NERVOUSNESS IN OLDER CHILDREN
In older children the line which separates naughtiness, fractiousness,
and restlessness from definite neuropathy begins to be more marked.
The nature of the young child, taking its colour from its
surroundings, is sensitive, mobile, and inconstant. With every year
that passes, the normal child loses something of this impressionable
and fluid quality. With increasing experience and with a growing power
to argue from ascertained facts, character becomes formed, and if
tempered by discipline will come to present a more and more unyielding
surface to environment, until finally it becomes set into the
stability of adult age.
We may perhaps, with some approach to truth, look upon the adult
neurotic as one whose character retains something of the
impressionable quality of childhood throughout life, so that, to the
last, environment influences conduct more than is natural.
All the emotions of neurotic persons are exaggerated. Disappointments
over trifles cause serious upsets; grief becomes overmastering.
Violent and perhaps ill-conceived affection for individuals is apt to
be followed by bitter dislike and angry quarrelling. On the physical
side, sense perception is abnormally acute, and many sensations which
do not usually rise up into consciousness at all become a source of
almost intolerable suffering. To these most unhappy people summer is
too hot and winter too cold; fresh air is an uncomfortable draught,
while too close an atmosphere produces symptoms of impending
suffocation.
In some neurotics there is an excessive interest in all the processes
of the life of the body, and when attention is once attracted to that
which usually proceeds unconsciously, symptoms of discomfort are apt
to arise. Thus so simple an act as swallowing may become difficult, or
for the time being impossible. To breathe properly and without a sense
of suffocation may seem to require the sustained attention of the
patient; or again, the voice may be suddenly lost.
More commonly, perhaps, neuropathy exhibits itself in an undue
tendency to show signs of fatigue upon exertion of any sort, mental or
physical. Sustained interest in any pursuit or task becomes
impossible. Nameless fears and unaccountable sensations of dread
establish themselves suddenly and without warning, and may be
accompanied on the physical side by palpitation, flushing, headache,
or acute digestive disturbances.
All these manifestations are best controlled by selecting a suitable
environment, and as a rule the character of the environment is
determined by the temperament and disposition of those who live in
close contact with the patient. Like the tiny children with whom we
have dealt so far, the behaviour of neuropathic persons is subject
wholly to the direction of stronger and more dominant natures. With
faulty management at the hands of those around them, no matter how
loving and patient these may be, the conduct of the neurotic tends to
become abnormal.
In children beyond earliest infancy we recognise a gradual approach to
the conditions of adult life. Fractiousness and naughtiness,
ungovernable fits of temper, inconsolable weeping and inexplicable
fears should disappear with early childhood even if management has not
been perfect. If they persist to older childhood we shall find in an
increasing percentage of cases evidence of definite neuropathic
tendencies which urgently call for investigation and for a precise
appreciation of the nature of the abnormality. It may be that the only
effective treatment is that which we recognise as essential in the
grosser mental disturbances--removal from the surroundings in which
the abnormal conduct has had free play, and separation from the
relatives whose anxiety and alarm cannot be hidden.
In young nervous children fear is the most prominent psychical
symptom. The children are afraid of everything strange with which they
come in contact. They are afraid of animals, of a strange face, or an
unfamiliar room. Older children usually manage to control themselves,
suppress their tears, and prevent themselves from crying out, but it
is nevertheless easy to detect the struggle.
Often we find those distressing attacks to which the name
"night-terrors" has been given. The child wakes with a cry,--usually
soon after he has gone to sleep,--sits up in bed and shows signs of
extreme terror, gazing at some object of his dreams with wide-open
startled eyes, begging his nurse or mother to keep off the black dog,
or the man, or whatever the vision may be. Even after the light is
turned up and the child has been comforted, the terror continues, and
half an hour may elapse before he becomes quiet and can be persuaded
to go back to bed. In the morning as a rule he remembers nothing at
all.
