BODY PARTS AS SYMBOLIC OBJECTS 3
INTRODUCTIONCases showing behaviours very similar to those seen in s.l.d. children studied in the U.K., (described in 'Body parts as symbolic objects 1', and 'Body parts as symbolic objects 2' ), were studied in Thailand. The children were patients at a child psychiatric hospital, near Bangkok, most of them being diagnosed as having developmental delay and 'autism', (although, as usual, the children had no difficulties in forming relationships with, and attachments to, adults). The children regularly spent some days of the week at the hospital, often with a parent, in various therapeutic and educational activities, but slept at home. The similarity of the cases has implications for the nature of the behaviour.
CASES AND OBSERVATIONS
Case 1. 'Beam' Age:-6
Talk with the mother
Bites forefinger and middle finger. They're very swollen and thickened. When she gets angry she bites until it bleeds. Also hits chin with her fist. She does this also when she's calm and relaxed but not so hard. It started at the age of 4 or 5. She also plays with her hands, grasping and grasping. Both started at the same time. She does it because she's 'emotional'. We ask the mother when does she get angry? Mother replies that it's when
1. she's told to do something she doesn't want to do
2. she doesn't get what she wants
Mother says that it's become a habit. Mother wraps clothing around her elbows to try to stop it. Mum was the one who tied the bandage round the right wrist and to her waist, to keep the hand down by her waist, away from her mouth. This is how I saw her at the hospital on 26.4.04. Fingers are distorted, she can't hold anything. Sometimes she bites until the bone is broken. What is mother's response to these behaviours?
1. If she's told to do something , if B. engages in this behaviour, she takes B.'s hand away, but still perseveres with the request/demand.
2. If she can't get what she wants, and B. does this behaviour mum takes her hand away and still doesn't give her what she wanted.
It seems that the mother is being sensible here, and not rewarding B's behaviour by 'giving in' to her. Has she always done this or has she just started after receiving professional advice? Mum holds her hands when she sleeps. B. is in a group, having her hands held by a member of staff. Then when they are released she clenches her hands in a very awkward and twisted way, moving her fingers all the while, pushing her hands together and regarding them all the time. Only sometimes does she grasp the forefinger of one hand with the other hand. Quite a lot of force used in all this. Sometimes pushes/bends fingers of one hand over with the other hand. Doesn't seem keen on me holding her hands. Forefinger and middle finger of right hand very swollen.
It's very hard to get her to hold objects, eg a ring to put on a peg. Sometimes when she grasps something she brings it to her mouth. Staff members say she needs help to eat. She seems better at holding small objects. Is it that she can't hold or that she won't hold? When the writer is working with her, (with pegs and stacking rings, geometric shapes on pegs, and different shaped pieces to be put through the same size and shape holes), there is some biting of the right fingers. There seems to be some shaking of the hands in the manipulation of objects, a sort of tremor.
The right hand is pressed to her mouth and pushed with the left hand. Lots of tension in the hands. She can open her hands without problems and can hold adult's hands quite normally. Stress might be a factor. When eating she can, rather awkwardly, hold a big spoon underhand, with a crude, palmar, fist grip. She is usually given help to keep hold of the spoon in the form of staff's hand over hers. Also help is given to get spoon to her mouth. When adult is holding her hand on the spoon handle she may sometimes keep her arm stiff, (perhaps it's simply that her mouth is still full and she's not ready for another spoonful?) When hand holding the spoon with rice in gets to her mouth there is some hand shaking , some tremor, but this doesn't really look like intention tremor. She's quite good with finger feeding - she can pick up a little piece of meatt. While being fed her left hand is nice and relaxed in her lap.
Then, in free play, B. stands in the middle of the room, not interacting with anyone and not playing with anything. Afterwards, B. sits watching a singing and computer animation video with the other children. Her hands are quite relaxed, by her sides. She becomes sleepy and is put to lie down on a mattress in a corner of the room. She falls asleep, on her back, with her hands quite relaxed and open on her chest/tummy. Later, when she wakes, or is woken, her hands are still relaxed.
Hypotheses concerning the peculiar hand positions and movements.
As a way of avoiding having to follow adult demands, many of which involve doing some manual, fine motor task, her peculiar hand and finger positions seem very effective, she's 'put her fingers away '!* But she hasn't simply made a fist, her fingers are constantly writhing , she puts one finger over another finger of the same hand, then changes their positions etc. Perhaps she is attempting to achieve a complete state of 'put away-ness', or maybe 'locked- awayness', where every finger is covered by another. This is, of course, an impossible task but B. persists in the attempt, hence the constant movements.
This is, I admit, a strange theory! How would we try to get data to support or disprove it? If there were a way of achieving, what is for B., the impossible task of putting every finger away would this abolish the hand and finger postures and movements? What is not possible for B. herself to do is quite possible for another, and quite possible, if inanimate objects were also used. So I suppose when another person put his hands over hers, when he holds her hands, then the finger and hand contortions should stop. This indeed seems to be the case and so to this extent the theory is supported. The other person has put her fingers away and so relieves the tension, the demand to use the fingers. Perhaps this is why the mother holds B.'s hands at night. Or again perhaps would some kind of tight fitting mitt, perhaps without even a division for the thumb, have the same effect?
We might even consider that the strange hand positions are a way of communicating to the mother and other adults, when she is faced with a request to do a fine motor, manual task that "I won't do that, because I can't do it, look at my hands, I've put, in fact locked , my fingers away!"
