FAMILY DIAGNOSIS: AN APPROACH T O THE PRE-

SCHOOL CHILD*
NATHAN W. ACKERMAN, M.D., AND RAYMOND SOBEL, M.D.
Council Child Development Center, New York, N. Y.

T HE motivation for this study is twofold: first, the traditional cate-

gories of psychiatric diagnosis for children prove of little avail in at-
tempting a dynamic definition of child personalities in the era between birth
and five years; secondly, the incomplete personality of the preschool child
cannot be understood save in the context of a group dynamic definition of
the family. Accordingly, we undertook to define such child personalities not
as separate individuals, but rather as functional parts of the family group,
more specifically, as an expression of the sociopsychological configuration
of the family unit.
I n order to define a young child in these terms, it is necessary to make
both a dynamic and genetic study of the family group, going back to its
original formation in the period of courtship between the two parents. Such
a study needs to be pursued in several steps: 1) The development of the fam-
ily group (aims, standards and values of the family) through condition-
ing effects of group influence, currently and in the past. 2) A definitive pic-
ture of the individual personalities of the parents and siblings. 3) The fusion
and patterns of interaction of the parents a t each stage in the history of
their relationship, leading up to the point where the parental relationship
and the individual personalities of each parent accommodate to the ad-
mission of the child into the family group.
Throughout such a study it is necessary to treat the persons and the en-
vironment as a continuum and to mark out the patterns of interaction be-
tween intrapsychic and extrapsychic factors. For this there is needed a
systematic appreciation of the group psychological influences which con-
dition the goals, values and defense reactions of each member of the fam-
,ily, as well as a knowledge of the intrapsychic determinants of behavior.
Briefly, our method consists of studying the families of preschool children
presenting varied clinical pictures. The data on each family are the product
of a professional team study, involving the collaboration of the child’s
nursery teachers, the psychologist, the respective therapists (psychiatrist
or social worker) of mother, father and child, the group therapist of mother
and father, the social worker and the pediatrician. Using such data, we try
to group families according to their internal dynamics and social position,
and to describe the child’s present-day problems in terms of adjustive be-

* Presented at the 1949 Annual Meeting.

744
 ACKERMAN AND SOBEL 745

havior required to maintain equilibrium within the disturbed family con-

stellation.
We recognize that the disturbances of adult life are determined by the
vicissitudes of the preschool years, and further recognize that the psycho-
logical functioning during the preschool years can be expressed only as a
resultant of the multiple forces interacting within the family group. There-
fore, our unit of definition is not the substantive child, but rather the inter-
action of the child and the significant persons in his environment.
Accordingly, we believe that the treatment of the young child should
begin with the treatment of the family group. However, we find ourselves
confronted with the fact that, up to the present time, no adequate criteria
for family disturbances, as group disturbances, have been found. Until
such criteria are formulated so that we may describe (and later classify)
such family disturbances, we have no frame of reference for the treatment
of families as groups, despite the claims of many child guidance clinics to
the contrary. Although the trends in child guidance are toward family orien-
tation, the child and the mother, but not the farnib, are treated.
We do not know whether it is possible to treat families as groups. Perhaps
it is not possible. I n the interest of further study of etiology and prevention
of disturbances in young children, we must first have at hand reliable
methods of describing their malfunctioning. This paper is an attempt to
provide such a method in the light of the reciprocal psychosocial forces
moving between the family group and the preschool child. Thereby, we hope
to move one step closer to the goal of prevention.
The Council Child Development Center, an organization designed for
the study and treatment of preschool children in a family context, has been
the source of our case material. There are several different, yet integrated,
levels of approach, including individual treatment by child analysts, a thera-
peutic nursery, group therapy of mothers and fathers, individual therapy
of parents by psychiatrists and social workers, as well as educational talks
by nursery teachers and pediatrician. The emphasis upon the child as part
of a family group is maintained through “integration conferences,” held at
regular intervals, in which those of the staff in contact with the various mem-
bers of the family group exchange observations and ideas and plan therapy.
We have taken several family studies from our files and, using our multi-
professional approach, have examined each family chronologically fr0.m its
earliest beginnings at the time of the parents’ first contact, through mar-
riage, conception, birth of the child and, finally, the ensuing years. We have
traced, as in the specimen study reported here, what we consider to be the
main continuous thread, namely, the parents’ interlocking needs of each
other, of the child and, later, of the family. These needs, intrapersonal,
physiologic, as well as culturally induced, explain the original impetus to
746 FAMILY DIAGNOSIS

