Chapter 10

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.