On this theory one might teach the child to use a more healthy and normal way of expressing disinclination. The mother might, on asking B. to do something, encourage her to decline with a shake of the head, and keep her hands relaxed. So the mother might demonstrate that B. is allowed sometimes to say "No, I don't want to do that", that this is sometimes acceptable.
Roughly similar perhaps is a neurotic symptom, where for example, in wartime, a soldier manifests a hysterical paralysis of the arms and hands, so saying; "Look I can't hold a rifle, so don't ask me to!" Supposedly such a case is unconscious, but there are probably a number of possibilities from this to a fully conscious malingering. * See the similar behaviour of the boy who folded his arms, (described in "The development of communication in children with developmental delay and/or communication problems"), as a signal that he had put his hands away, because he had completed a manual task which the psychologist had set him in the course of a psychological assessment.
A very slightly different view may be taken of B's finger movements. In the first view we said that she is attempting to achieve a state of perfect put-away-ness, or locked-away-ness, an attempt which is impossible, and which is therefore endless and unfinishable. The state of 'put-away-ness' or 'locked-away-ness' is associated with a non-use of fingers and the child is saying "I can't use my fingers, they've been put/locked away".
The slightly different view is more active. We might say that the child/fingers can't do what the adult is asking him/them to do, as he/they is/are too busy, putting them/being put, or putting themselves, away.
Of course any of these strange behaviours, such as hand regarding, and biting , and finger movements, whatever their original motive and drive, might later be strengthened and made more likely, by the reaction of the adult, e.g. mother, to them. If the mother gives attention, releases the child from task demands and so on, the behaviour will be reinforced, as a sort of secondary gain.
In fact the behaviour perhaps evolved over time with the child adding more finger contortions, as the mother attempted to get the child to do tasks, and gave the child attention for, and demonstrated concern over, the behaviours.
Questions for which I received no answers.
1. Before age 4, did she grasp objects normally, with a grasp type somewhere on the normal developmental sequence? Maybe a crude palmar grasp.
2. Is she right handed ? Is dominance established?
3. What is her M.A.?
4. Is she a task avoider for other types of activity, non-manual activities, e.g. gross motor activities? I should have tried her with this but I didn't think of it at the time.
5. Does B.'s hand behaviour occur when she's alone? One would have to observe her surreptitiously, e.g. through a one-way mirror.
6. Is it worse with different people?
In view of the likelihood that s.i.b. is rewarded and reinforced by endorphin release we should make sure that B. is given opportunities to engage in healthy exercise, as a more acceptable way of gaining such biochemical rewards, e.g.the mother might take B. swimming.
As far as I observed her hand behaviours are entirely negative, I didn't see her smile at a hand, for example. Is this true at all times? I did not observe her to be at all aggressive to others, she seemed to be entirely self- punitive. Is this true? While one doesn't want to suggest that we encourage the child to be aggressive to others, we may try to make her more assertive, and more physically active. It seems to be a common phenomenon that a highly self-punitive child, if he begins to direct more of his aggression outwards, seems to become psychologically healthier.
Case 2. Lalita, ('Praw')
d. of b. 31. December. 2000. Age 4
Information got from sister on 27.5.04
T.r.a. She looks at her hand and then 'counts' her fingers, pointing successively to the fingers of the hand. She likes to massage her hands and her arms. Parents do this every day, in line with hospital instructions. She may do this after she has finished playing with toys. She started massaging her own hands and arms after the parents began to do it. After a bath, at 8.00 p.m., parents will massage her. Sometimes when they don't do so she will do it herself. When she does it she is not looking at the parents and so it's not obviously communicative. She sometimes does it when she's tired, parents may see her and ask if she's tired, on which she smiles. Sister says she possibly only does it when she's in a bad mood, when she's crying, and then sometimes she shuts her eyes. When asked, the sister says that the crying is in response, not to separation from the mother, but in response to being asked to do something she doesn't want to do, being asked to do something not in the routine, or if she sees a toy associated with an activity she'll be asked to do, one which she doesn't like. When she cries it's for a long time, no one can stop her, she stops by herself. P. moves her mouth like speaking nearly correct; so sister says, but with no sound. She likes to look at her parent's lips. Sometimes she smiles at her hand, sister says with no external trigger. Sister says she's happy and smiling if she's doing nothing . She takes adult's hand and 'throws' it up to a desired object, which is up on a high place out of her reach, e.g. snack on a high shelf. Sometimes sister hides her baby doll, and P. takes sister's hand, and takes her all over the house to look for it. She takes her upstairs to the cupboard, which is locked, where the toy is always placed. The mother wanted to wean her away from the doll because it was taking her attention from other things. In the past she would hug the doll when she was crying, and before leaving home. (The toy is apparently a very large one, the same size as her, and in fact it's a teddy bear).
If a door- knob is high, and she can't reach it, she'll push adult's hand up towards it.
If she wants the toilet to urinate she pulls down her shorts and knickers, and then goes to the toilet herself. If she wants to defecate she will get adult's hand and pull them to the toilet, or pull down her clothing and then pull them to the toilet. She will pull down her clothing anywhere, she pulls them half way down only.
She also flaps, as usual probably when excited).
Denver II Date Given: 3.6.04
Father is informant. He gives the birth-date as 29. December. 1999, which is correct, I think.
Level is about 2 years
She scribbles well. In the 'imitate vertical' item she starts with a good vertical but this is carried on into circular movements.
Level is about 2 years
Level is about 2 years
Imitates mum doing the laundry. She can indicate her wants, by getting father's hand and pushing it up towards a desired object up on a shelf, or similar. If the father refuses to co-operate she will get a chair.
