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Facilities for the care of crippled children in British Columbia Kinnaird, Ellen Anne Stewart 1950

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FACILITIES FOR THE CARE OF CRIPPLED CHILDREN IN BRITISH COLUMBIA by Ellen Kinnaird Thesis Submitted in Partial Fulfilment of the Requirements for the Degree of MASTER OF SOCIAL 10RK 1950 The University of British Columbia A B S T R A C T The aim of this study is to discuss the existing facilities for the treatment and care of crippled children in British Columbia with a view to determining those a.spects in which adequate coverage is given and those in which lacks exist. To con-sider that the crippled child will receive a l l the necessary bene-fits from maximum physical treatment, is to ignore al l the other parts of his personality. Social work philosophy recognizes that care and treatment of anything less than the child's whole person-ality is to deprive him of his right to become a valuable and con-tributing person to his home, family and community. The method used has been to trace in a descriptive manner, with some analysis of the present program, the development of- the chief facilities existing for this purpose up to the present time. The study attempts to illustrate the resources available today and the philosophy which forms an integral part of the pro-gram in the various institutions. It is noted that there is a growing acceptance generally of the contribution which social work theory and philosophy can make in assisting the child-patient to adjust to treatment and living away from home. The study uses a recognized authority in the field of planning for handicapped children, as a frame of reference. The criteria", outlined by this authority show more clearly the positive and negative aspects of the present program and the effects of the latter on the crippled child. General suggestions are made to assist in developing, through the co-operation of a l l the professions concerned, - a pro-gram under which every crippled child in British Columbia may be assured of his right to a useful and happy l i f e . i TABLE OF CONTENTS Chapter 1. The Rights of Crippled Children. Approach to the subject. Types of condi-tions discussed. Social Aspect. Chapter 2. Out of the Past. 11 A summary of the Children's Hospital up to the present. Queen Alexandra Solarium from the beginning. Chapter 3. Long-term Hospital Care. 21 Location and staff of the Solarium. Main-tenance. Referrals and eligibility. Beds and f a c i l i -ties. Classification of cases. Brace-making. Adjust-ment of the child. Contacts with the parents. Dis-charge and after. Expansion. Chapter lu General Hospital Care. 31 The Children's Hospital. Staff, referrals, and eligibility. Treatment and facilities. Discharge and follow-up. Out-patient department. Spastic Unit and the child with cerebral palsy. Other general hospital care. Chapter 5>. Clinical and Other Facilities. U3 The Health Centre for Children. The Travel-ling Clinic. The Junior Red Cross Society. Chapter 6. Rehabilitation and Training. $0 Facilities and treatment. Plans materiali-zing. The Vocational School to be opened. Chapter 7. Review and Action. Comparison with standards set up in United States. Need for personnel. Lack of statistics. Lack of facilities for special cases. Case finding. Co-or-dination and indexing. Educational Facilities. Rehabi-litation. Chapter 8. To Fulfil the Rights of Crippled Children Co-ordination. Private agencies under, a government program. Expansion of physical facilities. Provision of educational facilities. Rehabilitation and employment. The social aspect of the child himself. CHAPTER I THE RIGHTS OF CRIPPLED CHILDREN "Every crippled child, irrespective of race, colour, creed, or the financial sta.tus of its parents, has the inevitable right to the best and earliest pos-sible treatment, the best training which modern voca-tional guidance can give and an education to f i t him or her for self-support either wholly or partially. 1 , 1 This credo was set out in the annual report of the Crippled Children's Hospital for 19hk, but i t was the belief in these rights of crippled children which has been behind a l l the history of the Children's Hospital (formerly the Crippled Children's Hospital) in Vancouver, and the Queen Alexandra Solarium on Vancouver Island. These two large institu-tions provide care and treatment for crippled children throughout British Columbia; other programs and institutions in other provinces and countries have also been founded as a result of the belief of the people in these rights. In the beginning, services in the Children's Hospital were avail-able for those children who were so crippled that they were unable to work or co-ordinate their movements; but, as the change in the name of the hospital suggests, there has been a. broadening to include a l l disabilities of children. This has reached the point where, for purposes of having a l l crippling conditions reported, the Dominion Government has defined the term "crippled child" to mean a person not over twenty-one years of age who, because of disease, accident or inherited defect, is restricted in his normal muscular movements. However, many conditions included in this definition dor not result 1. The Crippled Children's Hospital, Annual Report, 19UU, p. Ii. 2. in the same social problems for the child or his family which are brought about by the loss of the power to move freely; for example, deaf and blind children, although i t is true that their incapabilities are no less serious than the others, are not prevented from moving around and so are not com-pletely helpless. With adequate training they often become quite self-sufficient in their sphere. "Where the conditions are amenable, i t is usually not a long protracted treatment which is required, but a series of operations lasting for a definite length of time. The diabetic, except when he neglects fo follow the doctor:!s orders, is able to do as much for himself