Child Health Services in Portugal
- Author:
Professor VITOR M. FONTES, M.D. V
Director, Institute Antonio Aurelio da Costa Ferrina, Lisbon
The meeting of the Mental Hygiene Congress in August of this year in London, with its sections on Child Psychotherapy and Psychiatry, presents a splendid opportunity at the present time.
It is essential that the nations be represented to their fullest and that the Congress occupy itself with the major problems which are found in those countries most tragically assailed from the Mental Hygiene point of view.
In addition to this viewpoint, which is fundamental, and by its side as a problem for solution, it might be as well to create a census of working conditions existing in the countries represented there, so that those conditions which are beneficial may be utilized for the common good, in a spirit of collaboration independent of other circumstances not those which are the moral principles of humanity.
With this sentiment in view and within the framework of the specialty which we practise officially in our country and also because we feel great pleasure at the request which was made to us by Dr Tredgold, we will set forth below a brief resume of what takes place in the realm of Child Hygiene in Portugal.
Until 1941 treatment and help extended to abnormal children was limited to those labelled delinquents, to those who underwent malforming influences through the circumstances in which they lived (children in moral danger), to some followed up by the educational services, to minors and to children whose senses were affected, namely the blind and the deaf, looked after in special establishments. Before this date there were only two schools for mental defectives, one for males founded by Doctor Costa Ferreira, physician and schoolmaster, and one for females, the Medico Pedagogic Institute of Condessa Rilvas. These two foundations catered for little more than a hundred boys and girls.
In 1941, the Portuguese Government began the organization of Child Mental Health Services in the country with the founding of the ” A. A. da C.F. ” Institute, established in the re-education school referred to above, but amplified and remodelled in its aims and functions.
This institution which functions in Lisbon is a dependent of the Ministry of National Education (Order No. 31,801 of 1941, and new re-organization Order No. 35,401 of December, 1941). It comprises a psychological observation clinic for children with mental abnormalities and the centre for study, organization of treatment services, re-education and aid to all those mentally affected in the country.
In order to carry out these functions the Institute has three aims:
Selection of children with mental abnormalities.
(b) Setting up of training courses for the technical personnel to be engaged in the work. (c) To prepare and organize the various Child Mental Health Services of the country.
To carry out its first aim the Institute possesses a dispensary with an external consulting service, social domestic welfare and the organization of technical brigades who go to the schools or official and private establishments for child aid treatment or education, in order to observe children brought to notice for the above reasons.
Some children may also come for consultation free. Observation of the child begins by being made by a nurse, who watches its behaviour in the waiting room. Toys are provided for the children while they await their turn for examination. Children and parents (or those accompanying the child) then pass on to the Social Service department where a social worker takes down particulars of conditions of family life (as much from the economic as the moral aspect) and of general health. The child then goes into the medical psychiatrist’s room, who performs a clinical examination, employing all possible methods used * Translated from the Portuguese. in this type of examination, i.e. tests (Termann, Fay, C. Buhler), neurological examination, psychiatric and physical examinations, direct observation by conversation, free drawing and whatever other means the case demands.
The case sheet, drawn from these three sources, accompanies the doctor who examined child and family, to the director for discussion of diagnosis, and where possible the future handling of the case. The characteristics of examination concentrate on two major points: paying the greatest attention to information obtained socially and at the same time paying great respect for the feelings of the patient and his family, sparing them as much as possible questionnaires carried out in public by numerous inquisitors, a grievous trespass on the closest secrets of their lives, perhaps those most secret. To avoid this both doctors and social workers are alone with the examinees, and the utmost efforts are made not to duplicate questions, bearing in mind that the essentials are to be found in a case sheet compiled from the various sources of the respective services. And above all conditions of family life (of great importance in child psychiatry) are compiled only by social workers who are, as a rule, more welcome by the families in enquiries as to their more intimate affairs. When the examination is complete it then remains to indicate the ultimate course to be followed in treating the child. A final decision cannot always be made as the result of one examination; to guard against this difficulty there exists in the Institute building, a boarding school specially set up for those requiring further observation. When admission is decided upon, before the child enters the boarding house, the Social Service, through the medium of its workers, visits the child’s family in their own home and there take a careful history; this is taken with all possible discretion and caution but is nevertheless full and well informed. When the history has been taken the child enters the boarding house which admits boys from 5 to 15 years of age (the female section functions in another building, the Medico-Pedagogic Institute Condessa Rilvas).