She finds the little doll right at the start of the session, and is very interested in it. After the item it's involved in is given, I take the doll away from her, in the face of strong resistance, as I want her to pay proper attention to the other Denver tasks. In the actual test item, 'Feeds doll', she puts the teat end of the 'bottle' into her own mouth, rather than into the little doll's 'mouth'. This might be compared with her use of one of her hands look at. Here again there is only one symbolic object, here it's her hand, the interaction is with a real object, being itself, i.e. herself. (My translator says that families here do use milk feeding bottles with their children as well as breast-feeding.) In her demonstration-imitation of pulling down her clothing, she is again, we could say, only using one symbolic element, the room in which she performs the action represents the toilet . (In higher mime-types of communication the object is removed, and P. might learn to mime the action of pulling down her clothing).
Level is about 9 months.
She says "Mae" (= "mum"). She says this if she's with her mother, and she's angry. She learned to imitate a clucking sound, but only after a while, not immediately. Imitates the sound of a motorcycle. Says "Jaw jan"(= "plate"), but not to ask for food.
Comments on the test results
Note the imitative behaviours described here. Her shorts and knickers dropping can also be regarded as a form of demonstration-imitation.
Case 3. 'Plaeng'
A large obese boy. He will be 5 in July.
Observation. 1st June 04
In a lesson, smiling and happy, regards his hands, one at a time, either hand. He is reported to speak well*, like a three year old, not be 'severe', and be overactive, with poor attention. Gives sidelong looks. He is sitting at a little table with his grandmother. Teacher/nurse comes over to his table, and tries to get him to say where a named pictured object is, and then to name some pictured objects, whereupon he looks at his hand, and becomes aggressive. He squeezes his grandmother's hand when she pulls his hand away from his face. He also squeezes the teacher's hand. (Actually he uses his nails, his hand is clawed).
* Is said to say:-
"I want to eat rice with chicken"
"I want to toilet", shouts "Finished!" to grandmother, to clean him after he's defecated in the toilet.
He can name all the objects pictured, ( black and white schematic symbols) i.e.
soap, ruler, bottle, glass, pan, broom, shirt, shorts, skirt, shoe, sock, belt, cap, spectacles, buttons, toothbrush, toothpaste, comb, scissors, umbrella, table lamp, dish, spoon, fork.
Case 4. 'Fahng' d. of b. 19.6.1999 Age:-5
Poor eye contact. Loves to dance to a music video, or any music. Likes to be cuddled and tickled by people. Is with mother at an individual table doing table top activities, e.g. using Playdough. There is much resistance to sitting still, she extends her body, and much task avoidance, she turns her head away from the task and looks somewhere else. If she is being taken somewhere e.g. the toilet, she's floppy and doesn't take her weight. There is a lot of negativism. She chews the neck of her top. Always laughing. Is this in response to a real situation, or not? If being held in place by mother to do some activity she doesn't seem to get angry, but just laughs. She is really trying to get away, but is prevented and laughs. She gets free to join another mother and child playing with a ball. She looks at them and touches the ball, as usual laughing heartily. Then she goes to another mother and child and gets their ball. Previously I had seen F. fall, after colliding with another child. She cried for a little. Later lies on her back on the floor, playing with a rattle, has this in her mouth. Then she puts the rattle under her armpit, and laughs, then under her chin and laughs heartily. She's interested in other children, gets close and strokes them, or their clothing. Then hides behind curtain, and then reveals herself.
27. 5. 04 Talk with the mother
Birth-date is June 19 1999. She's 5 years old. When she goes to bed she rubs her hands together before she goes to sleep. She hates mushy food, and rice in soup, has done since she was 2. Mum says she hasn't seen F. look at her hands!!!! She can't speak, except for three words from a Thai cartoon. If she's hungry she'll bring a plate and spoon to mum. If she wants a snack she brings the packet to mum to be opened. If she's thirsty she gets a bottle of drinking water from the fridge and gives it to mum to open.
(During the talk with the mother a ball she was playing with got stuck in a chair, she looked at mum, and made a loud noise. Mum got the ball out for her.) She makes eye contact with mum if she wants something. As for the toilet she still wets herself, there is no signal. Apparently she is scared of the toilet seat, (because of efforts to toilet train her before she was ready?) When wanting to defecate she might stand up and look at the floor. If a desired object is on a high shelf she'll get a chair to stand on, or a table. Only rarely will she pull an adult to the place and 'throw' her hand up towards the object, usually if she can't get the thing herself she will give up. She plays well with her sister and father. Mother says she only laughs when playing. She plays run and chase with her sister, both roles, but doesn't know the 'tig' rules. Sister is 7. Dad sometimes pretends to bite her wrist, she is scared of this, cries, with no tears. She doesn't bite her own hands. She sings 'in her language'. Drools a bit. ( She is also seen to laugh in ball play, when the ball rolls to her and contacts her body. So perhaps any body contact makes her laugh, animate or inanimate, in play or even when she is being restrained).
1. June. 04
Test: Denver II
Behaviour and co-operation
Not very good: is being silly and laughing ,as usual. She throws test materials away, including the little bottle. The results are therefore only provisional.
Level is about 18 months.
Level is about 2 years 6 months.
Level seems to be about 6 months
Mother says she can build a tower of 4 or 5 blocks. Now she says she has seen F. engage in h.r.b.! Mother says it involves just the one hand, and it's more often the R hand than the L. At first mother thought she was asking for something, and she taught her to put her hand out; now she doesn't think it means this. When asked what she thinks it does mean mother says she thinks she's playing. (This seems a good reply, in view of my theories).
