Occupational and Physio-Therapy as Adjuncts to Child Guidance
A SUGGESTION FOR DESIGNERS OF CHILD GUIDANCE CLINICS :Author: E. Wellisch M.D., D.P.M., Consultant Phys. Med. (Austria) Medical Director, Cray ford Child Guidance Clinic, Kent
Children usually cannot sustain long psychotherapeutic conversations as adults do, and, therefore, they often need a special psychotherapeutic approach which is best provided by indirect and practical methods. The most ]rnportant and widely used of these methods is Play therapy. There are also other, though generally less essential, methods which can often be very helpful. They are, however, so far used only very little in child guidance work and therefore deserve greater attention than they nave received in the past. One of these methods Is occupational therapy, which in many respects ls closely related to play therapy. Another method, which again has a close relation with occupational therapy, is physiotherapy, a form of treatment which can in many cases be usefully combined with psychotherapy.
Occupational Therapy in Child Guidance Occupational therapy is already widely applied in mental hospitals and other places of treatment of mental disorders, but so far has only been little used in child guidance clinics. An exception, however, is, for instance, the Davidson Clinic, Edinburgh, which in so many respects is doing pioneer work. 9ccupational therapy, which is ” any activity, mental or physical, definitely prescribed and guided, for the distinct purpose of contributing to and hastening recovery from disease or injury”, assists psychotherapy through creative activity. Its value for child guidance work is manifold. It promotes accessibility to psychotherapy in children with a practical bias who are otherwise difficult to approach. Certain children who lack practical ability can be taught to enjoy handiwork, an experience which has great beneficial psychological effect. There are also children who find ” play ” with toys ” too childish ” and resent any form of play therapy. They have, however, no objection against “real work” and can be successfully influenced by occupational therapy. The value of occupational therapy to children who need vocational guidance is considerable. An occupational therapy department also is from an economical point of view valuable for a child guidance clinic. Toys and play material are frequently damaged but often difficult to repair or replace, and there is also a constant need for new play material. An occupational therapy department can be very useful in covering these needs and thus provide the clinic with important materials on which to a certain degree the result of the treatment depends.
The occupations and crafts used in child guidance have to be adjusted to the special purpose. They can be divided into four main groups.
The first group consists in toy-making and repairing. A very important play technique is the method of building miniature playworlds with little houses, trees, figures, animals, etc., a method which was designed by Dr. Margaret Lowenfeld. The little toys needed for this purpose can be made of various materials such as papier mache, wood, or metal. To make these toys at the clinic is not only fascinating work for the children, but it can be of great practical value for the psychotherapist if he can order what he needs for special purposes. The making of puppets, either flat figures, marionettes or glove puppets, and of stage material would be a great asset. The same applies to the making of dolls’ houses and soft and other toys.
Another group includes various simple crafts, such as needlecraft, weaving, basketry, raffia and cane work, wood and metal work, and also the use of waste material. The arrangement of country dances and other physical exercises is also important. These are forms of treatment which equally belong to the spheres of occupational and physio-therapy. Of greatest therapeutic value can be the use of music in child guidance work, both in the form of singing and instrumental music. There is no other means which can influence the child’s emotions as well chosen and performed music can, and there is no doubt that musical treatment, if directed by an expert, has a great future.
The occupational therapy department of a child guidance clinic requires a special room and a trained occupational therapist. The other staff of the clinic will usually neither have the expert knowledge nor the time necessary for this branch of the work.
Physiotherapy in Child Guidance Physiotherapy, or the use of mechanical force, heat, water, light and electricity, is a subject which is still neglected in the syllabus of many medical schools. This is the reason why its great importance for medicine in general and psychological medicine in particular is so little recognized. There are, however, signs that physiotherapy will play an increasing role in psychiatry.
Physiotherapeutic procedures are a valuable part of the treatment in some mental hospitals. In child psychiatry, physiotherapy has until now been used only by few clinics, as, for instance, by the Institute of Child Psychology, London, but there are a number of reasons why this form of treatment is especially suitable to assist the work in child guidance clinics. In psychological disturbances, particularly of children, psychotherapy can often be made easier by an additional bodily approach. There are, of course, patients for whom such an approach is contra-indicated and their careful selection is very important, but the number, especially of maladjusted children, who can benefit from a simultaneous somatic treatment is considerable. Maladjusted children frequently suffer from psychosomatic disorders, and, although the organic disturbance is not always conspicuous, it is often an important and sometimes even causative factor of the disorder. Improvement of the somatic state often has a favourable result on the maladjustment. Physiotherapy is particularly suitable as a bodily approach for several reasons. The somatic disturbances of maladjusted children are frequently disorders of the muscular and vascular systems which are especially well influenced by physical agents. These agents are often successful when drugs or injections are not, and they also have the advantage of being non-poisonous. Physical agents, such as warmth, and its carrier water, light and electricity, also have a strong suggestive influence on the child. They are the forces of nature which play an enormous role in the unconscious mind. Physical procedures often require systematic physical training and a certain discipline which can have an excellent educational influence on the child. Many forms of physiotherapy are followed by a period of rest during which the patient has a feeling of increased, well-being and is pleasantly relaxed. This period often gives a unique opportunity for psychotherapy.