courtship and marriage and later, though modified, become the conscious
and unconscious frame of reference for the emotional life of the growing
child. We have studied the determinants of these needs in each parent’s
background, and have attempted to trace the vicissitudes of the parental re-
lationship according to the changes and modifications of such needs by the
emergence of the family group. Inasmuch as the parent’s needs may be
conscious or unconscious, rational or irrational, the problem of tracing the
family relationships through them is necessarily complicated. However, they
do provide the key to the personality of the preschool child since they main-
tain the field of forces to which he must accommodate in his development.
Our method of study is illustrated in the following case presentation.

George, five years and one month, was referred to us by a local hospital.
His mother complained that he had been irritable and cranky since birth,
which was full term and normal. H e was breast fed for six weeks, during
which time he cried constantly. The mother brought him to several doctors,
finally being informed by one that she should wean him. She did this reluc-
tantly, pumping her breasts for an extended period of time. When George
was four months old, his mother again made the rounds of physicians, and
was told that he needed an “extra dose of love” together with phenobarbital.
He took his formula poorly, many changes of it being tried without result.
The mother felt that at six months he was “snubbing her,” and responded to
his apparent lack of affection for her with anxious, frozen doubt and im-
mobility. From the age of six to ten months, while the mother worked at
night in a defense plant, George was cared for by his paternal grandmother,
a domineering and overwhelming woman who was upset by his crying and
objected to his mother’s “spoiling him,” but nevertheless picked him up to
prevent his tears and noise.
George continued to be a tense and irritable baby, seemed to develop in-
terminable colds, and was fed large amounts of candy and ice cream in the
mother’s anxious efforts to pacify him. A t about eighteen months, he de-
veloped diarrhea and foamy stools, later diagnosed as celiac disease. H e was
placed on a starvation diet for a short period and lost considerable weight,
and the mother became even more anxious about his food intake, at times re-
sorting to forced feeding. At this time, he became fearful of taking his pants
off as he had been receiving painful injections of iron in the buttocks.
Finally, another diet was instituted and he regained weight, but still had
symptoms for several months. The mother, feeling it would be too much of
a burden for him, made no attempt at bowel training until George was three,
when the diarrhea cleared.
At this time, she entered him in a nursery school but was upset by his
disinclination to play with other children and his lack of vitality. She pushed
 ACKERMAN AND SOBEL 747