Second talk with the mother
If she does it mother puts her hand down, because she doesn't like F. doing it, because she's not learning any more. Mother agrees she chews her top but says she doesn't bite others, or herself. As usual with this informant her statement is very quickly put into question, this time not by another of her statements, but by an occurrence, that of F. giving my translator/helper,(A.), who was holding her in place, a little bite on her hand or arm! She doesn't head bang. Now mother says when she's angry she may bite someone! If father holds her a long time she doesn't like it and bites his hand or forearm, the one holding her. She doesn't suck her thumb.Mother says she had a convulsion after birth, on the first day, her body looked blue. She sometimes toe walks, says mother. She doesn't flap.
For the need to urinate there is no sign. She might vocalise "eeee", in the toilet , after she's wet herself. For defecation she might hold herself, as though she is cold, or hold something and vocalise "ugh, ugh", (to express effort).
If she's hungry she gets a plate and bowl, and gives them to her mother, not always. She opens the fridge for a drink. If there is a bowl of drinking water in the fridge she can drink from herself. If there is drinking water in a bottle she gives this to mum to open. If she wants to go out of a room she touches the knob, cries and looks at mum. If mother ignores this and F. has something in her hand she'll throw it at her mother! She may also pinch her, with a whole hand type of pinch. She doesn't pull mum to the door. Mum says she didn't bite the nipple when breast-feeding. Her favourite food is said to be fried meat. This is salted, dried beef, which is then fried. Mother says she sometimes bites the middle and ring finger of her right hand, this just started two or three days ago.
Level seems to be about 15 months
More from the mother
She was one month post-mature, delivered at 10 months. She can imitate the intonation of a song. She has no meaningful words. She does not 'jabber'. She has vowel sounds, "ah", "wu". She does repeat syllables :-"na-na-na", "mae-mae-mae". She copies 'speech' sounds. She imitates her mothers cough. She bites people.
(At some later stage the mother added that in fact F. had suffered 20 or 30 convulsions; these were now under control with medication prescribed by the hospital).
F. demonstrates a good precise finger tip and thumb tip grasp of a tiny object. We get her to build a tower of 2. Or rather the equivalent, or better, because there were two blocks already placed by us in a tower, and she added a third. (We had tried to cut out her silly playing around and throwing things away by not giving her any attention,, no eye contact during this behaviour. Then I got A.to build a tower, giving her the blocks one by one, and praising her for this. This worked reasonably well and F. did the tower as described above. (She is seen to have wet herself and is taken to be changed). She walks up and down steps, one foot per tread. She has a good overhand throw of a tennis ball but not to anyone. (This is probably negativism, or just done as part of her general playing about). Kicks a piece of paper, instead of a ball. Can stand on one leg and put the other through a leg opening in her pants, when being changed.
She is offered a big furry cuddly animal toy, a dog, is very pleased, laughs uproariously. Mother says she has one at home, she hugs it. With the toy at the hospital it was seen that she also likes to put it up on a high place and then take it down. Mother says she like to throw the one at home. (So perhaps its control over something seen, in a symbolic sense, as a sentient being, a person, maybe a parent-figure (anthropomorphism). Mother says she likes furry 'dolls', not smooth ones.
Is being kept in her chair by a member of staff. A little upset. Then is given a face cloth with quite a rough texture. Very pleased with this, giggles. Squeezes it between her chest and chin. Chews it and laughs loudly. Then throws it away. Then strokes the head of a boy who is sitting next to her, and then uses the cloth to rub his head/hair. Flaps the cloth up and down, flings it away and giggles.
Note the oral-aggressive behaviour to others, when angry, and to parent symbolic/substitute objects, such as the neck of her top, and the rough textured cloth, in play. Clothes, and cloths are symbols/substitutes for the parent, especially the mother, because it is this person who dresses and undresses the young child. It is especially the neck of the top, e.g. T-shirt, which is chosen to bite or chew because here the element of constriction (= parental control), is greatest. We must observe also that the front/top/neck of the mother's clothing is spatially close to her breast and so the chewing of F's T-shirt is obviously an oral-aggressive attack on the mother's breast, because of this chain of associations:-
mothers breast---->front/top of the mother's clothing----->front /top of the child's clothing.
[In the U.K.group of cases recall L. Mc., who was also aggressive to this part of a person's clothing, but with interesting differences. She used her hands, to grab the neck of clothing, and she went for other people's, (adult's), clothing].
(The case is similar to tight hair styles in girls, being a symbol of such control, by the mother, who is the one who puts the girl's hair in such styles. A feeling of freedom, and of being able to do what the child wants, is associated with the loosening of the hair from such restraint; the child, (or adult), 'lets her hair down'. Frustrations of the child's desires by a mother figure result in disguised attacks on the the adult, expressed in chewing the hair or pulling on it. The child's hair is a symbol of the mother because it's the mother who washes the hair, combs and brushes the hair, and puts it into various styles, especially for little girls. The mother's face and her manipulations of the hair, perceived visually, together with tactile sensations, become associated in this. Sometimes the ministrations might get rough, if the hair being combed is tangled and knotted, and the the hair will get tugged, but sometimes the intervention is gentle with the hair being brushed and stroked).
Note that the behaviour of flapping the cloth up and down, and then flinging it away, is an expression of total control over the adult symbol/substitute; the same behaviour is also seen with F.'s teddy, and has a similar interpretation.
The behaviour of squeezing the cloth between her chest and her chin, is similar to the behaviour of a girl seen years ago at a residential school for s.l.d. pupils, many of whom had the 'autistic' label. In this U.K.case the girl got great pleasure and amusement from flexing the elbow of a male member of staff, with her finger or hand, or another person's finger or hand, trapped in the angle between the upper and lower arm. (This person was wearing a short sleeved shirt or T-shirt at the time).
