SUMMARY AND DISCUSSION OF

Rapport Introductif et Rapports de Psychiatrie Ge'ne'rale,

Premier C0ngri.s International De Psychiatrie Infantile, Paris, 1937

HELEN THOMPSON, Ph.D. The Clinic of Child Development

Yale University, New Haven, Conn.

The first paper of the First International Congress of Child Psychiatry was delivered by Doctor H. Wallon of the Colli.ge de France of the Sorbonne. His theme was, Les Bases Neuro-physiologiques de la Psychiatrie Infantile. Dr. Wallon introduced his subject by pointing to two important differences between adults and children. The child has not formed the every day habits, associations, and attitudes which have been built up in the adult and which are so important in adult psychoses. Secondly, disabilities of children are usually due to retarda- tion or defect of development rather than to lesions in a mature organ. These differences make the problems of child psychiatry different from those of adult psychiatry.

Dr. Wallon continued his discussion with a consideration of the pertinent physiological characteristics of the child. He said that biological fatalism is not an inevitable conclusion since any one behavior trait is the product of many, if not all genes, and genes are modifiable by their surrounding protoplasm. The in- creasing knowledge of the role of the endocrine glands and their hormones in timing the appearance of behavior patterns and the integrative action of the nervous system makes possible the recognition of an atypical syndrome and its particular neuro-physiological basis. He cited many examples showing the rela- tion between behavior and physiological conditions, such as the excision of the choroid plexus, which results in arrested development of the brain, the effects of thyroid dysfunction on behavior, the association of Little's disease with brain lesions, and the more complicated behavior syndromes of cortical origin.

The processes of mental development have two aspects, exteriorization and interiorization. The child's emotions and feelings are being transferred from self to the environment of people and things, while his sensory motives are being transformed into intellectual ones. I t is this second aspect of development which gives rise to conditioned reflexes. Again in the discussion of conditioned reflex phenomena Dr. Wallon gave many illustrations of the relations between neural anatomy and neural function as shown by behavior.

He concluded by emphasizing the fact that neurophysiological development is constantly expressing itself in the developing child and it merely remains for the scientists to identify more fully and exactly the origin of mental difficulties, there- by determining the child's possibilities and limitations.

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THE CONDITIONED REFLEX I N CHILD PSYCHIATRY

The second session of the congress was devoted to the question of the condi- tioned reflex in relation to child psychiatry. The facts and opinions presented on this subject were as diverse as the countries represented. Each speaker was strictly limited to 20 minutes for his actual address and, in consequence, he gave verbally only a digest of his full report, which is printed in the proceedings of the meetings.*

The contribution of the science of conditioning to child psychiatry may be grouped under four heads. I . Normal behavior, 2. Education, 3 . Psychopathology and 4. Therapy.

I. The Conditioned Reflex and Normal Behavior Many discussants emphasized the value of the conditioned reflex studies in

understanding normal behavior. Dr. Peiper of Germany told of studies there which successfully investigated, by conditioning, the child’s ability to distinguish colors. He said observation indicated that conditioned reflexes could be formed from the first months of life and, by the theory of conditioned reflexes, mimicry, coordination of movement, and even the child’s first words, as well as the sub- cortical responses of the infant, could be explained.

Dr. C. de Scantis (Italy) also, but with some reservations with regard to the conditioning theory of Watsonian Behaviorism, commented on the contribution of the Russian group to the understanding of learning and general development of children.

Dr. Dublineau of Paris summarized the technique which he used in studying 74 boys, 10 to 16 years of age, varying in intelligence and conduct. He found that the formation of a conditioned reflex, its extinction and its reestablishment, gave only a limited indication of the intelligence and behavior tendencies of the child. In addition, it was necessary to study the process of induction and reflex rhythms. He commented that compensatory excitation was particularly important and marked in turbulent, non-adaptable subjects. By the analysis of similar factors associated with behavior problems one might determine the physiological basis of personality.