him into activity whenever possible. H e reacted by further withdrawal and

retreat into solitary fantasy games of being a pussycat or gazelle. I n other
nursery schools at four and four and a half years, he was even more shy
and withdrawn, avoiding any aggressive play. His mother felt self-conscious
and inadequate because of this.
Our nursery teachers’ description of George at the time of his entry in the
Council Child Development Center confirmed the mother’s fears that he
was excessively withdrawn, showed ingratiating behavior, and made se-
ductive efforts to gain adult attention. H e did not form relationships with
his peers, and remained at the periphery of the group as an onlooker. When
introduced into other children’s play, such as pirates, he would immediately
become the pirate’s pussycat. The over-all picture was of pathetic lack of
emotional contact.
The mother, 30, is the product of an extremely disturbed home. She was
unloved by her hysterical mother and browbeaten by her aggressive and
hot-tempered father. At an early age, she despaired of the possibility of love
and affection from her mother whose hysterical comas prevented any such
ties. She found that her father could be pleased by intellectual achievement
and from this managed to win some approval. She had always been solitary
and lonely, but with great yearnings for intimacy and closeness, none of
which ever seemed to be fulfilled. Her only sibling, a younger brother, was
even more isolated than she, and since the significant people of her childhood
were constantly involved in violent arguments and scenes, or in carrying
grudges in cold and detached silence, no warm emotional contact with any
member of her family was possible.
Her character structure developed toward extreme passive dependency,
and her relationships became confined mainly to aggressive and overwhelm-
ing women. She had little feeling of self-esteem, viewed her outstanding in-
tellectual successes a t college as worthless, and, following her graduation
with honors, worked as a clerk. A t this time, a friendship with another girl
developed into an active homosexual affair, which was to last two years and
in which she ostensibly played a masochistic downtrodden role to fit in with
her aggressive and sadistic partner’s need for her submission. Her only
sexual satisfaction was through making her partner achieve orgasm. After
some time, her partner became unfaithful, finally abandoning her for another
girl in a particularly cruel fashion. Because of the despair that followed, her
father learned of the affair and threatened her with legal prosecution should
she return to her partner. It was at this point that she met her husband.
The father, 34, also comes from a severely disturbed family. H e is one of
the several offspring of an irresponsible, alcoholic father and an aggressive,
dominating mother. His past history is a continuous story of withdrawal
from human relationships into intellectual pursuits and fantasy. H e was
74.8 FAMILY DIAGNOSIS

lonely and unhappy for his entire life, and so withdrawn and shy that he
could not get or hold jobs despite a doctorate in chemical engineering. Com-
munication was almost impossible for him and he consistently shied away
from any interpersonal contacts. Clinically, he is an ambulatory schizo-
phrenic, lacking the major symptoms of this disorder. H e is exquisitely
sensitive to hostility and in almost an uncanny fashion senses rebuff or
rebuke.
Mr. G met Mrs. G at a lecture on world affairs which each had attended
to escape feelings of loneliness. H e had just been rejected by the Army for
neuropsychiatric reasons and, despite ample opportunities for jobs, was er-
ratically employed in war work at a meager salary. H e had few friends and
had just lost his girl with whom he had as close a relationship as was possible
for him. H e had no other contacts with the world with the exception of
his work and, at best, he had few there. He was lonely and felt acutely the
need for companionship. Mrs. G met Mr. G while she was on the rebound
and utterly desolate from her unhappy homosexual affair; she was seeking
some emotional contact to assuage her desperate feelings of abandonment
and isolation. She found some part of her unfilled need in the relationship
with him, at the same time feeling that it was not what she really wanted.
He felt that she was one of the few persons to whom he could relate safely
and, in a hesitating and shy way, continued to see her. They would say
scarcely a word to each other on their dates, at the time feeling the silence
to be an indication of tacit understanding. However, she attempted several
times to renew her old homosexual relationship, eventually being cruelly
rebuffed by her former partner. Mr. G made an effort to break off the re-
lationship with Mrs. G when this occurred, but changed his mind when she
showed up in his apartment in a near panic.
The social situation at this time was as follows: She was living with a
friend and he was living alone. Both were working below their capabilities.
Eventually, she moved into his apartment for a few months during which
time they seldom had any sexual contact. (The first time he kissed her she
became angry, and it was not for some time that they ventured into sexual
intercourse.) Although they were in financial difficulties, money was not im-
portant. The time they spent together was taken up by silent walks or mu-
seum visits. They shared little of their everyday experiences, had few friends,
and were taciturn about their problems. They never discussed their former
lovers with whom they were both still deeply involved.
Although she accidentally became pregnant shortly following their recon-
ciliation, Mrs. G had fantasied having an illegitimate baby by Mr. G for
some time previously. This fantasy child was to fulfill all her unrequited
yearnings; and when she did find herself pregnant, she was intensely happy,
having but few feelings of social disapproval. Despite her doubts about her
husband-to-be, and his own difficulties in relating to women, she decided to
 ACKERMAN AND SOBEL 749