Phobias of all sorts are common in nervous children, and result from a
morbid exaggeration of the instinct for self-preservation. Some cannot
bear to look from a height, others grow confused and frightened in a
crowd; dread of travelling, of being in an enclosed space such as a
church or a schoolroom, or of handling sharp objects may develop into
a constant obsession. I have known a little girl who was seized with
violent fear whenever her father or mother was absent from the house,
and she would stand for hours at the window in an agony of terror lest
some harm should have befallen them. As if with some strange notion of
propitiating the powers of darkness these children will often
constantly perform some action and will refuse to be happy until they
have done so. The same little girl who suffered such torments of
anxiety in her parents' absence would always refuse to go to bed
unless she had stood in turn on all the doormats on the staircase of
her home. Other children feel themselves forced to utter certain words
or to go through certain rhythmical movements. They fully understand
that the fear in their mind is irrational and devoid of foundation,
but they are unable to expel it. Often it is hugged as a jealous
secret, so that the childish suffering is only revealed to others
years afterwards, when adult age has brought freedom from it. We will
do well to try by skilful questioning to gain an insight into the
mental processes of a child when we find him showing an uncontrollable
desire to touch lamp-posts or to stand in certain positions; or when
he develops an excessive fear of getting dirty, or is constantly
washing his hands to purify them from some fancied contamination.
The treatment of all these symptoms calls for much insight. The
child's confidence must be completely secured, and he must be
encouraged to tell of all his sensations and of the reasons which
prompt his actions. The nervous child has a horror of appearing unlike
other children, and will suffer in silence. If his troubles are
brought into the light of day with kindness and sympathy they will
melt before his eyes. Even night-terrors are, as a rule, determined by
the suppressed fears of his waking hours. If they are provoked by his
experiences at school, by the fear of punishment or by dismay at a
task that has proved beyond his powers, he should be taken away from
school for the time being. Night-terrors are said to be aggravated by
nasal obstruction due to adenoid vegetations. Clothing at night should
be light and porous, and particular attention should be paid to the
need for free ventilation.
We have spoken in an earlier chapter of the trouble sometimes
experienced in inducing a nervous child to go to sleep. In older
children insomnia is common enough. Even when sleep comes it may be
light and broken, as though the child slept just below the surface of
consciousness and did not descend into the depths of sound and
tranquil slumber. We have often noticed how different is the estimate
of the patient from that of the nurse as to the number of hours of
sleep during the night. The sick man maintains that he has hardly
slept at all, whilst the nurse, drawing us aside, whispers in our ear
that he has slept most of the night. In estimating sleep we have to
consider not only its duration, but also its depth, and the patient
who denies that he has slept at all has lain perhaps half the night
with an active restless brain betwixt sleep and wakefulness. Often
enough when he comes to consider in the morning the problems that
vexed his soul at midnight, he is quite unable to recall their nature,
and recognises them as the airy stuff that dreams are made of.
Although in a sense asleep he may have retained a half-consciousness
of his surroundings and a sense of despair at the continued absence of
a sounder sleep.
With nervous children we are apt to find sleep which is of little
depth and which constantly shows evidence of a too-active brain. The
body is tossed to and fro, words are muttered, and the respiration is
hurried and with a change in rhythm, because there is no depth of
anæsthesia. The body still responds to the impulses of the too-active
brain. From the nature of his dream--as shown by chance words
overheard--we may sometimes gather hints to help us to find where the
elements of unrest in his daily life lie. Sleep-walking is only a
further stage in this same disorder of sleep, in which the dream has
become so vivid that it is translated into motor action.
If a child begins to suffer from active sleeplessness we must not make
the mistake of urging him to sleep. He is no more capable than we are
ourselves of achieving sleep by an effort of will power. To urge him
to sleep is likely to cause him to keep awake because we direct his
attention to the difficulty and make him fear that sleep will not
come. If he understands that all that he needs is rest, he will
probably fall asleep without further trouble.