as a normal child; the epileptic child likewise is able to carry on alone much of the time without fear of a breakdown i f he follows the doctor's orders. Even the child with rheumatic heart disease is assured of being able to stand on his own two feet i f necessary, and he is free to move his body within certain limitations. Other conditions included in this definition do not set the child apart too much from his friends; while he is receiving treatment to cure the condition, he is able to adjust to his circumstances in the manner of other children. Among these.could be listed such deformities as flat feet, knock knee, posture defects, hare lip, and so forth. S t i l l others are crippling or disabling for a time, but respond to surgery; and an acute illness hospital can be used in the treatment of these cases. All these conditions may cause a poor social adjustment to be made on the part of the child; because of this they a l l require early treatment, and the best of education in many cases. The dictionary definition of a cripple is one who limps or who has been deprived of capability for service. It is to the facilities for the care and treatment of these cases that the present study is confined, for three reasons. In the first place, for many years crippled children have 3. been obvious for whom facilities were more readily provided, because their handicaps were plainly visible and a medical diagnosis was not necessary to inform others that there was a need for help of some kind. Secondly, crippling conditions require not only intensive and prolonged medical treatment, but because of this protracted treatment, provisions for educa-tion and social adjustment must be made. Finally, because of their appearance and behaviour, some crippled children, whether undergoing treatment or not, are unwanted by playmates of their own age. Indeed they are frequently unwanted even by their parents, who, because of the emo-tional and economic strain of raising a family, find that they are unwill-ing or unable to rear a crippled child. Accordingly, four sets of crippling diseases are to be included. While these do not include all that could be listed under each separate cause, they do include those which result in the serious crippling of the limbs or other parts of the body to prevent free movement: 1 . Conditions due to accidents, including amputations, burn contractures, and nerve injuries where loss of movement is incurred. 2. Congenital malformations, from which stem such defects as club feet and dislocated hips. 3. Diseases of the nervous system and sense organs, which are responsible for the development of cerebral palsy and poliomyelitis. ii. Diseases of the bones such as tuberculosis of the bones and chronic osteomyelitis. These diseases all have in common the need for a long term of treatment, followed by an even longer convalescence, which increases the complexity of the' problems in treatment, so that facilities must be made available i f these children are to be given a normal l i f e . Certain facilities are fundamental to any program for crippled children, but they may, of course, h. be modified or extended in relation to problems arising in particular localities. People generally are aware of the most necessary services required, and many people, without studying the question further, believe that i t is sufficient to establish hospitals. Although few in number in British Columbia these have been established; but from their work with cripples there has emerged an awareness of the cost and drawbacks of long hospitali-zation. Consequently the aspect of prevention along with treatment outside hospital has been emphasized, with the result that out-patient clinics have grown up along with the hospitals for those who are able to live at home while undergoing treatment. However, these alone a r e not satisfying the needs, and i t has truly been said that the process of meeting ifcBe needs of orthopaedic cases shows that these children may present a wide variety of problems. Their problems may be related to the disability and to medical treatment itself, to personality development and social adjustment, and particularly in cases of congenital deformity, to family relationships. Ihere the patient's needs are complex the helping process is likewise a complicated one. It may involve intensive casework treatment, utilization of community resources, and close co-operation among a l l the professions 2 attempting to meet the child's needs. In addition to the problems of lengthy hospitalization and its effects on the child and the family, the cost of this hospitalization to the family and the community, and the difficulty of bringing children regularly to out-patient clinics, there is the cost of providing the child with suitable convalescent care and the decision as to whether this need 2. Florence Levy, "Meeting the Needs of Orthopedici Children", The Family, XXIII, May 19U2, U25. 5. should be met by the provision of special institutions or foster homes or a combination of both systems of care. Very similar to this, also, is the need of suitable accommodation for children who are diagnosed as incurable, who because they become too big to be handled by the parents, require care outside the home on a somewhat" permanent basis. The same question arises — s h a l l these children be placed in institutions without respect to their capabilities to enjoy l i f e , or is there some way in which they can live within their limitations, away from their homes and. s t i l l have some pleasure? If a l l these problems could be solved so .that there would be sufficient bed space for the children requiring i t , clinics to care for those who remain at home, and foster homes or institutions for those who would be out of place in the others, with the best medical care provided, a crippled child s t i l l could not be fully assured of receiving his rights. In obtaining adequate medical care i t is important not to lose sight of the fact that, for the child to adjust