have the baby. H e agreed, and they were married two months after its con-
ception. Each had always been acutely aware of the other’s sensitivities
and this feeling crystallized into a tacit agreement to keep distance and to
avoid any expressions of hostility. Despite their factual living together,
there was actually little contact between them, and neither made any at-
tempt to break the long silences which prevailed at home. The fantasy of
the loving child was always there to counteract Mrs. G’s doubts and fears,
and she was able to tolerate the actual lack of communication in the relation-
ship. Mr. G, on the other hand, was satisfied with her physical presence
alone. Despite economic privations and a housing shortage, they main-
tained a delicate balance between the dual threats of contact and isolation.
I t was some time before Mrs. G became aware that the child could not
fulfill her enormous needs for love, and within a few months she increasingly
felt snubbed by him. I t was not until she left her work in the war plant
that she was fully aware of this feeling. She felt it to be a repetition of past
experiences of perpetual disappointment-as one more episode in which the
maternal loving which she had so constantly sought was not forthcoming.
Neither lover nor husband had fulfilled her needs, and now the child had
failed to fulfill them. Mr. G had been away for four months, completing his
studies, and when he returned somewhat prior to this time, their relation-
ship became further strained. Economic pressures increased and after the
fiasco of his business venture with her brother, he became increasingly
anxious, depressed and withdrawn. Rebuffed by the child, and unable to
gain contact with her husband, the mother felt herself caught in the old
pattern of her own family life and began to freeze up as she had in the past.
The anxious detachment of both parents began to have its effect on the child
not yet a year old, and George progressively refused to be fondled and loved.
Irritability, crankiness and persistent crying further widened the gap be-
tween mother, father and child. Although Mrs. G repeatedly made efforts
to play with George, her advances were either rebuffed or she misinterpreted
his failure to respond quickly to her to mean rebuff. The father had but little
to do with the child a t this time, and the influence of the rigid and domineer-
ing grandmother during this period from six to ten months of age cannot be
overestimated.
The social situation a t this time has been alluded to above but, addition-
ally, there were the following features : The trio, for they could scarcely be
called a family at this point, were living in the grandmother’s home. The
mother was working in a war plant; the father was away from the house
most of the time. The grandmother cared for the child in her characteristi-
cally domineering fashion. There were no social contacts on the part of the
mother, whereas the father spent his evenings away from home a t scientific
meetings.
The family moved from the grandmother’s house to another city when
750 FAMILY DIAGNOSIS

George was ten months old. The parental relationship was so strained at
this point that the mother was secretly thinking of divorce, but the prospect
so frightened her that she quickly repressed it. The tacit agreement of de-
tachment (which heretofore had been comforting) became unbearable, but
she preferred it to separation, which she conceived of as complete isolation.
Her attempts at communication with her husband failed repeatedly, and
their sexual life regressed to oral forms of intercourse, fellatio and cunni-
lingus. This one channel of contact became constricted, and after some
time she responded with orgasm only upon being masturbated. Her attempts
to communicate her dissatisfaction were infrequent, fraught with anxiety,
and were met by superficial reassurance and denial of difficulties by her
husband. Her reaction was to suppress all her feelings and to play the role
of devoted wife and mother, a t the same time being aware of the falsity of
her position. Although she went through the motions of being a good
mother, her activities were constantly underscored by hostility engendered
by her frustrated needs.
The social situation had changed considerably for the worse. Throughout
this time, they were living in a tiny, cramped apartment where George, al-
though he had his own cubbyhole of a room, had ample opportunity to ob-
serve his parents’ sexual activities. The mother was working and the un-
employed father stayed at home doing most of the housework and taking
care of George, who at the end of this time developed celiac disease. Money
was extremely important for the family group and the nominal breadwinner
found herself unable to work. Social contacts were very limited and the
family was becoming progressively more isolated.
At this time (when George developed celiac disease) the parental relation-
ship was beginning to change. Although the father retreated into himself as
previously, the mother’s similar defenses of suppression and withdrawal
were insufficient to protect her from anxiety. She wished to be loved and
cared for, but found herself involved in caring for a sick child, who required
constant attention, and receiving no assistance from her husband. At this
time Mr. G, who had been working, became unemployed (this was to con-
tinue for almost two years), and it was up to her to become the main support
of the family, which she did by teaching. Mr. G cared for the child a great
part of the time when he was two to four years old. H e apparently handled
him with some degree of ease as the child was not a threat to him. However,
about the end of this period, when George’s motility and language patterns
were fully developed, this changed. Heretofore, George had shown what
little hostility he was capable of in sly and devious ways, but now explosions
of aggression against both parents became evident. The father reacted either
with direct retaliatory violence or with complete withdrawal, at times even
stalking out of the house. The mother assumed a pose of firmness and ob-
 ACKERMAN A N D SOBEL 751

