Notes on the Investigation and Treatment of Difficult” Children in the United States of America
- Author:
Shrubsall, M.D., F.R.C.P.
During recent years there have been frequent suggestions that special methods ?f investigating and treating difficult and delinquent children were employed in the United States of America, and that the results obtained were such as to render it desirable that such methods, or a modification thereof, should be tried ?ut in England.
Thanks to introductions most kindly given by Miss Scoville, Executive Secretary of the Commonwealth Fund, an opportunity was afforded the author, during the summer vacation of 1926, of seeing these methods in action for a very short period in a representative city, and of paying fleeting visits to other cities t? see local modifications….
Attention was paid particularly to three classes of activities, rirst, those carried by the education authority and certain ancillary agencies, secondly, to those of a special body of workers, known as Visiting Teachers, and thirdly, to those of the Child Guidance Clinics, conducted by the National Committee for Mental Hygiene of New York as part of the programme financed by the Commonwealth Fund, with more special reference to that in Philadelphia.
PhilaH^i a”thor’s special thanks are due to Miss Scoville, to Dr Allen and all the staff of the All- White iriT-a Chilfl Guidance clinic, to the officers of the Philadelphia education authority and of the must hi ?s f?undation for every facility in observing the work done, while full acknowledgment informof the use of various reports of the Commonwealth Fund and others from which muclj ?”??manon has been culled.
THE SPECIAL INSPECTORATE.
The methods of examination of retarded children by the inspectors, who are psychologists, are practically identical with those employed by the certifying officers in London. The procedure consists of a series of Stanford-Binet tests to ascertain the mental age score and the intelligent quotient, a series of performance tests of a varied character and a series to ascertain the amount of school knowledge possessed. The psychologists are apprised of the past history by reports from the school teachers. A summary of the record is sent to the school for the information of the teachers. Children who fail to learn to read or calculate are recommended for special classes even though their general intelligence is of a higher level than would be deemed to reveal mental deficiency in England.
The psychologists, in coming to a diagnosis, appeared to make use of any medical facts which are recorded on the medical records, and in so doing were forced to some extent to act on lines which in England would be regarded as medical rather than as purely psychological. That the importance of medical training in this work is indirectly recognised, is shown by the fact that in Newark, New Jersey, the head of this department is a medical man with a psychiatric training, although he ranks as a school teacher and is on the staff of the superin- tendent of schools and is not under the medical officer in charge of the division of medical inspection.
Children are referred for examination with a view to special education when they fail to make progress in the grades in the ordinary schools. It has been recognised, however, that innate lack of intelligence is only one of the causes of the failure of children to make progress and there are other and more common factors which may be operative. Even when the most advanced methods of teaching exist and auxiliary classes of all kinds are available, there are some children who do not make the progress that might reasonably be expected, the efforts of the teacher being neutralised by undermining influences outside the school, or by some faulty connection between the training within the school and the life outside. Frequently even, it has been pointed out, the home and the school, through lack of acquaintance, and misunderstanding, have unwittingly worked against each other, the one thwarting rather than reinforcing the best efforts of the other.
Sometimes the problem is evident as in the case of truancy, misconduct or retardation ; at other times it is less obvious. The boy or girl may come to school but may derive little profit as the mind is wandering far away from lessons, or because of fatigue from out-of-school activities or bad home circumstances. In several American cities the school is recognised as the place from which to work for the prevention of delinquency and other social problems by tackling the earliest symptoms of maladjustment. Many students of juvenile court procedure have shown how delinquency is encouraged by desultory and unguided pursuits in spare time, and how difficult such habits are to modify once they have been acquired. The adjustment of all but the simplest cases requires the technique of social work and an ability to see behind the overt behaviour to the underlying causes, to recognise what the child needs and to supply the lacking elements.
THE VISITING TEACHER.