in the most suitable way, his mental and emotional development must move along at least as quickly as his physical development; preferably faster, i f possible, because in many instances the necessity for him to make his own interests in l i f e , as well as to consider special employment, must be taken into consideration in his training. Thus education, recreational facilities, vocational training, and social services are necessities, not for the treatment itself, but as a founding-out of that treatment- so that the crippled child may grow into maturity with such a personality that he can accept l i f e on an adult level. The methods of education of handicapped children differ according to circumstances. For those who live at home and are unable to go to the neighbourhood school, a good correspondence course will meet their require-ments, but at the same time such a course is lacking in that i t gives the children l i t t l e in the way of social contacts. For those in hospital, there may be teachers provided who are trained to educate the children in such a way that, in spite of their physical handicaps, the youngsters find i t easy to learn because the subjects are unfolded to them as they are sufficiently mature to receive them. There has been a trend towards having hospital schools made available to crippled children living away from the hospital, and this is made possible by providing transportation to and from the hospital. This scheme has some drawbacks but does offer stimulation to the in-patients from those who come in daily, bringing in with them, news of the world outside with their own young interpretation of i t . Even more perhaps, i t offers stimulation to the young out-patient as he is made aware, by visiting the hospital, of his present freedom and the privilege of having varied contacts, which he would not have i f he were hospitalized. Although nothing is mentioned in the statement quoted regarding the rights of these children concerning recreation, i t is impossible to omit discussing this important phase of care. The normal child who does not know what to do with his leisure can, at least, derive some^atisfaction merely by going somewhere and looking at things; but usually he finds in later l i f e that unless he has had hobbies and definite interests he is dissatisfied and unhappy. The crippled child, with his limited ability to move, dies emotionally i f he is left without interesting hobbies although his incapacity may limit considerably what he can do. With this in mind, one cannot help but see the absolute necessity of such a child being edu-cated to enjoy his leisure time and as much of his time as possible, i f he is completely; helpless. For many children, who are severely crippled, vocational training 7. will offer l i t t l e because of their condition, but with an educational background, many others, although seriously crippled, will be able to work i f properly trained. This training could be made available for those who could arrange to attend a vocational school, as i t is not economically sound to have such a school attached to a hospital where the desires and conditions of the patients would create such a diversity of professions to be covered. However, this is a most important part of the care that the crippled child, especially one in his teens, requires, and i t constitutes a problem in the way i t should be provided and to whom i t should be given. In this aspect of the study, there is included the whole problem of reha-bilitation of the crippled child so that he might at last be able to assume his place in the community. This entails the extensive education of and and interpretation to the community in general, as well as to the employers and people with whom the crippled child lives, so that they may understand his capabilities and potentialities in addition to something of the condi-tions which were the cause of his crippling. This leads to the trend toward prevention of these conditions. It matters l i t t l e how far advanced a program for crippled children or others may be. Unless there is a search for causes of the conditions and an ardent desire to treat as many of these causes as possible, the program will exhaust itself and leave people without the hope of a cure for a i l -ments that would respond to proper treatment. Prevention in many instances may be carried on through the existing health centers for children where they may be examined from the time they are very young and any deformities treated before they become serious. The out-patient clinics also offer somewhat of a preventive service in that the child may be treated soon and the members of the clinic can be on the watch for developments of further 8. conditions. A system of reporting by the private doctors of the deformi-ties in the new-born or young could be used to ensure that a l l these child-ren receive adequate medical care by means of a follow-up service, because frequently parents are unwilling to attend a doctor i f they are unable to meet the costs of treatment. Prevention is not easy. It means intensive work by medical men for small returns. For those who are short-sighted in this regard i t means a lot of expense for no apparent good. More than anything, the preventive aspect requires considerable interpretation £o the community as i t appears to be human to want to help that which is de-formed, but slow to move where nothing has yet happened. Finally there is always the question of cost. Hospitalization is expensive; equipment, likewise, is expensive and changes frequently with new research; to the observer, the results of treatment often appear to be so minute that he wonders whether i t is worthwhile. Where ever programs have been founded for crippled children, the cost has been met by private subscriptions and private organizations, and even today much of the cost of care for crippled children is met':.through these means. We see before us the extensive work done in the United States and Canada by private