Dr. Wintsch (Switzerland) recalled the conditions necessary for the establish- ment of a response and gave examples to show how behaviors are developed in the every day life of the child. Dr. Wintsch and Dr. Dublineau showed not oniy how the conditioned reflex theory explains normal behavior but they also asserted that the theory forms a liaison with Freudian psychology. Dr. Dublineau said that mechanisms of psycho analysis find their significance in the Pavlovian principles. Dr. Wintsch closed his paper with the statement that in confronting the totality of his observations, one perceives that a liaison is established between the symptomatology of the unconscious and its precise causes, between psycho- analysis and physiology, and thus between Freud and Pavlov.

* Premier Congr2s International d e Psychiatrie Infantile. Vol. I . Rapport Introductif et Rap- ports de Psychiatrie GCnCrale S.I.L.I.C. Imprimerie, 41 rue d u Metz, Lille, 1937.

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However, we have other points of view with which to reckon. Dr. Gemelli clearly showed by reporting his studies that the simplicity of the technique of the conditioned reflex, however important it may be, is inadequate in view of the complexity of behavior. By placing a child in a situation with stimulating objects, one may observe the child’s characteristic and individual responses. The introduction of new obstacles or other forms of modification reveals how the child’s response is organized. Dr. Gemelli maintained, therefore, that by the use of a constant stimulus one elicits not an artificial constant response as in the conditioned reflex method but individual behavior which yields diagnostic criteria. Dr. Gemelli further stated that this mode of research betrays the functional structure of the child and leads to the helpful point of view that maturity consists in the organization of the child’s entire activity toward the aims of life, while the doctrine of the conditioned reflex is too simple and therefore inadequate for the study of personality on which psychiatric research must be based.

Dr. Gesell* (U.S.A.) furthermore, pointed out that the conditioned reflex concepts must be examined in relation to other theories of learning and cited particularly Dunlap’s Beta hypothesis of learning. Dr. Gesell also called at- tention to the fact that the maturational processes of the child, which have been amply demonstrated in his laboratory as well as elsewhere, necessarily emphasize the totality of behavior rather than the primacy of unitary reflexes. He referred to the fact that the infant is less susceptible to laboratory condition- ing than the older child and suggested that, according to the maturational con- cept, the scope of natural and wholesome conditionability is always determined by the maturity of the organism. Dr. Gesell also warned that risks are involved in subjecting a young child to untimely artificial stimuli with artificial frequency since his sensori-motor organization is in the processes of formation. I t would be ironical if study resulted in abnormal behavior rather than in an understanding of therapeutic methods! Concerning psycho analysis and conditioned responses Dr. Gesell quoted Dr. Meyerson and Dr. Adolph Meyer who hold that an identifi- cation of conditioned reff ex phenomena and psycho analytic theory is, to say the least, premature.

Dr. de Jong of Holland regards the value of conditioned reflexes in child psy- chiatry as dependent upon the relation between lower or reflex mechanisms, and higher or cortical processes. He described his investigation of this relation- ship using infants, normal children, idiots and the insane. He concluded that the lowest idiots and subanthropoids are qualitatively different from normal man and he thus distinguished between a neo-intellect, with ability to comprehend and the palaeo-intellect, without this ability.

Dr. Meignant of France, appears to represent a consolidation of the points of view of the speakers in general. While he opened with a statement that the study of conditioned reflex is of very great importance for neuro-psychiatrists,

* Dr. Gesell’s paper has also been published as follows: Gesell, Arnold. Conditioned Reflexes in Relation to the Psychiatry of Infancy. AM. J. OF ORTHOPSYCHIATRY. VIII, I , pp. 19-30, 1938.

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he concluded that conditions of the experiment do not give an exact picture of that which happens under ordinary conditions because, in the laboratory the dominant centers are under rigid control and, as Dr. Marinesco has demonstrated conditioning is not possible unless there exist corresponding dominant centers, not only in the cortex but also in the deeper parts of the nervous system. In conclusion he pointed out that the great laws of conditioned activity are only the great laws of physiology of the nervous system.