jectivity, which, in actuality, covered her rage as well as intense feelings of

being hurt. Her reactive overcontrol broke down frequently and she would
on occasion break out explosively with the same type of retaliatory violence
shown by her husband. It became increasingly impossible for the parents to
maintain their isolation and distance-producing defenses with each other
in the face of George’s behavior, and they were constantly drawn against
their will into, among others, the problems of discipline and socialization.
They could no longer ignore their interpersonal difficulties as previously,
and a good deal of buck passing of their parental responsibility resulted.
Mr. G finally sought psychiatric help but discontinued therapy after a few
hours because of his inability to talk about himself and because he had been
pressed into going by his wife. Mrs. G’s explosive outbursts became more
frequent and a t the time of her application to the Council Child Develop-
ment Center she had just begun psychotherapy with a private practitioner.
The family and its social situation a t this time were chaotic. The mutual
nonaggression pact had broken down; the parents’ sex life was progressively
deteriorating; stormy scenes alternated with days of silence. T h e father, as a
result, found it harder to look for a job, let alone find one, and the mother
was unable to support the family alone. The landlord made attempts to
evict them, to which the entire family reacted with near panic. Because of
his resemblance to her father, Mrs. G found herself completely helpless in
his presence, reacting later with impotent rage and depressive anxiety at-
tacks. She was unable to appeal for assistance to Mr. G who was even more
frightened of the landlord than she. As a result, she covertly released her
hostility by “accidentally” flooding the landlord’s ceiling on several occa-
sions, eventually bringing a lawsuit upon Mr. G.
George was becoming more and more withdrawn, and the efforts of both
parents to show any real affection to him were met with sullen head shaking
or, on occasion, by anal language, spitting and kicking. H e uncannily found
the weak spots of each parent and exploited them mercilessly when his
frustrated needs for love were a t a peak. At times, he became omnipotent
in fact: he could put mother into a hysterical rage by sneaking behind her
and pinching her buttocks; he could make father speechless or have him run
out of the house in blind fury by taunting him with defiance; both could
be made anxious by his stamping on the floor of their apartment, which
was above that of the landlord. These manifestations were always followed
by intense fright, fear of retaliation, and then by withdrawal into fantasy
games and passive compliance. At the age of five years and two months,
he entered our nursery.
George and his mother have received individual therapy for over a year
now. During this time, Mrs. G has shown remarkable progress toward self-
assertion and has lost a good part of her tendencies toward self-immolation.
752 FAMILY DIAGNOSIS