Day-dreams also may become abnormal, and tell of an unduly nervous
temperament. Any one who watches a little child at play will realise
the strength of his power of imagination. The story of Red Riding Hood
told by the nursery fire excites in the mind of the child an
unquestioning belief which is never granted in later life to the most
elaborate efforts of the theatre. All this imaginative force is
natural for the child. It becomes abnormal only when things seen and
acts performed in imagination are so vivid as to produce the
impression of actual occurrences, and when the child is so under the
sway of his day-dreams that he fails to realise the difference between
pretence and reality. Imagination which keeps in touch with reality by
means of books and dolls and toys is natural enough. Not so
imagination which leads to communion with unseen familiars or to acts
of violence due to the organisation of "conspiracies" or "robber
bands" amongst schoolboys.
If evidence of abnormal imagination appears, the child must be kept in
close touch with reality. We must give him interesting and rational
occupation, such as drawing, painting, the making of collections of
all sorts, gardening, manual work, and so forth. In older children we
must especially supervise the reading.
In many nervous children we find a faulty contact with environment, so
that instead of becoming interested in the thousand-and-one happenings
of everyday life and experiences, they become introspective and
self-conscious. As a result, sensations of all sorts, which are
commonly insufficient to arouse the conscious mind, attract attention
and, rising into consciousness, occupy the interest to the exclusion
of everything else. The conscious mind is not capable of being
occupied by more than one thing at a time. If attention is
concentrated upon external matters, bodily sensations, even extreme
pain, may pass altogether unnoticed. The Mohawk, Lord Macaulay tells
us, hardly feels the scalping-knife as he shouts his death song. The
soldier in the excitement of battle is often bereft of all sense of
pain. On the other hand, the patient who is morbidly self-conscious
becomes oblivious of his surroundings while he suffers intensely from
sensations which are usually not appreciated at all. Self-conscious
children will complain much of breathlessness and a sense of
suffocation, of headache, of palpitation, of intolerable itching, of
the pressure of clothing, or of flushing and a sense of heat.
Excessive introspection influences their conduct in many ways. At
children's parties, for example, they will be found wandering about
unhappy, dazed and unable to feel the reality of the surroundings
which afford such joy to the others; or they may be anxious to join in
play, but finding themselves called upon to take their turn are apt to
stand helplessly inactive, or to burst into tears. At school, though
they may be really quick to learn, they will often be found oblivious
of all that has gone on around them, not from stupidity, but from
inability to dissociate their thoughts from themselves and to
concentrate attention upon the matter in hand. In such a case we must
aim at developing the child's interest to the exclusion of this morbid
introspection. Taking advantage of his individual aptitude, we must
strengthen his hold upon externals in every way possible, and we must
explain to him the nature of his failing and teach him that his
salvation lies in cultivating his capacity for paying attention to
things around him and developing an interest in suitable occupations.
Fainting fits are not uncommon amongst nervous children from about
the sixth year onwards, and are apt to give rise to an unwarranted
suspicion of epilepsy. In other cases fears have been aroused that the
heart may be diseased. In children who faint habitually the nervous
control of the circulation is deficient. We notice that when they are
tired by play, or when they are suffering from the reaction that
follows excitement of any sort, the face is apt to become pale, and
dark lines may appear under the eyes. Yet there may be no true anæmia
present: it is only that the skin is poorly supplied with blood for
the moment. After a little rest in bed, or under the influence of a
new excitement, the colour returns, and the tired look vanishes. If
children of this type are made to stand motionless for any length of
time, and if at the same time there is nothing to attract their
interest or attention--a combination of circumstances which unhappily
is sometimes to be found during early morning prayers at school--the
want of tone in the blood vessels may leave the brain so anaemic that
fainting follows. The first fainting attack is a considerable
misfortune, because the fear of a recurrence is a potent cause of a
repetition. Standing upright with the body at rest and the mind
vacant, the circulation stagnates, the boy's mind is attracted by the
suggestion, he fears that he will faint as he has done before, and he
faints. Schoolmasters are well aware that if one or two boys faint in
chapel and are carried out, the trouble may grow to the proportion of
a veritable epidemic. It is important that this habit of fainting
should be combated not only by general means to improve the tone of
the body and circulation, but also by taking care that the child
understands the nature of the fainting fit, and the part which
association of ideas plays in producing it. Disease of the heart
seldom gives rise to fainting.