The regime of the boarding house is by necessity the most liberal possible, within a framework of discipline readily accepted by the children; familiar surroundings, and an atmosphere into which teachers, doctors and above all prefectorial staff, enter, gives them a truly family life. The opportunities for observation in the boarding school are multiple ; various tests (in addition to those mentioned, the manual labyrinth of Rey, Ozeretzky, etc.) clinical pathology laboratories, X-rays, observation classes and especially observation of the children in the untrammelled life of the boarding school, that is in their amusements, refectories and dormitories.
As we said observation classes also function in the Institute ; infant classes and those of the various grades of primary education. Nevertheless these classes are not intended primarily for the education of abnormal children. While he teaches, the master (himself a specialist in this type of observation) continues to watch his pupil and to appreciate the causes of his mental abnormality or inability to learn.
The various workers in the boarding house, doctors, teachers and prefects have each their own case sheets where all information in regard to the child under survey are noted down. This ranges from laboratory analyses to psychiatric examinations, from neurological examinations, detailed and repeated, to notes on improvement in school work, i.e. reading, writing and arithmetic. Also noted are performances in manual work, games, etc. and finally in great detail, the notes made by workers in regard to the daily life of the boarder, the behaviour of each child, in his milieu, in the dining room, in the dormitories, how he comports himself at table, how he sleeps (night terrors, dreams), if he is violent at play, cunning, lying, loyal, a coward, a cheat, aggressive or co-operative. Every fortnight the technical personnel have a clinical meeting in which the children’s case sheets are read and weighed up. The case is discussed by everyone and when it is considered that the case is complete the ultimate destination of the child is marked down on the case sheet, whether it be re-education, treatment or simply help.
During the observation, which in general is considered completed in a term of one to two months, the Social Services pay return visits to the minor’s house and also to his school or office where he was working ; * it not only continues to collect all elements which may perhaps help completely to clear up the case but also continues to solve as much as possible the family situation, by re-organization of broken homes, attempts to place unemployed fathers and to hospitalize any member of the family who requires one or other form of treatment.
The child is then discharged from the boarding house and if his continued treatment is possible, when it is indicated, it is proceeded with on this understanding and the family continues to visit the dispensary or Social Services in whatever form suits them best. If the child cannot be admitted to the recommended institution by reason of lack of accommodation or because what exists is not sufficiently differentiated, then he remains under surveillance at close hand and the best transitory solution is sought.
Since the organization of the Institute and by its direct intervention, there have already been created in Lisbon several institutions for complementary treatment. Thus, in the suburbs, a re-education school, the ” Albergavia de Lisboa ” has been founded with a large estate and buildings for mentally abnormal children who while they are unable to proceed to elementary studies, are nevertheless able to absorb and learn simple tasks fitting to their mental capacity, the teaching being carried out by personnel trained to teach this type of child.
The re-education school carries one hundred boys. In Lisbon a re-education school for seventy-five girls functions in collaboration with the Institute, with gardens, and training centres in dressmaking and other domestic work, well fitted for the pupils boarded there.
In the ” Julio de Matos ” Hospital (Psychiatric Clinic for Adults) a building for children was opened in 1943 for forty boys for cases of psychopathic personality who require treatment in this type of speciality.
Finally by the initiative of, and organized through the Institute, twelve classes with a maximum of fifteen pupils each, will begin work this year beside the primary schools of Lisbon and the Public Assistance Institutions for Infant Education; these are for backward scholars who require individual teaching. These classes work under the technical direction of the Institute and employ personnel trained there.
Besides children boarded in these institutions and those who are accommodated in special classes, the Institute also assists, treats and re-educates numerous children either as boarders (cases of childhood neurosis, caused by bad home influences, psychopaths with familial reactions which a few months as boarders and some family re-education may help) or as out-patients where many cases for motor re-education by reason of neurological disease are cared for: there is also an Orthophonic section which has many patients.
