A METHOD OF INTEGRATING PHYSICAL AND PSYCHIATRIC EXAMINATION
Authors: David M. Levy
Journal: American Journal of Psychiatry (1929)

By taking advantage of rapport established in the physical examination of children, an interview was developed to follow that procedure, which incorporated phases of the psychiatric study that dealt with the child's verbal response to his own body. This interview was elaborated in a series of twenty children to include four groups of responses: (1) to anatomic variations; (2) height, weight, strength and appearance; (3) body growth and maturity; (4) knowledge of sex difference, and sex activity. The group studied included fourteen boys and six girls ages ranging from five to fifteen years, intelligence ranging from dull to very superior, referred to the Institute because of various educational and generally mild "behavior problems." The findings were summarized in a series of tables, studied in relation to other data made available by social investigation, family history, intelligence, educational tests, and physical findings; and related to other clinical cases and contributions from the literature. Although presenting no evidence of gross deformity or disease, the twenty children studied yielded eighty responses indicating special interest in or sensitivity to some body part. On the basis of the type and number of such responses, the part of the body selected, and correspondence with physical findings, a selection was made of children having excessive body interest. The various factors suggested by our cases in explanation of excessive interest in body parts form (or function) were in relation to parental oversolicitude, history of illness and injury, exposure to sick people and talk about sickness, body variations significant to the patient because they were in special contrast in his group, or had special group values, or because of special experience. Because of its importance in explaining excessive body interest, typical conditions tending to create parental oversolicitude (over-protection) were investigated and found to be as follows: 1. Conditions narrowing the emotional life of the mother because of marital conflict, or death of the father, difficulty with family or relatives, lack of contact with neighbors, absence of secondary interest; in general, restriction of social and sexual satisfactions. 2. Conditions in which children were made to solve conflicts or unsatisfied ambitions of the parents. 3. Parents ignorant or immature, vacillating between marked overprotection and neglect. 4. Conditions in the child intensifying protective attitudes through death or lack of other siblings; special hazards of accident and disease, weakness, deformity, inability to adapt to other children; and a series of events in the form of miscarriage and still births causing a prolonged and intensive period of maternal anticipation. 5. Lack of modifying influence of the child's behavior through absence of or "negative" paternal role, or play life with other children, allowing prolongation of infantile traits. Response to crooked teeth was found especially significant because of masked movements used to conceal them, including narrowing of the smile and limitation of lip excursion in conversation; hence, an effect on spontaneity of speech and behavior. There was a close correspondence in our group of special response to the skull, or scars of the skull and excessive body interest. It was attributed to psychologic reaction of parents to the child's head injury or operation. Of all parts of the body the visible mouth area was most productive of "sensitivity." Eyes and hair also received frequent responses. Breast and genital responses were relatively much more numerous in boys than in girls, in keeping with more frequent exposure to nakedness among males, and the age of the group. Variations in body form or function in frequent derogatory contrast among boys were thought to be shortness, weakness, thinness, small penis; in girls, facies, hair, obesity, tallness. In general, sensitivity among boys was related to competition in terms of strength and size; among girls, to competition in terms of physical attractiveness. In certain cases it was shown how sensitivity to a body finding may draw special attention to that finding in others; how sensitivity to a secondary sex trait may create doubts about sex identity; how masturbation-threats in boys, training of sex prudery in girls, may involve excessive interest in the genitals, in the body, and in sex; how a general self-derogatory attitude may involve body parts; how one "point of sensitivity," may spread to other parts; and how lack of reassurance by the parents may prevent the child from awareness of "good points." The wish to remain a child and not grow up was expressed by seven of the twenty children studied. In these cases there was evidence of a fear of the future, or an overly cherished childhood with parent-child overdependency, or both. This overdependency could not be corrected by group play in five of the seven because of lack of companions. In the others the wish to grow up was probably reenforced by unhappy conditions in childhood (poverty, school difficulty, severe discipline) and the wish to solve problems requiring immediate maturity for reasons of family devotion, protection, rivalry, revenge. The wish for marriage or its rejection was apparently influenced by a number of the same considerations as for growth and maturity. The usual wish of a girl for a baby was probably intensified in one of our cases by loneliness and lack of affection. The rejection of children by two girls was partly due to their rejection of the female rôle. A frank rejection of marriage was explained by one of the patients as the design of his mother, who needed him for support, and taught him to be afraid of marriage. A number of boys under age twelve rejected the idea of body hair, one "accepted" only facial hair, another body hair if "light." A study of other cases indicated that revulsion of hair is a frequent finding in our preadolescents. In the study of knowledge of sex differences, instances were found of the fallacy in boys of attributing a male penis to the female even after observing their naked forms; of generalizing from exposure to the mother that the sex organs of all girls are hairy; of a theory by a girl on sight of her brother's penis, that he had stolen hers and that all men similarly are thieves. Of the children questioned none had correct notions about the navel. In two instances the scrotum was thought to be a box for water, an idea probably derived from the water closet. In logical relation with opportunities for observation, usual methods of sex instruction, and knowledge of body processes, more children were ignorant of coitus than of birth; more were ignorant of birth than of pregnancy. False theories of birth included navel, Cæsarean, urinary, rectal, oral and breast. None believed the stork theory. Exposures to scenes of sex activity of parents and other adults were frequent, in keeping with general observations in this field. The response of children to these scenes, as to sex difference and sex theories, is confirmatory of psychoanalytic findings. The practice of masturbation was reported by eight of fourteen boys, median age of ten. The effect of knowledge about sex and sex activity on personality is a problem difficult to demonstrate by direct study although in some cases it was shown that excessive curiosity was found closely related to taboos against nakedness, and excessive questioning about the origin of all things to incomplete sex information. It was inferred that exposure to the nakedness of parents might cause more difficulty in mature sex adaptation than exposure to the nakedness of children; that very early knowledge of sex difference is necessary to prevent false generalizations; that early knowledge of sex processes is necessary to prevent distortions of fact and their later vulgarization; that training of girls to be constantly aware of aggressive sex tendencies in the male may help create excessive sex interest and homosexual tendencies; that the child's attitude toward sex activity is derived from the details and setting of the act, from his attitude towards the people who first reveal it, besides his previous experience.