These behaviours might be regarded as sensual/sexual and as substitutes/symbols for the insertion of one body part into a body space or cavity. The suggested activity might be a sexual one between two people, or might be auto-erotic, especially, in the latter case, female auto-eroticism.
On the other hand, the front/top of the child's clothing is to be regarded as a symbol of the mother and of her breast, as stated above, and the gentle pressure between chin and the chest and the cloth might be seen as representing oral satisfactions at the mother's breast.
Case 5. 'Oy' Age about 3
14 May 04 Observations
This child was seen to regard her hand, with palm presented to her, in a thumb up position, with fingers spread. She was moving this hand slightly, up and down, and to and fro. She was crying at the time, I think.
This seems to suggest the possibility that there might be transitional, hybrid forms between the type of hand behaviour we have concentrated on, and the type involving interruption of a light source, the simple sensory stimulation type. In this case note that the hand was not held up to any obvious light source, e.g. an artificial light source, or a window etc We may entertain the idea that there is not a sharp dividing line between one form and the other.
As the baby lies on his back and looks up, at his mother's face, the main source of illumination will be above him. His mother's face might be framed by a sort of halo. His hand (s) might be out/up stretched towards her, he'll see his hands also, as well as his mother's face.
Information from mother.
As for the h.r.b. mother says that at first she looked at both hands and spun. Now apparently she just looks at her hands. If she is looking at the television she tends to look at one hand only. If she is running about she tends to look at both hands. When looking at one hand only it is always the left. If she's upset or mother doesn't allow her to do something she wants, she'll look at her hand. The mother says she still won't give her what she wants. The mother says she doesn't like dolls or teddy bears. ( When my translator offers her a big cuddly toy she pushes it away). Apparently she likes to play with Leggo. She likes to line up the leggo and then form a square. If very hungry she will say "Mama", if very upset/angry she will say "Yaa" (= "No!"). There is a lot of flapping. At home is father and mother and a big sister of 13. Apparently father is firmer with her than the mother is. Mother says she can feel jealous; if her big sister hugs her mother Oy will push her sister away. She doesn't suck her thumb or finger. She likes to have a cloth, a comfort cloth, drink milk, or go to sleep. She gives no indication that she needs the toilet. She can open the fridge, get out a bottle of drinking water, and give this, and a cup, to her mother, when she's thirsty.
There was some h.r.b. but this time it didn't seem any different to the standard h.r.b. I've seen in the U.K.
The Denver II was administered to the child, when possible. It
was usually necessary to pen the child in a corner when carrying
out the test.
These questions guided the observations of the child's behaviour and their relationship with the parent
These questions were put to the parents concerning the child's h.r.b. and other behaviours.
Name of child D.of B.
Have you seen the h.r.b. (or related behaviours such as h.d.b. etc.)
Describe it. Are there different types? Positive, with a smile at, and even a kiss of the hand, or negative, with a frown at, or even a bite, or slap of the hand? Doe it involve one or two hands? When only one hand is used is it more often one hand than the other, and if so which one? When did it start, how old was the child when you first noticed it?
What makes it happen, each type, or does it seem to happen without a trigger?
What is the parents' reaction to it, what do they do?
What do you think it's about?
Which of these behaviours occur: hand, thumb or finger sucking?
Which finger, which hand?
Does the child hit the chin or mouth area with a hand? If so which one? Is one hand used to bring the other hand to the mouth to be bitten? Does the child chew her clothes, e.g. front of the neck of a T-shirt? Does she pull her hair? Under what circumstances do these other behaviours occur, and what is the parents' reaction to them? Does the child toe walk, or flap, and again, when might these behaviours occur and what's the parents response to them? Does the child live with mother and father? If not who does she live with? What is the relationship lke between mother and father? Do they have arguments? About what? Who is the child closer to, mother or father, or is it about the same? What spatial arrangement corresponds to the emotional distance between the members of the family? Is the child interested in dolls, teddy bears and so on? What does she do with them?
Who is the parent who is firmer with the child, who disciplines
most, or are they about the same? How do they discipline? What
behaviour do they punish, and what reward? Does one or both
parent over- indulge the child?
In the early development of the child how did she feed? Did she sometimes bite the nipple? If so what was the mother's response?
How does the child communicate? Does she use t.r.a.? What type does she use? Does she pull adults to places and objects, and 'throw' their hands up to desired objects etc. or bring objects to them for them to do something , e.g. brings a drinking water bottle from the fridge and gives it to them to open, brings a plate for food etc.? How does she indicate her basic needs, for food, for a drink, for the toilet? What other desires does she signal, and how? Does she have any higher type of communication, e.g. demonstration-imitation, putting her own hand up to a desired object high up, etc.?
|We may compare the behaviour of the above children with that of the U.K. children in my first two papers. All these hand and mouth, or mouth area, behaviours seem to be universal. They are not simple neurological phenomenon caused by brain damage, but are quite complex. They are independent of culture and if any learning is involved it is learning that every child everywhere is exposed to. They are to be regarded as natural communicative phenomena, perhaps using the sort of universal symbols described by the psychoanalysts. They involve images and symbols, which might be hard wired into the nervous system of everyone, whether he be from Bangkok or Birmingham.||
Another analogy might be with the idea that the C. N. S. has been pre-programmed
to learn some type of language, maybe always along certain lines. In our case
the situation could be even more determined in that some of the
symbols might be in existence at birth.