With a view to handling such cases many schools now have on the staff a special officer, usually a woman, whose duty it is to ” see the child as a whole.” Sometimes she is called a. ” visiting teacher,” sometimes a ” school counsellor,” sometimes a ” home visitor,” but in any case her purpose is to seek out and help a child who is unable to adjust readily and happily to the educational and social requirements of the classroom or the playground.
Children are encouraged to take their own difficulties to the school counsellor or visiting- teacher and to look upon her as a personal friend who will not give them away, and it has been found that they at e taking advantage of this opportunity in increasing numbers. Generally, however, a case is referred to the visiting teacher either by the principal of the school or by a class teacher, schools differ in this respect?in some the principal leaves his colleagues a free hand to make references, in others he wishes first to consider each case for himself.
A large part of the visiting teacher’s day is spent in calling at the home of the children. Sometimes the visits are made during school hours lO talk over serious problems with the mother when she is alone and comparatively undisturbed, especially such problems as might involve criticism of the family attitude toward the child or the school. At other times the visits must be made after school so that matters may be talked over with the mother and child, or in the evening, to find working parents, or the whole family at home. In the homes the visiting teacher frequently assumes the role of interpreter, clearing away misunderstand- ings about school requirements, explaining the school s aims and demands and the child’s needs ; she may have to interpret to the children the attitude of their conservative parents.
The visiting teacher also goes to playgrounds and other places to observe the child at play and to get better acquainted with him and his gang. A very important part of her duties is reporting back to the school and to the teachers directly, the conditions found, so that the school view may be supplemented by a knowledge of the background. A visiting teacher refers to the appropriate social agencies all cases requiring their special assistance, attends conferences and works co-operatively with such agencies to secure co-ordination.
Action taken with regard to treatment has been grouped under 4 headings . 1. Through outside agencies. 2. In the School. 3. In the home; and 4. With the child.
The proportions in which these have been used vary from community to community and in accordance with the type of case which forms the predominant reference.
Action through outside agencies is perhaps the most frequent type of treatment because of the large number of activities embraced, such as the treatment of physical defects, the securing of financial relief for the family, provision for country holidays, and the like.
The visiting teacher does not duplicate the activities of other agencies but rather transfers cases where needed to the appropriate quarter, and endeavours to secure permanent family rehabilitation rather than employ temporary palliatives. Changes within the school form a smaller item owing to the relative inelasticity of the school organisation, although the visiting teachers can often secure, with the consent of the principal changes to other classes in the ordinary grades or transfer to open-air classes, ungraded classes, rapid promotion classes or other special groups. Here it may be noted that conduct difficulties have been found to arise quite as often from a child being placed in a class which does not allow full scope for his abilities as from his being in one the work of which is beyond his mental powers.
Treatment which affects the home and the child is used frequently in all types of cases. This may involve
Attention to the physical condition of the child;
(b) Attention to home surrounding’s, which usually means better facilities for study and sleep, especially in scholarship cases, freedom from worry, creating an interest in his work and decreasing undue excitements. (c) A change in the parental and family attitude towards the child, encouraging sympathetic supervision and discouraging continual nagging, which appears to constitute the sole idea of discipline in some households. (d) Care for the moral condition of the child, with more attention to his behaviour, his whereabouts and his associates-
The question of obedience has to be emphasised, for it seems to be a very general opinion that many present-day children have learned from very early years that by obstinacy and bad behaviour they can attain desired ends or be bribed to good behaviour on a steadily increasing scale.
It has been estimated from a study of case records that the results of the activities of the visiting teacher has been 74 per cent, definite improvement, 18 per cent, some improvement, and 8 per cent, of definite failures, and it has been noted that improvement has not been specially characteristic of any one type of reference.
In general, save in most exceptional cases, it is not regarded as part of the visiting teacher’s duties to concern herself with attendance cases, or to appear in the Juvenile Court in support of any proceedings, since it is felt that such actions would tend to undermine the feeling of friendliness with the family, which is an essential item in the whole concept of the ” visiting teacher ” movement.
As a general rule persons appointed as visiting teachers have had both teaching experience and training in social work. The former is necessary if the visiting teacher is to understand the school side of the problems, and the latter if she is to make effective contacts in the homes.