organi-zations for the care and treatment of the victims of poliomyelitis. The Shriners are famous for their hospitals for crippled children. Year after year, funds are forthcoming from the different organizations for food for crippled children, accommodation, camps for them in the summer, transporta-tion for them to and from hospitals, clinics and so forth. With the excep-tion of Britain, at present, where medical services are al l provided, and United States of America, where there is an excellent program financed by the Federal and State governments in addition to private contributions, financing is done to a great extent through voluntary means. However, problems arise in a l l areas as duplication of some services and gaps in others are apparent because of the seeming impossibility fo close co-ordi-nation between so many individual societies and donors. At the same time, regardless of how much may be planned for the crippled child with respect to treatment, education, vocational guidance, and recreation, the child's needs have not even started to be met i f he is nor prepared emotionally and psychologically to use the services available. This statement is not made without considerable thought and the fact has been proved in dealing with children in institutions of a l l kinds, as well as those in foster homes or even in their own homes. H. W. Hopkirk found in his study of institutions serving children that frequently in work with handicapped children, the behaviour problems were more difficult to solve than were the problems of their physical handicaps. Even the slight-est physical handicap assumes major proportions in a child's l i f e , and many times in an adult's, because he has not known how to adjust socially. On the other hand, children who have been brought up with severe handicaps, because they ave learned to accept their limitations, without being bound by them, have been able to move out of the family circle into an indepen-dent position in the community. This is inherent in the rights of the children, who are crippled, and points to the fact that without a good social service department, including, well-trained social workers, no matter how much planning and effort is expended in collecting funds for and setting up services for crippled children, they are being deprived of a basic right. These are the problems that generally arise for a program for the care of crippled children and the programs in different localities will require modification or extension depending on such factors as the economic stability, the geographical location and lay-out of the locality, the size of the locality, the racial origins of the inhabitants, and so on. For example, a good program for the care of crippled children in British Columbia, where there are vast sparsely populated areas would be very different from that in Britain, where the area to be served is small and thickly populated, although the fundamental requirements are the same in ' both places. However, a study of what is being done in other areas will serve as a standard to show where the program in British Columbia has gaps as,vwell as where i t is in advance of those in other places. Only-by studying the services offered in British Columbia to crippled children and the facilities through which they are offered will i t be possible to learn whether the crippled children of British Columbia are receiving "rights" in terms of early treatment, education, and vocational guidance irrespective of their background. CHAPTER II OUT OF THE PAST Just over twenty-five years ago a Women's Institute in British Columbia, aware of some of the difficulties faced by crippled children, voted a sum of twenty-five dollars to commence a fund for the building of a hospital for these youngsters. As contributions came in, arrangements were made to purchase a large private dwelling for this purpose; and, eventually in 1923 the Crippled Children's Hospital was opened to provide treatment and care to the crippled children throughout the Province. There was no way at this time of knowing how many children were in need of ortho-paedic treatment, but there was much faith in the general public's willing-ness to contribute and much hope for the future of the project, which was intended to provide adequate medical treatment for crippled children re-gardless of the ability of the children's parents to pay. As early as 1929, Dr. Erkanburg of the Seattle Orthopaedic Hospi-tal, discussing the possible numbers of crippled children in British Columbia, estimated that out of a population of 600,000 people there were probably 3,000 cripples of whom a great many were under sixteen years of age, and many unable to pay for adequate treatment. Further public support was solicited and during the years, different organizations contributed to the maintenance and work in connection with the hospital. The Vancouver East Lions Club has been a constant supporter of this work over the years, along with the Elks, Rotary, Kiwanis, Harmony Service Club and others too numerous to mention but no less faithful in their interest and support. In spite of years of depression the public interest was sufficiently great to support this needed service. Not only were individual and group donors participating but also larger civic and business groups. The 12. Vancouver Board of Education provided a school teacher; Woodwards, Clarke and Stuart, and other local business houses provided the necessary text books and school supplies. The Vancouver Public Library made books available to the children for leisure reading. It was commonly felt that, while treat-ment was most important, the search for causes and the eventual eradication of crippledom should be the foremost object of every community. A Gymna-sium, fully equipped, was provided so that the children's muscles might be given proper exercise. An important step towards early treatment and pre-vention of crippling conditions was made with the opening of the out-door clinic in the Swedish Hall where early