Moreover it is beginning to look likely that the trigger for the negative type is always of the same type, the frustration of one of the child's needs or drives by a parent or parent figure. The child attempts to relieve his feelings in phantasy, in an imagined revenge on the frustrating parent or parent figure. The same emotions are seen in the tantrumming child, not fear but anger .
|The corresponding trigger for the positive type of h.r.b., (or h.d.b.) is to be seen therefore as an instance of gratification of one of the child's desires by a parent or parent figure. It might well be that at the primitive level of thinking of the child, a friend, someone who likes/loves them, is someone who gives them everything they want, while an enemy, someone who dislikes them stops them having what they want. And the child loves those who love her, and hates those who hate her. Expressed in terms of control, for the child the adult who loves the child gives him control, not only over himself but even over the adult, while the enemy denies the child's control of himself and of others.|
|Therefore one way to test this theory is to deliberately act positively or negatively towards the child who engages in h.d.b. Positive or negative interventions should produce h.d.b. Positive interventions should produce positive hand symbolic behaviour, while negative ones should produce negative hand symbolic behaviour, always assuming we can see the difference. Positive interventions include giving the child a cuddle, smiling at him, giving him something nice to eat, and so on. Negative interventions include reprimanding him for something, telling or||
getting him to do something he doesn't like e.g. to sit up
properly if he's slouching in his seat, to go back to his chair
and stop running around the room, and so on. Positive h.d.b.
includes smiling at the hand, or even kissing it; negative h.d.b.
includes frowning at the hand, slapping it, biting it and so
In the typcal case in our groups the child shows a much lower level of functioning in the area of communication, (verbal communication), than in other areas. This is to be explained on the gounds of higher order, more complex functions like
spoken language naturally being more
affected by cerebral dysfunction, than are other areas.
Now if such a child has needs to satisfy, in phantasy, the lack of language means she cannot do this as an inner, unobservable process. Neither can she use visual -kinaesthetic images of a sign language, either through incapacity, or because she has not been taught such a language. Therefore the child has to resort to using a lower level symbolic process, involving props, (properties and props in the sense of supporting something , here the phantasy process.)
Therefore another way to test these ideas would be to give the
child the means of engaging in her fantasies other than looking
at the palms of the hands. Once this was done the hand regarding
might disappear, especially if the new means were more effective.
So we might provide the child with figures whose identity is
indeterminate, a sort of partly unstructured stimulus, as in
projective tests, and in a similar manner as is done in the
Bene-Anthony Family Relations Test. But we would use 3-D figures,
faceless dolls of different sizes. We would give the child a
figure for each member of her family, e.g. mother, father,
brother and sister etc. We might in fact use glove puppets, in
the same variety. Such a puppet uses the person's hands, a
situation very much like h.d.b.
We might present these objects to the child to see if they interest her. More specifically we might create the desire to engage in phantasies concerning the
parent or parent figure as in
Test 1, by engaging in positive or negative interactions with the
child. Of course such symbolic behaviours with the dolls might
need to be learned before the use of the hands would diminish in
frequency. (Of course, the acquisition by the child of any sort
of more internal symbolic process should cause the disappearance
of h.d.b.; if the child gained some proficiency in sign language
the same result should follow. But of course many, or most, of
the children we are discussing are unlikely to be able to gain
any great competence in sign, and so the point is academic).
On providing the child who engages in h.d.b. with puppets, one of a generalised faceless adult male, and one of a generalised faceless adult female, we may then look to see which hand he uses for each one of these. If he assigns hands consistently then we may draw the appropriate
conclusions regarding the symbolic
values of his two hands in his h.d.b., and his h.r.b. Rather than
actual glove puppets we might just use simple, easy to don,
gloves, (so of a somewhat larger size than the child's hand),
with very schematic features for the palm side.
This leads onto the question of what form of communication our h.d.b., or h.r.b.is, where does it fit into the scheme we have sketched out in our paper on the development of communication? (The communication is with ourselves and the purpose of the communication is self-gratification, in phantasy, but this doesn't affect the type of communication. it is; after all, as we said, we could indulge in the same phantasy wish fulfillments totally internally, using internal visual images of scenes and scenarios, together with auditory images, of words spoken etc.) The type is clearly close to the use of 3-d figures and puppets marked in the diagram.
What is the relationship between a substitute object and a symbolic one?
Summary and conclusions
Hypotheses, suggestions and questions for future research
We theorise that the hand represents a parent. Perhaps interventions by male adults make the child phantasise an image of the father, which is represented by one of the hands, and likewise for females. If two hands are used it is likely that these represent the two parents. It is possible that the hand chosen for a parent may reflect the dominance of that parent in the family, or the desire for dominance over that parent.
In cases where one hand is used to bring the other to the mouth area, e.g. the chin, to strike it or be bitten, it is possible that, in the first case, this is a representation of two parents acting against the child, and, in the second, of the active hand being a representation of one of the parents acting with the child against the other parent. Perhaps this could be an enactment of an Oedipal or Elektra phantasy in the child's mind.
One difficulty is in deciding which elements or aspects of the phantasy are fact, and which are pure wish- fulfillments. One would argue that part must be fact, to allow the child a suspension of disbelief. But more certainly a large element of realism is provided by the fact that, in early and simple phantasies, the creator will play himself, or perhaps himself with only very few changes, and the characters of family members will remain close to their characters as perceived by the child. The main phantasy elements will be found in the course that events take and their outcomes. The child will be triumphant in any confrontation with a parent, especially the same sex parent, and he/she will enjoy a successful resolution of the Oedipal/Elektra situation.