The same vasomotor instability which shows itself in the tendency to
syncopal attacks is apparent in many other ways. Sudden sensations of
heat and of flushing, equally sudden attacks of pallor, coldness of
the extremities, abundant perspiration,--raising in the mind of the
anxious mother the fear of consumption,--and excessive diuresis are
common accompaniments. A further group of symptoms is provided by the
extreme sensibility of the digestive apparatus. Dyspepsia,
hyperaesthesia of the intestinal tract, viscero-motor atonies and
spasms, and anomalies of the secretions, whether specific like that of
the gastric juice or indifferent like that of the nasal, pharyngeal,
gastric, and intestinal mucus, are all of common occurrence. Whenever
the nervous child is subjected to any exhausting experience, any
excitement, pleasurable or the reverse, or any undue exertion, whether
mental or physical, one may note the subsequent gastro-intestinal
derangement, including even a coating of the tongue. The slightest
deviation from the usual diet, the most trivial fatigue, a chill of
the body, even a change in the temperature of the food may set loose
the most extreme reactions in the gastro-intestinal tract--motor,
sensory, or secretory. It is not an accident that so often the mucous
diarrhoea, which may have afflicted an excitable child in London for
many months, and which a visit to the seaside, with all its healthy
activities, may seem to have completely cured, relapses within a day
or two of the return to the restricted environment and uninteresting
routine of life in London. The child who was happy and busy and at
peace with himself, at play in the open air, resents the sudden
cessation of all this, and the nervous unrest returns. To attempt
treatment by dietetic restrictions alone is to deal only with a
symptom. The gastro-intestinal reactions are so violent that the
parents are generally voluble on the subject of the many foods which
cannot be taken and the few which are not suspect. To prescribe rigid
tables of diet is to add to the alarm of the mother, and to sustain
her in the belief that the child is in daily danger of being poisoned
by a variety of common articles of diet. Only by lowering the
excitability of the nervous system, by occupying the mind and giving
strength to the child's powers of control can we effectively combat
the hyperaesthesia. If necessary the personnel of the management of
the child will have to be altered. There may be no other way to
achieve certain and rapid improvement in a condition which is causing
grave danger to the child and very genuine distress and suffering to
the parents. A violent reaction to intoxications of all sorts is a
further stigma of nervous instability. Sudden and even inexplicable
rises of temperature are frequent complaints, and the constitutional
effects of even trivial local infections are apt to be
disproportionately great.
Fatigue is easily induced and is exhibited in all varieties of
activity--mental, physical, or visceral. Mental work may produce
fatigue with extreme readiness even although the quality of the work
may remain of a high standard. To Darwin and to Zola work for more
than three hours daily was an impossibility, and yet their work done
under these restrictions excites all men's admiration. The palpitation
and breathlessness which follows upon trivial exertion, such as
climbing a flight of stairs, is a good example of visceral fatigue.
Among adult neuropaths we recognise the harm which may be done by
unwise speeches on the part of relatives, or still more on the part of
doctors. A chance word from a doctor or nurse off their guard for the
moment will implant in the minds of many such a person the unyielding
conviction that he or she is suffering from some gastric complaint,
from some cardiac affection, or from some constriction of the bowel.
It may take the united force of many doctors to uproot this
pathological doubt which was implanted so easily and so carelessly.
The medical student is notoriously prone to recognise in himself the
symptoms of ailments which he hears discussed. Little children, too,
are apt to suffer in the same way. How much illness could be avoided
if mothers would cease to erect some single manifestation of
insufficient nervous control into a local disorder which becomes an
object of anxiety to the child and to the whole household.
Undue liability to fatigue, irritability, instability, lack of
control over the emotions, extreme suggestibility, prompt and
exaggerated reactions to toxins of all sorts, excessive vasomotor
reactions and anomalies of secretion, weakness of the
gastro-intestinal apparatus--these, and many other symptoms, are of
everyday occurrence in the nervous child. To discuss them more fully
would be to pass too far from our nursery studies into a consideration
of psychological medicine.