This then is the function of recuperation of mental abnormalities carried out by the Institute. The other function is the training of technical personnel for these specialized Services. To cover this an order was published (32,607 of December, 1942) regulating the founding of a specialization course for teachers of abnormal children in the Institute. The course consists of two subjects, Psychology and Paediatrics, orientated for the purposes of the specialty. Primary school teachers or anyone with a University degree can matriculate in this course. The certificate of this course is the indispensable legal condition by which one can be employed as a teacher of abnormal children.
The course is essentially practical: it extends over one year, and its theory is orientated in the direction of observation and recognition of the known facts of abnormal psychology applied to abnormal children, taught also with this end in view; what is more stressed is the practical side of teaching through the medium of apprenticeship, both in the classes which are taught in the Institute itself and in those attached to the primary schools.
Each pupil-teacher has some weeks of apprenticeship in the first, second and third infant classes. These classes are attended by the Institute masters and by the pupil-teachers’ colleagues. At the end of each apprentice week, the lessons taught by each pupil-teacher are discussed by the technical personnel of the Institute, including the director and the other pupil-teachers themselves. This teaching technique has shown itself of great use as it has allowed of a singularity of viewpoint most convenient in a subject so specialized. The final examinations of the course consist of theoretical tests, practical tests (lessons given on a chosen subject) and the writing of observation notes relative to abnormal children selected for the examination.
Preparation and organization of the various mental health services is carried out by means of a propaganda directed towards the non-lay public (doctors and teachers) and the general public. For this the Institute has brought into being conferences on Neuro-psychiatry and has publications on aspects of the specialty. Thus the organ of greatest circulation published by the Institute is a Bulletin entitled the ” Portuguese Child” of which already six volumes have appeared, corresponding to the six years’ existence of the Institute. In addition to the Bulletin, four volumes of monographs, treating of more limited subjects and more searching in their intrinsic sense are published. The Institute also has in its possession much valuable material within the sections in which they are made up. Thus in the Museum there are 250 brains of still-born and new-born Portuguese children. Each brain has its case sheet with all possible information obtained by the Services who came by the brains.
The Institute possesses also a collection of records obtained from its patients suffering from speech troubles, from orthophonic defects, from stammering, etc. There is also a selection of films showing patients with motor and other affections. The Library of the Institute is rich in reviews of special subjects, as it receives 119 national and foreign publications, 116 of which are obtained by exchange with its own Bulletin. In the six volumes of ” AC. CR. PORT”, psychological, pedagogic, morphological and social aspects of the Portuguese child are treated, with valuable foreign collaboration. We may mention in honour the names of collaborators, Tramer, Baumgarten, Cesell, Hanselmann, Schachter, Maragas and Planchard.
Of the four volumes of ” monographs ” two are on the subject of neuro-psychiatric conferences concerning children: Volume No. II is a study of ” The development of the cerebral cortex ” by V. Fontes and No. IV is a work on Pestalozzi, published in 1946 on the second centenary of his death.
The ” Organization of Psychiatric Aid in the Country ” Law, published in 1945 (Law No. 2006) included the Institute in its services, giving it the title of Dispensary of Mental Hygiene in the country with the powers already described.
The child section created in the three psychiatric centres in which the country was divided, namely North, in the city of Oporto, Central in Coimbra and South in Lisbon, are under the technical direction of the Institute.
To date since its organization in 1941, 4,894 minors have passed through the various branches of the Institute 617 as boarders, 4,277 through the other branches. Of these last 2,203 were admitted to the Public Assistance teaching centres, as they showed no evidence of mental abnormality, 175 were placed in the existing re-education schools, 180 are taught in the special primary classes, 40 are gathered in the infant section of the Psychiatric Hospital and the remainder continue to be assisted by the Institute or are at home awaiting consideration of their cases.
What remains to be done is to build asylums for large numbers of irrecoverable patients, to enlarge the special schools, and to attempt to extend to the whole country the benefits of assistance, re-education and child treatment.
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