The non-dominant hand might be a more natural symbol for the other person than the dominant hand, since this is something the child has less control over. But the child might have a parent very much under her control, and in this case we might expect the dominant hand to be the symbol for this parent.
This seems rather far fetched, and instead we might consider this line of reasoning. Until the child has established handedness he might use either hand, and either could become associated with objects, especially those often handled. But when it is established, it is the dominant hand, usually of course the right hand, which will most likely be associated with the parts of the mother's body, and so the mother herself.
The palmar surface
Another question, dealt with in the earlier papers, I think, is this:- Why is it that it is invariably, according to my observations, the palm of the hand which is looked at? As in the cases of hand biting, one might argue that anatomically, physically, this is the easiest and most natural side to present to the face. But I don't think this is true, to me it seems as easy, or maybe even easier, to bring the back of the hand to the face. How does one get real evidence for the ease or difficulty of a performance? One does this by determining the frequency of its occurrence. But this assumes that the strength of the motive for the performances are equal, and this may not be the case.
The reason must lie in these facts. You touch, feel, grasp, and use an object, with the fingertips and the palmar surface of the hand, not the back of it. So the tactile sensations and perceptions from this part of the hand are associated with other sense perceptions of the object, e.g. sight. (In grasping the object proprioceptive sensations, associated with the particular hand-shape, and therefore with the shape of the object are also associated with the visual perception of the object. Note that in mime and sign, hand shapes, especially if distinctive, are often used to represent an object). Consequently the visual image of the object will naturally be 'projected' onto the palmar surface of the hand. If this object is a face then it is this which will be seen in the hand. The baby, lying in its cot and looking up, sees its mothers face, reaches out and feels it, time after time. Naturally then it will usually be the mother's face which is imaged in the child's palm.
Recall, however that the hand, thumb, and fingers can also symbolise the breast and nipple , since these objects can partially substitute for that maternal organ. In feeding the child might be looking at the mother's face, at the breast, and at his hand which might be touching the breast. So these three objects, mother's face, mother's breast and nipple, and the child's hand, thumb and fingers become intimately and strongly associated in the child's mind.
It must be observed that babies suck their thumbs in the womb! It is not therefore a question of experience of the breast. The drive to suck a object is instinctual and unlearned.
Objects of a
certain size and shape will provide more satisfaction than
others, and be preferred. A subgroup of this class is made up of
nipples/breasts, they, in providing warm milk, will provide even
Which children show the behaviour?
I assume that h.r.b., and h.d.b. etc. is not seen in normal children, in normal circumstances. I assume its only seen in s.l.d. children. But some s.l.d. children don't show this behaviour. What is common, and special, (apart from the hand behaviour), in these children? We need a 'control group' of children, who don't show the behaviour but who are similar in other ways to a group who do show the behavior. Then we must try to discover some common feature, (or group of features), which all, or most, of the positive group share, and which none, or few, of the control group share.
Another hypothesis might be advanced for h.r.b. and h.d.b.
A complex object such as a human is not conceived as such by someone functioning at a primitive level. For a baby, the parent is so large, he may not even perceive the hand as being connected with other parts, such as the face, and so on. So when an s.l.d. child is restrained, he bites the hand that holds him. When an adult gives a child what he wants he usually uses his hand, when he doesn't allow the child to have or do what he wants, he often uses his hand in this situation. So the hand might be seen as a good hand or a bad hand, as in the ideas of the good breast and bad breast in the theories of Klein etc. The bad hand is hated and might be attacked, e.g. by the child's mouth; the good hand is loved and given affection. Then the child's hand becomes a natural symbol for the adult's hand, good or bad.
Again, a complex object such as an adult may not be seen as complex by the child because of the limited class of interactions between the adult and child. Take for example the child who, because of our very restricted type of interaction, probably only perceived me as someone to tickle her under the arm, or even just as a sort of mobile arm and hand.
H.d.b. and h.r.b.
These might be regarded as a transference situation in miniature.
When the positive transference appears, prompted by a current real action in which a parent figure satisfies a need of the child, is kindly or affectionate to the child, the child's hand plays the part of this person, who in turn is playing the role of the good mother in a fantasy/memory, which is partly internal and partly relies on an external prop, the schematic 'puppet' formed by the child's own hand, where the mother gives her full breast and its milk to the child, (or perhaps allows it to urinate or defecate wherever it wishes). The child may look lovingly at the hand, or fingers, and may mouth it/ them or kiss it/them.
On the other hand, when the negative transference appears, prompted by a real current need-frustrating action of a parent figure, the child's hand again plays the role of this person, in turn now playing the part of the bad wicked mother, denying her child her full breast, (or perhaps demanding that the child urinate and defecate only in certain places). The child then glares angrily at her hand, and may even bite it, or part of it, e.g. the fingers or thumb. If one wishes one could say that the bad breast/mother, which the child has introjected as a part and whole object, is activated by the negative action of the real parent-figure and this image is projected onto the hand as well as onto the real parent figure. Similarly for the good breast/mother and positive actions by parent figures. (The relatively unstructured nature of the stimulus represented by the palm of the hand is an advantage in its use as a sort of screen on which an image can be 'projected'.)
We have discussed the drive and trigger bases for, or aspects of, h.r.b. and h.d.b.
We might also discuss situational determinants. According to Klein, when the child is away from the real parents, e.g. at a residential boarding school, in a foster home or in hospital, it may be that the influence of the introjected unrealistically extremely good or bad aspects of the mother image are more able to influence the child's behaviour, via a real current trigger incident involving other parent figures/care workers etc activating one or other of the extreme polar images. This should not be difficult to investigate: of the children who show h.r.b. and/or h.d.b. compare the frequency of the behaviour when they are with the parents, with that when the child is not with them.
