The role of punishment in the psychiatric in-patient treatment of non-psychotic latency-age children with behaviour disorders is discussed. Punishment is defined as the removal of previously existing positive reinforcers or the administration of aversive stimuli. Ways in which appropriate social behaviour may be acquired are briefly considered. These include reinforcement of desirable responses, non-reinforcement of undesirable responses, reinforcement of incompatible responses and imitative learning. The reported effects of punishment on behaviour are reviewed and the psychological functions necessary before punishment can have the intended effects considered. For seriously disturbed children punishment is ineffective as a treatment technique. It reinforces pathological perceptions of self and adults even if it successfully suppresses behaviour. The frame of reference of the seriously disturbed child contraindicates the removal of positive reinforcers and verbal as well as physical aversive stimuli. Controls and punishments must be clearly distinguished. Controls continue only as long as the behaviour towards which they are directed. They do not include the deliberate establishment of an unpleasant state by the adult as a result of particular behaviour. Control techniques such as removal from a group may be necessary but when possible should be avoided in favour of techniques less likely to be misinterpreted. Avoidance of punishment in treatment makes even more important explicit expectations and provision of realistic controls. Natural laws may result in unpleasant experiences as an unavoidable result of certain behaviour. By definition such results can never be imposed by the adult. Treatment considerations may necessitate that the child be protected from the results of his actions. Avoidance of punishment requires a higher staff/child ratio, more mature and better trained staff. Sometimes children have previously been deterred from serious community acting out only by punishment. Should the therapeutic endeavours outlined not prevent such behaviour, treatment in a closed setting without punishment is indicated, not the use of punishment in an open centre.

Investigation into the nature and treatment of emotional disorders in children requires reliable and valid measuring instruments. The Children's Pathology Index is described. It consists of 38 five-item categories and may be administered in 20 to 30 minutes by child-care staff. Little training is required, results from four raters are pooled and raters may be changed on subsequent occasions. Factor analysis yields four factors I) Disturbed Behaviour Towards Adults; II) Neurotic Constriction; III) Destructive Behaviour; IV) Disturbed Self Perception. Results demonstrate satisfactory reliability for all four factors and adequate validity studies have been made for Factor I. The subjects were boys and girls aged 6–12 years, of different diagnostic categories, most of whom were admitted because of acting out behaviour disorders. Comments are made on the usefulness of Factor I estimates in assessing social acceptability of children whatever the other difficulties present or the diagnosis made.

Some principles which have appeared to be helpful to the staff in working with children showing serious behavioural difficulties in a children's psychiatric hospital, have been described. The necessity for dealing with the very disturbed behaviour focuses on the ‘here and now’ interactions characterizing the therapeutic milieu. These principles are intended to help the staff maintain a frame of reference which will facilitate the milieu. These principles are: 1) The child's behaviour may be viewed as an expression of his beliefs. 2) Active confirmation of beliefs is sought. 3) Behaviour should be viewed in interactional and not in structural terms. 4) The frames of reference of staff and children are distinct. 5) The importance of contradictory messages. 6) There is often confusion between the thought and the action. 7) Staff function as behavioural models. 8) Significant communication must be actively maintained. 9) The importance of verbal communication. 10) It is essential to establish a hierarchy of treatment aims. Communication theory appears to provide the most satisfactory framework within which to examine these principles. Reference is also made to some recent learning theory formulations which focus on the social context of learning. It is essential, if the psychiatrist is to facilitate therapeutic behaviour by the child-care staff, that he can communicate in a way that has meaning in terms of their actual role. Early treatment aims consist of avoiding confirming beliefs we wish changed, reflection of feeling, helping to discriminate between thought and feeling, maintaining affective interchange and providing suitable behavioural models. Methods of facilitating socially desirable responses are very briefly considered. Positive staff responses to the socially appropriate behaviour which even these very seriously disturbed children show, appear likely to be effective provided these are accompanied by congruent staff behaviour. Some reasons why these principles require constant reaffirmation and reexamination are proposed and comments made on their teaching.

No abstract

It is now well recognized that the pa-that if an investigation is worth undertient response associated with the admini-taking there is no point in encouraging srration of medication has many deter-unlimited bias. minants. These include the staff involve-A second vital consideration in the dement and optimism which may be part sign of experiments into the effects of a of a drug investigation, the non-pharm-drug is the need for adequate, objective, acologically derived effect of the med-repeatable and quantifiable measures of ication (the so-called "placebo" effect), change. c?anges in the patient's interp~rsonal.enMuch current drug research is poorly vIronmentwhe0er at home or In hosl;">Ital, designed. Dunham and Howard (7) surwhether -occurrIng by ch~nc: or delIb.er-veyed six psychiatric journals for the fisately .t~rough therapeutI~mtervennon cal years 1957 and 1960 for articles rea~d clinical changes ;:flectII~g the natural porting research on the therapeutic value history of the condition being treated.of energizing and tranquillizing drugs. Gralnick (10) has pointed to the dan-They found that while the total number gers arising from a failure to take these of articles had increased by 36% in 1960, factors into account. Uncritical and ex-"most of the articles in both years and aggerated claims for a new treatment practically all of the increase fall at the method are likely to be followed by an lower levels of methodological adeequally uncritical rejection of the metho? quacy". Collaborative interdisciplinary as a whole, including any real value It research involving trained research workmight have. He warns that the same may ers was highly desirable in psychopharhappen with the new drugs unless they macology, in the authors' view. are subjected to thorough search and Thioridazine, first reported on, clinitudy a.n~unl~ss the treatment approach cally, in 1958 by Fleesan et «1 (8) and IS multidimensional from t?e start.Cohen (6) has since been the subject of !he use of the dou?le-bh~d procedure many reports. Doub.le-blind stud~es comUSIng placebo makes It poss~ble for most paring the drug with placebo In adult of these factors to be taken Into acco.unt, psychiatric patients (8, 14, 15, 29, 31, 1, since their influence will tend to contmue 11, 13) have all shown thioridazine to be whether the patient is taking placebo or more effective than placebo with few drug.side effects. The first five studies includNash (21), in his balanced appraisal of ed adequate objective measures of the double-blind procedure, emphasizes change. Further investigations employing the necessity for the investigator to "an-such measures, but without placebo, (23, ticipate damage to the experiment by fac-34, 37) concluded the drug was effective tors impeding attainment of double-blind and safe. Comparison with other phenoconditions, and to adapt his procedure to thiazines using placebo (8,9,11,14,31)