In early childhood the difficulty of the refusal of food often passes or diminishes when the child learns to feed himself with precision and certainty. To teach him to do so, it is not wise to devote all our attention to making him adept at this particular task. The fault is that the brain centres which control the movements of hands, mouth, and tongue have not been developed, because his activities in all directions have not been encouraged. It is much less trouble for a nurse to feed a little child than to teach him to feed himself, and if he is not given daily opportunities of practice he will certainly not learn this particular action. But the fault as a rule lies deeper. The child who cannot feed himself cannot be taught until fingers and brain have been developed in the thousand activities of his daily routine, by which he acquires general dexterity. A child who is still too young to feed himself is learning the dexterity which is necessary as a preliminary in every action of the day. If he can carry the tablecloth and the cups and saucers to the tea-table, imitating in everything the action of his nurse, it will be strange if he does not also imitate her in the central scene, the actual eating of the food. If, on the other hand, he is waited upon hand and foot, if he is restrained and confined, sitting too much passively, now in his perambulator, now in his high chair, now on his nurse's lap, his imitative faculties and his tactile dexterity alike remain undeveloped. The child who is slow in learning to feed himself shows his backward development in every movement of his body. One may note especially the stiff, "expressionless" hands, indicating a general neuro-muscular defect. I have seen many children of eighteen months or two years of age in whom the movements necessary for efficient mastication and swallowing had failed to develop satisfactorily. In some a pure sucking movement persisted, so that when, for example, a morsel of bread or rusk was put in the child's mouth, it would be held there for many minutes and submitted only to suction with cheeks and tongue. Attempts to swallow in such a case are so incoordinate that they give rise frequently to violent fits of choking, which distress the child and produce resistance and struggling, while at the same time they alarm the mother or nurse so much that further attempts to encourage the taking of solid food are hastily and for a long time abandoned. In this helpless condition the other factors which tend to develop what we have called negativism have full play. The want of imitation and the lack of dexterity is not the sole or perhaps the main cause of the child's refusal of food and of the apparent want of appetite, but it is the cause of the failure to learn to feed himself, which places him in a condition which is peculiarly favourable to the operation of other factors. If only we can teach the child to feed himself, the difficulties of the situation become much less formidable.
The first of the factors which encourage the persistent refusal of food is the extreme susceptibility of the child to suggestion. A particular article of diet may be refused on one occasion, perhaps in pique, because another more favoured dish was hoped for or expected, or perhaps because the taste is not yet familiar. Then if on this occasion a struggle for the mastery is waged, and a painful impression is made on the child's mind connecting this particular dish with struggling and tears, from that day forward the child may persistently refuse it on every occasion it is offered. Matters are made worse if the nurse, anticipating refusal, attempts to overcome the resistance by peremptory orders, or by excessive praise extolling the delicious flavour with such fervour that the child's suspicions are at once aroused. Previous experience has made him connect these excessive praises with articles which have aroused his distaste. If these fads and fancies on the part of the child are to be avoided, it is essential that we should do nothing to focus his attention on his refusal. It is better that his dinner should be curtailed on one occasion than that taste and appetite should be perverted perhaps for years. Every nurse or mother should cultivate an off-hand, detached manner of feeding the child, and should patiently continue to offer the food without uncalled-for comments or exhortations. Let her always remember the force of suggestion on the child's mind, and that a confident manner which never questions the child's acceptance will meet with acceptance, while a hesitating address, from fear of the impending refusal, will be apt to meet with refusal. Sometimes a still worse fault manifests itself, when nurse and mother speak before the child of the smallness of his appetite, and of his persistent refusal of this or that article of diet. The suggestion then acts still more powerfully on his mind. He is aware that the whole household is distressed by his peculiarity, and he grows to identify it with his own individuality, and to regard himself with some satisfaction as possessing this mark of distinction. If there is any difficulty of this sort it is often directly curative to reverse the suggestion and to speak before him of his improving appetite, and to say that he begins every day to eat better and better, even if to do so we have to break a good rule never to say to the child what is not strictly true. Or once or twice we may take his plate away before he has finished, saying positively that he has eaten so much that he must eat no more. If in spite of every care antipathies to certain articles of food appear and persist, we must be content to bide our time. When the child grows of an age to reason, we should seize every opportunity to make him feel that his persistent refusal is a little ridiculous and childish. Little by little the seed is sown, and will germinate till one day we shall note with surprise that he has taken of his own accord that which he has neglected for so long and with such obstinacy.