As for what capacities and abilities are involved/required we need to get information on developmental levels of the children who show this behaviour. In the Denver we may consider the general level or the fine motor level, the language level and so on.
The Oedipal situation.
This may be represented in h.r.b., and in h.d.b. The adult's response to h.d.b. and h.r.b.
What are the possible ways in which we may respond to the behaviours of the child, here specifically the h. r. b.'s or h. d . b's?
This means, of course, to behave as if the child's behaviour had not occurred, or as if one had not noticed the behaviour. A rather strange mixture of 1. and 2. is provided by the practice of clearly signalling to the child that one is going to ignore the child and what he does, for a time. This might be done by, e.g. making something of a display of turning your face away from him.
2. Not ignore
This means, of course, that one's behaviour is different from what it would have been had the child not behaved in the way under discussion.
2a. React positively
The adult might react in a positive manner, one which has the effect of increasing the frequency, or probability of occurrence, of the behaviour. Even manifest interest in, and attention to, the behaviour, will serve this function.
2b. React negatively
The adult may react in a critical, disapproving manner, one intended to decrease, and possibly having the effect of decreasing, the the frequency and probability of occurrence of the behaviour.
2c. Interpretation, in the psychoanalytic sense
Although initially the adult and child pay attention to the behaviour, which might have the effect of increasing its frequency, the intention is to conceptually re-categorise it in a way which will, in fact, decrease the probability of its occurrence. Interpretation of the child's behaviour was always provided to the child by Klein, according to her, with benefit. This was done verbally. Now the first point is that it is quite debatable whether such interpretation has the intended effect at all, in reducing unacceptable behaviour. Another point is that our S. L. D. children's verbal abilities are very limited. Their verbal reception abilities may be slightly better than thier associative and expressive verbal abilities, but all are at a very low level, and verbal interpretation must be regarded as completely inappropriate. An appropriate mode of interpretation for such children would have to be a visuo-manual one, and one at a very early stage of this, e.g. using photos. So, for example, if the child looks angrily at his hand, after a confrontation with a parent figure, we might show photos so:-
Show a photo of the child's real mother denying the child something, then the photo of a care worker getting the child to e.g. sit up properly in his chair.* These two situations and the adults in the situations must be shown to be different and the incidents to take place at two very different times. The parent figure is trying to say something like:- This is me now, I only asked you to sit up, I'm not your mother and I'm not taking the good breast away from you.
*Note that there is a lot in common in these two behaviours, that of the boy 'Plaeng', and the girl I first saw exhibiting h.r.b., at a residential special school in the U.K. ( J.W.). In both the child was relaxing, resting, getting comfortable, getting into a more horizontal position, like a baby.
In classical analysis the therapist contrasts the patient's transference 'mistake' with reality via a verbal presentation of reality. With our patients we would not be able to use this method. We might use a more basic and concrete symbolic language, that of photos. Here we could stress the historic, past nature of the relationship with the parents by referring to photos kept in the child's personal history book of photos. But these would have to contain explicit photos depicting personal things like the mother weaning the child from the breast. It would be very difficult to show this process by a single photo. I suppose that we could fake these, via a computer. But the simplest and most direct way of contrasting the patients transference 'mistake' with reality would be to present reality. So, after a hand regarding episode by the child, we might bring in the child's mother. (We might observe here that Klein believed that the extreme parent images were more active if the real parents were not present, and our impression that it's possible that h.r.b. is more frequent when the child is away from home, in a residential boarding school, or hospital etc.). So we contrast the reality of the parent with the non-reality of the parent figure being the parent, and with the non-reality of the hand being either of them.
Which of these should we choose?
One needs to do research in this area, to get a definite answer.
It appeared to me that the polarisation in terms of emotional expression
seen in cases of h.r.b. in the U.K. was absent in the cases seen in the present
country. Instead of a gentle facial expression in the positive type, and a furious
facial expression in the negative type, the facial expression seemed rather neutral
in both types.
It is possible that this feature is related to a cultural aversion to public displays
of emotion, especially of negative
kinds. To substantiate this
theory one would need to observe cases of h.r.b. in other countries and cultures
which were similar with respect to such disdain of public emotional shows. It must
be said that in past times in the U.K. also, examples of h.r.b. might have not shown
much of an emotional range, i.e. in the days of the famous British "stiff upper lip!"
(Today, (09/01/2017), I am not at all sure about this, after witnessing the antisocial screaming and shouting of young Thai men in internet cafes, as they play computer games).
A different explanation is possible. Take this quote from Lonely Planet's Thai phrasebook. "Even when we know what the correct tone in Thai should be, our tendency to denote emotion, verbal stress, the interrogative, and so on through tone modulation often interferes
with producing the correct tone. So the first rule in learning to speak Thai
is to divorce emotions from your speech until you have learned the Thai way to express them
without changing essential tone value".
Of course the writer is talking about verbal communication, speech, and we are concerned with visual motor communication, but the comments seem to be of relevance.
Note here also the response of a Thai psychologist, (actually the chief psychologist from the second place I worked at, in Thailand, the facility in Chiangmai), to my observations about the relatively neutral facial expression which seems to be associated with a Thai child's negative hand regarding, in contrast to the scowls of a British s.l.d. child, and the normal Thai person's use of a smile, even in situations where an English person, (and even more so American people, who seem to feel no aversion to the expression of negative feelings) would be frowning or scowling. Her response was that "there are smiles, and smiles!"