The work carried out by the visiting teachers comprise some duties which in London would be attempted so far as is possible by the head or class teachers and others which fall to the lot of the care committee organisation. The movement is highly thought of, is steadily spreading and is regarded by some authorities, e.g., by Judge Hoyt, of the New York Juvenile Court, as ” the best existing preventing measure against juvenile delinquency.” The central feature is that there shall be someone with an adequate knowledge of the school and of the children, whom the latter can regard as a family friend to consult in any difficulty.
As regards children at the school leaving age, the duties gradually merge into those of placement and vocational guidance.
THE CHILD GUIDANCE CLINIC.
The principal objective of the All Philadelphia Child Guidance Clinic in the community is to assist in a dynamic way in the adjustment of children presenting problems in behaviour and personality. In a preliminary circular inviting the reference of cases for study, the following groupings of possible problems were suggested, though it was pointed out any combination of traits might be found. 1. Maladjustment indicated chiefly in personality, traits, sensitiveness, seclusiveness, secretiveness, inattention, apathy, day-dreaming, fanciful lying, ” nervousness,” tendency to cry easily, moodiness, obstinacy, quarrelsomeness, selfishness, laziness, lack of ambition or interest, timidity, cowardliness, general fearfulness, unpopularity or inability to get on with other children, general restless- ness and hyperactivity, wanderlust? etc,
2. Maladjustment, indicated chiefly by undesirable habits thumbsucking, nail biting-, enuresis, masturbation, mannerisms, peculiar food fads, disturbances in sleep, etc.
3. Maladjustment, indicated chiefly by undesirable behaviour disobedience, teasing-, bullying, temper tantrums, bragging or showing off, defiance of or rebel- lion against authority, keeping of late hours, seeking bad companions, lying, stealing, truancy, destructiveness, cruelty to persons or animals, sex activities, etc. The work of the clinic is limited to children within the age groups of approxi- mately 3 to 17 years, and it is pointed out that the more successful results may be expected from the study and treatment of children who fall closer to the lower rather than the upper age of groupings. The clinic was not designed to handle certain situations which might be :?
A. Unsuitable on medical grounds. 1. Ordinary cases of mental defect or cases in which mental deficiency has already been diagnosed as the outstanding feature of the maladjustment. 2. Cases of advanced mental disorder, such as epilepsy, dementia praecox, etc., in which reliable diagnoses have already been made and for which the clinic services would be able to accomplish little. ?B. Unsuitable on account of limitation as to possible treatment. 3. Cases in which only a psychological test is wanted. ?A. Cases in which the treatment plan or disposition of the case by commitment has already been made, where only a confirmation of the plan is desiied and where there is no opportunity for the clinic to assist in individual social adjustments.
5. Cases in which an agency has worked intensively over a long period of time, utilising the existing resources of the community and for which, therefore, the services of the clinic would be less useful.
For the purposes of demonstration the clinic naturally deals directly with a large number of its cases, but deals with others in co-operation with other agencies in which case it is the visitors of the agency who visit ihe home of the individual, being kept in contact with the needs of the case by attendance at staff conferences at the clinic and by co-operation of a special liaison officer.
The aim of the clinic is to investigate all the factors which may have led UP to a given behaviour situation, and thus a four-fold study of the child is made to include the social, physical, psychological, and psychiatric aspects of the problem. These four phases of the problem are brought together in a staff confer- ence, in which every aspect of the problem is discussed and a plan of treatment formulated. This enables the number of visitors to the home to be reduced to a minimum. This treatment in the main is carried out by the investigator of social conditions?termed a psychiatric social worker?who explains the situation to the family and suggests modifications in attitudes, treatment, etc., though from time to time, as may be required,, the psychiatrist has further interviews with the child, in which he discusses with him the entire situation in terms suited to his age, intelligence and insight into his own difficulties.