She has been able to face her own and her husband’s unconscious role in
the marriage and to talk about it with him rather than a t him. Until re-
cently, he has denied that there were any difficulties, but finally, with a
year of successful and profitable work behind him, has decided of his own
volition to resume therapy. As the mother has formulated her own difficul-
ties, she has become increasingly aware of the fact that her needs were based
in the past, that they were inordinate and unrealistic, and that neither
George nor her husband could possibly fulfill them. She has been able to
form and to recognize a deep dependency upon her therapist, which has given
her considerable insight into the genesis of her rage which she has so greatly
feared. The load of unreal expectation has been lifted from George to some
extent. I n his individual therapy, he has been able to work through succes-
sively his ingratiating compliance and intense hostility, finally getting to his
basic problem, his need for love. It has become evident that his aggression
was, in effect, a substitute for the anxiety brought about by the lack of con-
tact with the family; after several months of therapy, he began to show some
evidence of being able to accept and respond t o love.
In summary, this paper is an attempt to evolve a methodology for the
study of the preschool child in the context of the family group, by considering
the psychosocial effects of the family members upon each other. We feel
that this type of orientation is significant to the child guidance and mental
hygiene field on the basis of our contention that the personality of the pre-
school child cannot be described as such but only in terms of his inter-
personal and intrafamily relationships.
DISCUSSION
H. VANDER
ADRIAN VEER,M.D. :‘k We should be grateful to the authors
because in this presentation they have emphasized one sector of psychiatric
thinking which we sometimes ignore in our consideration of a case. I refer
to the derivation of psychodynamic processes from their interpersonal ori-
gins. T o my mind, the main theses of the presentation appear to be the
following: (a) People relate to one another in order to gratify their own needs.
(b) Behavior in any relationship is therefore a composite of three factors.
It is an expression of techniques for getting satisfaction which are permitted
by the individual’s own character and by the other person involved. Be-
havior also includes techniques for shutting out or suppressing the impulses
in one’s own personality that tend to interfere with the gaining of gratifica-
tion. Lastly, behavior expresses the individual’s frustration reactions, overt
or covert. (c) This formulation is particularly appropriate to the preschool
* University of Chicago Clinics, Chicago, Illinois.
 DISCUSSION: ADRIAN H. VANDER VEER 753

child, for several reasons. I n the first place, all his important social relations
are confined to his family. His behavior is therefore determined by the
home situation and is an adaptation to it. These facts make family therapy
the logical approach to the problems of this age group.
The case presented today is a particularly apt illustration of these prin-
ciples, because it concerns a family containing not one, but three preschool
children. All the members were bound together by strong dependent ties.
These were the chief impulses which they sought to gratify in their relation-
ships with one another. No one of the three had an important relationship
with an outsider. Each sought to manipulate the others in order to gratify
his needs and was eminently unsuccessful in this attempt. The principal de-
fenses against anxiety utilized by the parents were identification and sup-
pression of hostility. They could relate only to persons who were like them-
selves, and each attempted to control the destructive impulses in himself
which threatened to interfere with his obtaining satisfaction from the other.
The neurotic equilibrium between the marital partners was gradually
broken down by the child because he was not in a position to gratify their
dependent wishes and because he needed much more from them than they
could give. As the parents’ defenses disintegrated, they became ever more
frustrated and consciously unhappy. Therefore, a t the time they approached
the agency, every member of the family wanted help.
My only question concerns the necessity of a total therapeutic approach
for every disturbed preschool child, an implication made by the authors.
I doubt the validity of this contention for the following reasons. A parent is
willing to undergo the rigors of personal therapy only i f he feels some strong
discomfort about himself or about someone close to him. While this was true
in the present case, there are many families where such discomfort is not
present. In such cases, one parent or both maintain themselves in a state of
relatively unanxious equilibrium as a result of strong emotional investment
in relationships or activities outside of the family circle. I refer to those
fathers whose principal interest in life is their work and to those mothers
who are involved in many community or club activities a t the expense of
their maternal responsibilities, which are typically put off upon nursemaids.
Such parents may be relatively content in their personal lives, and the
disturbance in their child does not cause them much unhappiness because
relatively little of their interest is invested in the child. To such individuals
personal therapy has no appeal; treatment must therefore concentrate on
the child and on the concerned parent, if there is one. If there is no con-
cerned parent, then treatment must be directed to the child alone, with or
without his placement in a different and more satisfying environment.