diagnostic services and treatment were given. This clinic was the chief means of admitting patients to hospi-tal. There were no facilities for surgery at the Crippled Children's Hospital and St. Paul's Hospital staff offered its operating rooms for a l l these cases. It was possible to bring many children in from the outlying districts of the Province by the co-operation of the private citizens and the, at that time, Provincial Neglected Children's Department. Cases were brought in from almost every area of the Province and received at the Hospital. These referrals were made by Women's Institutes, medical men, individual citizens and organizations of the different districts. Until 1935, the diagnosis and causes of orthopaedic conditions present in children treated by the Hospital, were roughly divided into six classes. These consisted of deformities as a result of accidents, of infantile paralysis, of spastic paralysis, and those of a congenital nature, tubercular bone conditions, and miscellaneous conditions due to rickets, rheumatic fever, and so forth. The lean years had their effect with regard to the development of vocational training for these children, but appeared profitable as far as the obtaining of , .13. equipment and the giving of public education were concerned. By this time a hydrotherapeutic pool was built; a quartz lamp, and sun baths for physio-therapy were obtained. Public health services were used in the prevention of rickets, poliomyelitis, and congenital defects. From 1937, "at which time the Hospital was sufficiently well equipped to perform most of the surgery right on the premises, until 1939, when the war started, steady progress was made in expansion. Out-patient services were instituted for efficient and adequate follow-up care. Plans were being made early in this period for an X-ray department. The staff of doctors increased to ten in number, and the new and well-equipped labora-tories gave the doctors added efficiency in diagnostics and in treatment. Toward the end of this period, the out-patient department was moved to the Hospital; the emotional and environmental problems of the children and their families were recognized and a social worker was installed in the hospital. With this extra clinical service in addition to the social service, more follow-up work was made possible throughout the Province with old and neg-lected patients. There was continued support from the Library and volunteer teachers, from the Normal School, in addition to those supplied by the School Board, made for the broadening of the children's education. Until 19111, the Hospital grew and expanded as the needs arose and as new methods were learned. Because of its size and the extent of services, an organizational structure was created and this organization was one of the first steps to the broadening of the program to include every child regard-less of his handicap. Thus, i t was that the work was distributed into four channels: pediatrics, neurology, plastic surgery, and consultation. This appears to have been a far-sighted step and in line with some of the foremost thinking today that a l l children's handicaps should receive treatment. As 111.. new standards were sought in the important matter of keeping records, a unit system of records for Medical Social Service charts was installed along with accumulative admission records of registration, a system of summarization of charts, and morbidity records. Insurance coverage was extended to the six volunteer drivers and the system of accounting was set up for easier efficiency. Referrals continued to be received from many parts of the Province and from these a substantial number came from private physicians requesting orthopaedic information and advice. In order to cope with the increasing numbers of children needing service, i t was necessary to establish more clinics, and the number of these was increased from three to five each week. Visual and oral education of the children was instituted as a further ser-vice, the latter chiefly for children suffering from cerebral palsy. Prevention of crippling conditions was s t i l l the chief preoccupa-tion of those interested in this field, and the procedures, suggested in the Annual Report of 19U3, for early diagnosis, early treatment and prevention, are coming to pass at present. The registration of deformities at birth by doctors or nurses; compulsory registration of deformities by parents or guardians; diagnostic conferences and clinics; and legally established surveys, were a l l stated to be necessary means to the controlling of physical handicaps. However, the ensuing years brought practical means of treating crippled children in the expansion of the hospital to arrange for more beds and more equipment for thecare of post-polio victims and children suffering from cerebral palsy. Slowly, nevertheless, the Crippled Children's Hospital was becoming a general hospital for treatment of sick children up to about fourteen years of age and moving along with what is now, in many places, becoming general hospital procedure. There was the increasing 15. awareness of the need for and training of more medical social workers, so that the Hospital was used for a training center for students of social work. In 19^6, the Crippled Children's Hospital officially became the Children's Hospital, offering treatment to a l l sick children, and, by 19li8, i t was a well equipped Hospital, with an organized out-patient department, a travelling clinic to serve the rural areas, and a treatment center with a capacity of one hundred beds, a spastic unit, and forty-one specialists serving the Hospital. The second institution to be established in British Columbia in this field was the Queen Alexandra Solarium at Cobble Hill , Vancouver Island. The founding of this Hospital was the result of the feelings aroused in people, seeing children constantly being discharged from the general hospitals after the three hundred day limit, then in force in British Columbia, whether