I he general procedure from a medical standpoint does not differ essentially from that in use in England, nor indeed does the social information collected. It does differ, however, in the extent of detail. English clinics can rarely have the staff to make the full study undertaken in these demonstration clinics, and more usually the information has to be collected by the psychiatrist personally, a task which takes up much time which might be better utilised could the necessary information have been otherwise obtained.
The purpose of the full social history is to enable those working- with the child to have a clear picture of the conditions under which he has lived and to show the mental and physical influences which have been operating- since before his birth to produce his present state of development, and to indicate the nature of his reactions to those influences. Since the earliest years of life are those in which the foundations of character are established, it is most important to have a clear history of the events of early life. Since example is more important than precept, it is necessary to know about the other members of the family and their reactions to the subject, and since the parents’ attitude in time is dependent ultimately on the traits and habits ingrained in them in early life, it is well to know about the grandparents and the general circumstances of the early life of the parents and the social milieux in which they were brought up. Similarly it was deemed neces- sary to know something of those in immediate contact with the subject whose behaviour and attitude will influence him emotionally, such as his companions, teachers or employers.
In ascertaining the history of a case the psychiatric social worker registers each case with the confidential exchange and obtains reports from agencies that have known the family. Wherever physical or mental ill-health has been a con- spicuous factor, she secures definite and detailed information from any clinic which has known the patient, endeavours to interview the family physician, should there be such, and if he is interested, persuades him to attend the staff conference on the case which is held when the necessary data have been collected.
Important statements which cannot be proven or disproven at the time are specially labelled so that there may be no doubt how much is real evidence when the case as a whole comes to be reviewed, e.g., ” It is reported that the mother drinks, but the worker could not determine whether this is a fact or merely neighbourhood gossip.” The social workers are instructed that all relevant materials should be collected but must be carefully sifted to distinguish fact, fiction and emotional lies; in particular great care must be taken that the story should not be coloured by the worker’s own interpretation or moral judgments.
The general lines of enquiry include the reason for reference of the child to the Child Guidance Clinic, sources of information, family history, description of the home and the home and neighbourhood conditions, personal history, including health, habits, work, interests and occupations, companions, personality and con- duct, work and the action of other agencies in meeting the family problems. At the conclusion of the report the social worker gives the opinions of various inform- ants as to the possible methods of handling the existing situation. The aim of the whole report is to present a complete picture of the environmental conditions and particularly the mental standards, personalities and general atmosphere surrounding the child, so that all persons concerned may be visualised as concrete reacting personalities related to the problems presented by the child.
The physical examination is a complete medical examination with special emphasis on the neurological aspects but differing in no material point from a similar examination in England. In the psychological examination the child is taken through a complete series of Binet-Stanford tests, followed by various performance tests, and by a questionnaire designed to elicit the interests of the child both in play and work and the knowledge of the subjects in which interest is shown.
In summarising the results the psychologist reports on the child’s attitude, his willingness to co-operate, his degree of effort and attention, his comprehension of directions, power of planning and apparent reason for failure in any test. The psychiatrist obtains from the child his own version of his life story and interest, noting his disposition, temperament and reactions, so far as they can be observed at an interview, noting” such personality traits and the like as may enable him to classify the subject under one of the recognised types.
After all the data have been collected, a short summary is drawn up and the case is discussed at a meeting of the staff of the clinic, and any social worker from other agencies, the family physician or others interested in the case. A plan of action is drawn up. The course of action necessary varies in every case and must be adapted to deal with the cause of the behaviour complained of. As an illustration, however, suppose the trouble be temper tantrums, the parent might be told If the tantrums are used by the child to gain his own way, she should stop giving in to him, since each successful tantrum by which the child gains some end renders it easier for him to give way to another, until finally he may be rebellious even against himself. If the tantrum is for the purpose of gaining attention, she should stop Paying attention when he has them, but should pay more attention when he is good , if the aim is to secure a bribe, the parent must cease to bribe or the trouble will continue so long as anything can be obtained. If they are due to a physical cause, this must be treated, if due to lack of play, opportunities must be offered. If due to imitation of an irascible parent, the parent must be urged to exercise more self- control, etc., etc. This example is not altogether typical, since the advice might have been given without so much enquiry as has been quoted, but in most instances the advice has to cover a very wide field and explanations have to be given to many persons.