The main indications for physiotherapy of maladjusted children can be divided into two groups, bodily and psychological. In either group the symptoms must be considered to determine the type of treatment.
In the first group the most important indications for physical treatment are faulty posture and incorrect bodily mechanics. Faulty posture is frequently the somatic expression of depression, anxiety, dejection, lack of self-respect or poor general mental health. Drooping shoulders, scoliosis and other faulty bodily mechanics are often found in hypotonic, asthenic children. The children also often have a vascular instability with poor peripheral circulation, are pale, anaemic, and are liable to acidosis and over-excitement.
Another indication for physiotherapy is infantile bronchial asthma. Remedial exercises for asthma give such an excellent opportunity for simultaneous psychotherapy that they should be given by the staff of child guidance clinics. The same applies to other physiotherapeutic procedures which assist in relieving this distressing disease.
Another indication for a simultaneous physioand psycho-therapy is the presence of mild, and especially glandular forms of infantile tuberculoses. Further indications are neurological symptoms such as paresis, paralysis, neuralgia, migraine or other forms of headache, and also habit spasms.
In the second group, the outstanding symptoms which determine the choice of treatment are lack of energy and interest, Hstlessness and slothfulness. They are frequently characteristics of the asthenic child. A not uncommon indication also is infantile depression. Of considerable importance is self-consciousness, especially of adolescent children and particularly if they happen to be obese or afflicted with some bodily defect. Another indication is given by children who are not interested in or suitable for play therapy, or occupations which appeal to the imagination, but who love movement games and bodily exercises. The physiotherapeutic methods used in child guidance have to be adapted to this special Purpose. Only few and simple methods can and need be applied. They should comprise some procedures of medical gymnastics and mechanotherapy, hydro and thermo-therapy and of light-therapy. Electrotherapeutic procedures are not essential for the ordinary routine work. For the medical gymnastics a suitable room is necessary. There the courses training in general postural exercises and breathing exercises for asthma should take Place. The room should be equipped with stall-bars for the manipulation of postural deformities, such as scoliosis, etc. The hydrotherapeutic equipment should comprise one or several bath-tubs where full-baths, halfbaths, sprays, douches, and ablutions can be ?iven, as well as couches for wet packs and rest. Wet packs, followed by cold half-baths and gymnastic exercises, can be an excellent procedure in the treatment of muscular weakness, ‘istlessness and lack of energy. Cold showers are refreshing and stimulating; warm tub-baths, especially in combination with ultraviolet radiations, are useful in glandular tuberculosis of children. The admixture of extracts of pine needles or other aromatic and coloured substances can, apart from their other effect, exert a favourable suggestive influence.
Artificial light treatment is indicated in many disorders of childhood. The growing child needs light almost as much as food and is extraordinarily sensitive to it. Ultraviolet radiation is a prophylactic procedure of the first order to combat rickets in which a ” late or adolescent form ” is sometimes known to occur. Ultraviolet light is effective in tetany and certain forms of tuberculosis. In some cases of anaemia and anorexia it is also valuable. Bronchial asthma is another indication for ultraviolet treatment, especially if a certain grade of ultraviolet erythema is given at the skin of the thorax and the treatment is combined with local applications of heat.
Of excellent value for a child guidance clinic would be the installation of a ” solarium “. This is a room with a battery of ultraviolet and heat lamps. If the radiation is arranged so that it simulates natural sunlight and the floor is covered with sand, the room resembles a beach and can be used for play and psychotherapy at the same time. Even if only one room should be available for physiotherapy, many of the most useful procedures could be performed there. A more complete physiotherapy unit, however, should have two or three rooms for mechano and hydro-therapy and ultraviolet treatment. A trained physiotherapist should be in charge of the department and the senior psychiatrist should have a certain knowledge of physiotherapy.
As child guidance clinics are relatively recent institutions, they were frequently established in rooms of hospital outpatient clinics, school clinics, and similar buildings, as good as circumstances permitted. This, however, is only a provisional measure and in future child guidance clinics will have to be properly designed for their special tasks. May I suggest that the future designers and architects of child guidance clinics should, at least for some of the larger clinics, make provisions also for departments of occupational and physio-therapy. This would increase the scope and improve the results of child guidance treatment.
PUBLICATIONS
Eighth Annual Report of the Davidson Clinic Edinburgh, 1948. Haworth, N. A., and E. M. MacDonald (1940). theory of Occupational Therapy. London: Bailltere, Tindall & Cox. *-?Warschik, J. (1941). Phvsikalische Therapie. Wien: Springer-Verlag. usen, F. H. (1941). Physical Medicine. Philadelphia and London: W. B. Saunders Company. Welusch, E. (1932). Die Quarzlampe. Wien und Berlin: J. Springer. (1933). Die physikalische Therapie der Nervenkrankheiten. Medizinische Klinik, No. 26. (1934). Die physikalische Therapie der Neurosen. Mitteilungen des Volksgesundheitsamtes, H.ll. ? (1944). Physical Therapy in its Relation to Psychological Medicine. The Medical Press and Circular. Vol. ccxii, No. 5512.
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