2. The Conditioned Reflex and Education Dr. Ischlondsky of France, made a direct application of the laws of condition-

ing to child training and education. He said behavior deviation was due to a destruction of the equilibrium between excitation and inhibition. The five mechanisms which influence this equilibrium were:

I . Irradiation or induction. By this process a strong stimulus to the pain center might radiate to the sexual center. Physical punishment, for example, should be condemned and replaced by appropriate and effective words.

2. Excessive tensions in two nervous processes. A breakdown of the equilib- rium of excessive tensions produces pathological behavior. Therefore both in- hi bi tions and positive behavior should be trained slowly and progressively. Reaction to too strict discipline may result either in a “capricious child,” a “child who does not know what he wants,” a “spoiled child” or a “good child,” a “gentle child” or “well brought-up child.” Either extreme is to be deplored.

3 . Cortical arhythmy. The rhythm of physiological processes, such as sleep, should be preserved because the normal function of the brain depends on this rhythm. 4. Rhythmic movements. Such movements effect cortical rhythm. The close

correspondence of physical bearing to personality attests to this point of view. Eurythmics and dancing should therefore be a part of education.

5. Language. The laws of conditioning in general, apply to the symbols of language. Thus language must be developed slowly and conflicts between two thought processes must be avoided. Knowledge of diverse languages must be taught gradually and confusions due to premature use of bilingual synonyms avoided.

Dr. Dublineau (Paris) likewise recommended the application of the principles of conditioning to education. He emphasized the importance of recognizing early a child’s timidity and tendency to resist discipline and, the necessity of separating the normal from the abnormal. He warned against too many restrictions and too forceful training as well as too few restrictions; also he called upon society in general to give more and more attention to institutions designed to affect the development of young children.

3 . The Conditioned Reflex and Psychopathology Professor Ibrahim of Germany explained morbid symptoms as the conditioning

of behavior which is itself normal and cited as examples the whooping-cough tic

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and “respiratory affection cramp” of young children. In his opinion whether or not these behaviors are conditioned reflexes is unimportant but, it is important that they can be treated as conditioned reflexes.

Dr. Peiper, also of Germany, expressed practically the same point of view and cited vomiting, rumination, constipation, enuresis, fecal incontinence, nocturnal terrors, whooping cough and frequently asthma as behavior formed by condi- tioning.

Dr. CYintsch (Switzerland) emphasized that inhibitions are developed when the stimulus is too strong, too frequent, too gentle, too variable or too multiple. For example, he said children become shy, lack initiative, independence and productivity when they are protected from the normal stimuli and risks of their age; a child becomes shy and feels inferior when nagged; a child may become unstable when his environment is too varied and contradictory; and hostility or negativism is produced from dissatisfactions with life. I t was Dr. Wintsch who saw in the conditioned reflex theory of Pavlov a physiology of the emotion as studied by Freud.

Dr Gesell (U.S.A.) referred to the studies of Krasnogorski, Ivanov-Smolensky and Liddell which demonstrate that neurotic behavior, simulating that of psy- choses, can be developed experimentally but quoted Dr. C. M. Campbell who holds the explanation of psychoses in terms of conditioned reflex formulation to be premature and inadequate.

Dr. C. de Scantis (Italy) made the statement that the contributions of the Russian school were particularly important for neuro-pathology. Nervous dif- ficulties and even perhaps, certain psychoses are better understood when studied in their development, and understanding is important for prophylaxis.

I t was the paper by the Rumanian group, Dr. Marinesco, Dr. Jonesco-Sisesti and Dr. Kreindler, which lent reality to the discussion because they quoted freely from their experience with actual cases. Although they have been able to analyze the cortical processes of a child suffering from mental abnormalities by means of the conditioned reflex technique involving internal inhibition, irradia- tion, reciprocal induction, etc., they cannot state any general characteristics of such children because of the great variety of individual differences. Furthermore, they called attention to the fact that many factors are involved in conditioning, such as the form of stimulation, the variations in the physiological state of the child and the child’s attitude and type of nervous system. For these reasons the method cannot always explain the behavior symptoms but nevertheless, it is, in their experience, a very valuable method.