But the force which is acting most strongly in producing this refusal of food is the force of which we have spoken in a previous chapter—the force which results in negativism, the force which is in reality the habit of opposition, the love of power, and the desire to attract attention. Here again the refusal of food, if due to this cause, is never the sole manifestation of the fault. Just as the delay in learning to swallow and to chew properly and to feed himself is part of a general want of dexterity and capacity manifested in all his actions, so it will seldom happen that the child's anxiety to oppose is only seen at meal-times. Watch a nervous child in the nursery before the dinner hour. He is cross and restless and inclined to cry. The nurse hands him a doll, and he throws it away saying, "No, no doll." At the same moment he may catch sight of his ball, and it too is violently rejected, "No, no ball." Everything in turn is treated in the same way. Finally he falls upon his nurse, crying and beating her with his hands, saying, "No, no Nurse." If that long-suffering woman at that moment summons him to dinner, it will be strange indeed if his attitude is not "No, no dinner," and "No, no" to every mouthful offered him. How strong this love of opposition may be is illustrated by the case of a little boy who was brought to me for refusal of food. Three weeks before, he had been taken in a motor-car to his grandfather's to midday dinner on Sunday, when his absolute refusal of food had spoiled the day and had occupied the attention and the efforts of the whole party. Doubtless he had enjoyed himself, for three weeks later, when he caught sight of the car which was to bring him to me, and which he had not seen in the interval, he at once said, "Not eat my dinner." This child's father told me that the sight or sound of the preparation of a meal was enough to bring on a paroxysm of opposition. Now this force of opposition, as we have seen, only develops into a serious difficulty when the child's own will has been opposed too much, when authority has been too freely exercised, and when the child has been urged and entreated and reproved with too great frequency. His opposition grows with all counter-opposition. And he is not really naughty, only irritable and restless from the thwarting of his natural impulses, and unable to express his thoughts and desires. Negativism will not often confine itself to meal-times. It will show clearly in all the actions of the child, and to get him to eat well and freely we must so change our management of him that negativism disappears or at least diminishes. There is no other way. No entreaty, no force, no threats of force will ever succeed, but will only make him worse, and, since negativism is due to mental unrest, the struggles and crying will only perpetuate the cause. The one way to banish negativism and overcome the opposition is to cease to oppose, and to practise this aloofness not so much at meal-times, for somehow by patience the child must be got to take his food, but in all our conduct to him. Repression and reproof, and thwarting of the child's will, and coaxing and entreaty must cease. There is no fear that we shall thereby make the child unduly disobedient. We have already, in another chapter, decided that negativism is not strength of will on the part of the child which must be broken, but is the result of constant attempts to oppose his nature, and the consequent nervous unrest. If we cease to oppose, the symptoms will tend rapidly to disappear, the child will become busy and contented and happy in his play, and we shall hear no more of his refusal of food. If sometimes it recurs for a week or two, we shall know how to deal with it.
In children, as with us, periods of nervous unrest and unhappiness are apt to recur in a sort of cycle. This cyclical character of mental disturbance is often a marked feature. We see it in epilepsy and in what the French have called Folie Circulaire. We see it in the dipsomaniac, in the intermittency of his craving for drink and of his periodical outbursts, and we see it in ourselves in those periods of depression which recur so often, we know not why. Little children too sometimes get out on the wrong side of their beds, and never get right the whole long day. Their own experience of the vagaries of mental states should lead mothers to be indulgent to the children in their days of cloud and to be particularly careful not to goad them by well-intentioned efforts into bursts of naughtiness and passion, each one of which tends to perpetuate the condition and increase the nervous unrest. We know how closely dependent is the sensation of appetite upon emotional states, and we must do all in our power—and the task is sometimes one of real difficulty—to keep the child's mind sufficiently at rest to preserve the healthy desire for food unimpaired. If there is no sign of appetite, but every sign of restlessness and irritability, we must seek in the management of the child until we find the fault.
If food is taken mechanically and without appetite, if the preliminary changes in the stomach wall which are necessary for adequate digestion do not take place, but are inhibited by the mental unrest, the meal is apt to be followed by gastric pain and discomfort, or, more commonly with children, the stomach may promptly reject its contents. At the worst, nervous vomiting of this sort may follow almost every meal, although, again, it is curious to note how little, comparatively speaking, the nutrition of the child suffers. The vomiting too, as in adults, comes very near being a voluntary act, and mothers and nurses will often remark that they get the impression that it can be controlled at will. If once the diagnosis is made that the want of appetite or the vomiting is of nervous origin, the treatment of the condition is clear. Sedative drugs directed towards quieting the nervous excitability may be of service, but tonics, appetisers, laxatives, and drugs with a direct action on the stomach will have but little effect. Nor is there as a rule anything to be gained by modifying the diet or by excluding this or that article of food. The frequency of the vomiting is such that it is apt to have brought discredit one after the other upon almost every article of food which the child can take, with the result that many useful and necessary foods have been abandoned for long on the ground that they are the cause of the dyspepsia. A permanent cure will only be effected when the faults of environment have been overcome, when the cause of the nervous unrest has been removed, and when the child's mind is at peace.
Nervous vomiting of this kind is not difficult to control, if those in charge of the children can be made to understand that the cause lies in the anxiety which they themselves show before the child, increasing his own apprehension or adding to his sense of power or importance. Once the child is convinced that his conduct excites no particular interest, the vomiting soon ceases. In more than one instance, vomiting which has persisted for many months has stopped at once after the matter has been fully explained to the parents. In the most inveterate case of this sort which has come under my notice, the child was regularly sick as soon as he caught sight of a white cloth being laid on the table for meals. Yet even this child never vomited when he was under the charge of a particular nurse who had to return more than once to the family, and on each occasion was successful in breaking the habit.
CHAPTER IV
WANT OF SLEEP
So far, almost all that has been written—and there has been a great deal of unavoidable repetition—has been devoted to an attempt to determine the causes which lead the child to refuse food and the methods which we adopt to prevent or overcome the difficulty. Other neuroses may be studied in less detail, because they depend for their existence upon the same causes. For example, the habit of refusing sleep, which is as common and almost as distressing as the habit of refusing food, depends both upon a perversion of suggestion and upon the phenomenon that we have called negativism.