The time taken in investigating a case cannot be estimated very easily, as the range of variation is very great, but it may require at least an hour of the time of the psychologist and psychiatrist, half an hour for the physical examination, at least a day or two for enquiry by the social worker, possibly much more, and at least half an hour to an hour for a staff conference. It will be realised that in a demonstration clinic the time spent is more than would be feasible in one which was established on a permanent basis. The time required for later treatment by the social worker may be indefinite and there may be several further interviews with the psychiatrist.
The staff of the Philadelphia clinic consisted of: 3 psychiatrists, one of whom acted as the director. 2 psychologists. 9 social workers, one of whom acted as superintendent, and two of whom were students in training.
1 statistical recorder. 1 executive assistant, and a staff of stenographers, etc. A large part of the duties of the medical staff consisted in propaganda work of various kinds, so that it was difficult to attempt to estimate how much of their time was really needed for case work alone. Medical treatment was not given at the clinic, the patients being referred to their family practitioners or to hospital or clinic.
This staff is no doubt greater than would be allotted to a permanent clinic, but it is clear that the greatest saving of time is effected by giving adequate assistance to the psychiatrist at the clinic. One psychiatrist could usefully employ the services of one or two psychologists and several social workers. It is probable that in England many medical practitioners would prefer to carry out the tests given by psychologists in America, holding the view that in the course of such an examina- tion better contact is made with the subject so that in the end there would be a saving of time.
The most characteristic feature of the American Child Guidance clinics is the extensive use made of the social worker both for ascertaining all necessary facts with regard to the child and for following- up to secure the necessary adjustments in the home, in the school, or at work.
The actual psychiatrical work seems to be much the same in both countries, so that there is little doubt that the backbone of the successful American system is the efficient and well-trained psychiatric social workers and the thorough recognition of the fact that a family situation is always to be viewed as a whole, that behaviour, whether of a child or an adult, is the component of very definite factors in the individual and in the environment in which he lives, that it is a function of the whole individual and cannot properly be understood by a study of a single or isolated component.
Although the trained worker is now specially termed a psychiatric social worker, there is no doubt the general point of view is one which should be applied by all social workers in whatever field of relief they may be employed.
The two types of social workers referred to, the visiting teacher and the psychiatric social worker connected with the clinic do not really clash. Many cases of maladjustment do not require medical intervention, but the trained and efficient visiting teacher would at once refer to a suitable clinic any case in which there was the slightest suggestion of morbid mental processes at work, and thus secure suitable and adequate psychotherapeutic treatment. She could either hand over the case entirely or carry it on in conjunction with the clinic being kept in touch with all that went on through the intermediation of the staff conference. In cases of difficulty the former method would be likely to be more effective unless the visiting teacher should chance to have a very thorough rapport with the family of the child concerned.
In the main, the outlook of the visiting teacher and the psychiatric social worker is the same, the principle involved is that of recognising that a child’s behaviour is a mental phenomenon which can only become explicable when all the forces to which he is reacting can be reasonably appraised. Most of the situations require adjustments in the surroundings in which the child passes his days, and of these the home circle usually exercises more influence than does the school, if only on account of the longer period during which it is in action. Many of the difficulties have arisen in early life. Often efforts at adjustment and re- education in the home circle prove of great efficacy for the welfare of the younger members of the family than for the subject on whose behalf they were originally undertaken.
These specialised varieties of social work require a special technique and, in consequence, it is eminently desirable that the workers should have special training. Such courses of training extending over a period of one to two years. The use of actual case records for demonstration and discussion in place of more formal sets of lectures is a characteristic feature of the instruction in the American schools and presents many advantages in the way of clothing the dry outlines of theory with the interest that arises from direct human contact.
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