Because of their success with conditioning it will be appropriate to quote an in- stance from their experience. No. I . A.V., age 9 years had bizarre attacks of im- mobility when crossed. He would remain “stretched out” from 10 to 15 minutes without moving. “He seems dead.” Also, he had nocturnal enuresis and tics of the face and right shoulder. He was a problem in school and did not obey his parents a t home.

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After three repetitions, a conditioned reflex was established so firmly that it had to be repeated 27 times before it was extinguished. His bizarre behavior was not produced by a red light but it was immediately elicited by the ringing of a bell. The conditioned inhibition was obtained after 23 combinations of the in- hibiting agent. I t was easy to obtain a differentiation between an auditory and a visual stimulus and also between two auditory stimuli (metronome of 108 and 208) but very difficult between two visual stimuli, (a blue light and a violet light). When using an oral word for reconditioning, the conditioned reflex was also easily obtained but it was extinguished more easily than with other stimuli,

They cited five other cases in which quite different conditions were found show- ing the complexity and variety of individual behaviors. One comment which they make is that, in studying the inhibition of a school child, they have noticed that very weak stimuli, which never successfully inhibit a well formed conditioned reflex in other children, are successful in these children, but after a lapse of several weeks they find just the apposite true; that is, it is necessary to employ very strong stimuli to produce the same inhibition.

The Rumanian group also noted that certain behavior problems appear to be due to a pathological fixation of a conditioned reflex. They too joined in em- phasizing that the process of conditioning is a very complex phenomenon which involves the total organism.

4. The Conditioned Reflex and Therapy

As Llr. Gesell pointed out, the theoretical aspects of reflex conditioning properly far outweigh its practical applications. Reference has already been made to the suggestions regarding therapy presented by Dr. Ibrahim and Dr. de Scantis, and to the successful reconditioning studies of Drs. Marinesco, Jonesco-Sisesti and Kreindler. In addition, Dr. Dublineau’s contribution to this problem should be summarized.

Dr. Dublineau spoke of medical and psychoanalytic treatment of disorders and suggested that the conditioned reflex technique ought also be a part of therapy. He emphasized, however, that the technique must be adapted to the disorder. Constitutional disorders resist therapy but pathological conditions of recent origin are more easily treated. A paranoid adolescent of 16 years and three boys with suicidal tendencies, more impulsive than depressed, were all success- fully treated in Dr. Dublineau’s laboratory by conditioning methods.

He advised that affective suggestion may be more efficacious than commands in reconditioning and that a chain of positive reflexes may be successfully estab- lished by using two transparent light boxes. He illustrated the use of this tech- nique by describing the reconditioning of a paranoid boy of 13 years who hated his younger brother and his mother. The words “sa mere” and “aimer” were conditioned to one another by the usual technique employing light and sound so that when his mother came to visit him he welcomed her with joy.

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Dr. Dublineau also suggested that group reflexo-therapy is possible and pro- posed that the International Medico-Pedogogique be transformed into an Institute of Reflexotherapy.

COMMENT

And thus we have before us the studies, conclusions and suggestions of some of the most eminent international personages in the field of child psychiatry. To attempt to weigh their formulations of the relation of conditioned-reflex theory to child psychiatry would be most presumptuous. I t is obvious, however, from their discussion that :

I . The process of conditioning involves the total organism and is therefore both as simple and as complicated as the organism itself.

2. The laws of the conditioned-reflex which have been investigated and formu- lated help in understanding both normal and abnormal behavior.

3 . There are other concepts of learning and growth which are equally, i f not more important, for the understanding of behavior.

4. Many of the suggestions which conditioning holds for education are the same suggestions which arise from other theories of behavior.

5 . Successful therapeutic measures are reported in children nine years of age or older when their malady is of fairly recent origin.

6. Although certain behaviors of young children can be explained in terms of conditioned-reflexology, the infant is more immune to artificial conditioning than the older child.

7. Since conditioning and reconditioning is such a complicated process, involv- ing the entire organism, and producing excitation, inhibition, irradiation, etc., it is a device to be used only by the experienced who appreciate its complexity and its hazards.