia, etc.). Reading backwards from the analysis of the adult homosexual, one finds, in childhood, a strong attachment to the mother during infancy and early childhood, a horror of female genitalia acquired traumatically in an early period, and a fascination—something close to thralldom—with the penis of the father or another adult male.
Yet each of these characteristics of the childhood experience of an adult homosexual can be found in a boy’s normal development. The attachment to the mother in infancy and early childhood is the inevitable and necessary consequence of the mother’s nourishing and protective care. The mother is the first love for every boy, and later, in the oedipal phase, this love becomes the central problem in the conflicts of this period. The earliest reactions of a boy to the sight of the female genitalia are typically those of surprise, disbelief, shock. Awe and envy of the penis of the mature male are commonplace reactions in childhood. A marked preference for the exclusive society of males and a deprecation of females is characteristic of the pre-adolescent boy. Sexual games among boys are common experiences during the same period. Not any of these items in the retrospective history of the adult homosexual can be employed for prediction of future homosexuality in a child.
But there are these differences between the developmental history of the man who achieves heterosexuality and that of the male homosexual: In normal development these characteristics appear as stations along a developmental route. The biological tendency is forward-moving, toward genital primacy and heterosexuality. Normally the environment provides incentives for the unfolding of the maturational sequence. But in the case of the homosexual, impediments to development have occurred; the sexual development has remained fixed at one of the infantile stages. And it is here, Anna Freud points out, that we are still looking for answers.
From the evidence there are a multitude of determinants in which internal motives and external factors are mutually reinforcing in the outcome of these developmental problems. Certainly the motives of parents—often unconscious motives—must be weighed heavily in the process of facilitating or impeding the masculine development of the boy. Such factors as the mother’s depreciation of masculinity and her encouragement of her son’s erotic ties to her can provide the climate for feminine identification in the boy. The absence of a father or the failure of a father to provide a masculine model for identification can be factors which impede a favorable masculine development. Yet these factors alone will not determine homosexuality in later life. They can produce masculine-feminine conflicts within the personality, and these conflicts may produce a neurosis, but the neurosis need not lead to a settlement in favor of homosexuality.
To turn against the biological self, to repudiate genitality, is a sacrificial act. The sacrifice of masculinity is not made out of love alone, but out of fear. It is made when the ego is defenseless before a great and terrible danger; by renouncing genitality if abolishes the conflict. But when does the renunciation take place? Does it take place when the six-year-old plays girl? When the ten-year-old plays secret games with another boy? There is no time until sexual maturity, Anna Freud says, that one can use the term “homosexual.” That is, until biological maturity has been achieved, the sexual organization cannot be said to have genital aims. The stages of “becoming” in childhood fluctuate between heterosexual and homosexual positions, and we cannot know which factors will appear as decisive for later sexual organization. Thus the six-year-old who plays girl is not committed to homosexuality. He only tells us that he has conflicts regarding his masculinity. There are many alternatives to homosexuality which remain open in the course of development. The ego may defend successfully against the feminine tendencies. Or it may rework the masculine-feminine conflicts in the form of a successful sublimation. Or, in fact, the masculine-feminine conflicts can persist into adult life and yet not admit of a homosexual solution.
It is precisely because development is fluid in childhood that prediction poses such problems. And while some elements of personality have relative stability in childhood, the very process of maturation alters previously existing patterns. The impetus of the drives themselves can bring about shifts in the position of the libido, can break up previously established patterns and create new ones, as we see most clearly in the adolescent personality. There are also chance occurrences such as accidents, seductions, the death of a loved person, that may cause a dramatic shift in the organization of personality and cannot be built into the calculation at all. And then, if we grant the full implications of an ego to the child, we know that the child is not a tabula rasa. He is equipped at an early age with a mental apparatus that selects data and organizes experience, he reacts, interacts, and modifies himself with every action; he is equipped for adaptive solutions to conflict. The patterns are, at an early age, uniquely his own, formed and reformed out of infinite combinations.
All of this adds up to an indigestible number of variables for prediction. And even when we sift the factors and find that some mental characteristics have greater stability than others, we cannot predict the place of these characteristics in the final organization of personality. Suppose we find that an excessive concern with orderliness in early childhood turns out to be a stable characteristic. In later years will it be caught up in a compulsion neurosis as a symptom, or will it free itself from conflict and morbid anxiety and find a harmonious partnership with another group of intellectual characteristics to serve, let us say, a scientific career?
The reader may find it disappointing to learn that psychoanalysis is still confronted by large unknowns. At a time when the behavioral scientists are hot for certainties and computers are unfed in the laboratories of personality research, Anna Freud’s book makes it clear that psychoanalysis has little fare to offer the machines. Will it ever? To put it another way, one small child, infinitely complex, can still confound the fortune tellers.