or not they were cured. Dr. C. Wace, who had been active for years in pediatrics and orthopaedics, both in Great Britain and in British Columbia, brought this problem out to the public and, as in the case of the f i r s t Crippled Children's Hospital in the Province, a Women's Institute picked i t up and decided to take action to provide some facilities for long term cases where necessary. Money was raised by the Institute to do something for orthopaedic children and the members referred their plans and hopes to Dr. Wace. The outcome was that with the limited funds given, Dr. Wace, with Sir Henry Govern from England, looked for and chose the present site, thirty miles north of Victoria, for a hospital. The limited funds, however, prevented the obtaining of expert advice in the matter of clearing the land and of building. Mr. F.C. Morris, who, i t is felt, was a conscientious-person, cleared the land and constructed the buildings. He was untrained in this type of work and there were many criticisms of the building done, but i t was felt by those interested that the need was immediate and that the facilities, though uncomfortable—the staff slept on the wards in small rooms with the doors open—and inadequate for future requirements, would not make the treatment the children were to receive less effective. Finally, in April, 1926. the Queen Alexandra Solarium Society was incorporated under the Societies Act, and, on March 1, 1927, with Dr. Wace, the founder as the medical superintendent, the first patient was admitted and there was assurance from this time on that no child who could benefit from treatment would be discharged until a cure had been made or the maximum treatment given. In addition, the principle followed in connection with the admission of patients, was that no crippled child of the Province of British Columbia, who could be benefitted by the institution had ever been, or would ever be refused admission to the Solarium because the parents could not pay for his maintenance. 1/Uhile i t was realized that the lack of funds placed limitations on the work, the question of the ability to pay was not considered when a child was to be 1 admitted. Dr. Wace was convinced of the benefit of long term care in a considerable number of crippling conditions and through the years, he him-self, gave f u l l time service to the Hospital. He himself took the children from the Solarium into Jubilee Hospital in Victoria, and i t was there that he operated on them. In addition he held clinics in the Solarium's Victoria office for crippled children. The strong motivation for this intensive work was aptly expressed in the following words and the spirit with which these words were spoken appears to he the one that pervades the work entirely: 1. Queen Alexandra Solarium, Annual Report, 1930, p.«t 5. 1 7 . "As each year passes, I realize more and more the very great importance of a complete system for the care and cure of the crippled child. Starting with prevention and the earliest possible recognition and notification of crip-pling conditions, onward through treatment, whether operative or mechanical, education, aftercare, and technical training, a prolonged, but inevitably prolonged, of physical and psychological care is absolutely necessary i f we are to reap a real permanent, individual and economic reward." Knowing that the children had an emotional side to their personali-ties, Dr. Wace was aware that with uncomfortable casts and splints, they would not be able to make quick progress toward recovery. In order to in-sure that the children would be supplied with the most efficient and comfor-table casts and braces, he sent his daughter to England to learn the celluloid type of splint work. He had already had orthopaedic training and together they taught the art to men to whom Mr. Morris, the contractor, apprenticed himself, and he in turn taught i t to an old ex-patient, who carried on after Mr. Morris died. As a result of this innovation on the part of Dr. Wace, the splint shop was established and developed. In the early years of the Solarium1 sJ.history, the School Board supplied two teachers to undertake the education of the children. In addition to the academic work, the teachers instructed the children in leather-work, handicrafts, and generally helped with their entertainment. In the setting there is ample play space in a sheltered setting. Every facility was conscripted for the children's benefit. The tennis court was used for physical training classes in the morning by the physiotherapist, and during the rest of the day for recreation. Interested citizens con-ducted Girl Guide and Boy Scout groups. Another section of the people co-operated to provide moving pictures for the children. The children who were physically capable, could move around in the one-storey building • - 18. freely on their crutches and in their wheel chairs. Radios were donated for the youngsters. To foster the idea and to relay i t to the children that they were human beings requiring some help but capable of much inde-pendence, camps were established on the grounds during the fine weather. More donations were made from time to time, and seven years after receiving its f i r s t case, the Solarium provided X-ray treatment, laboratory, physiotherapy, diagnostic and consulting services which were considered to be among the best available by those in charge. Much of the success of this work was due to Dr. Wace's interest in the problem, an interest which was so great, that in 193U, he had been sent through the Province by the Provincial Government to advocate the importance of immediate attention to ailing children. The questions raised during this tour were in connection with the number of children needing attention, adequacy and efficiency of the institutions concerned. He found that further facilities were required. In addition to those services mentioned, surgery was performed at the Royal Jubilee Hospital, Victoria, and clinics were s t i l l held in the city. Later, and s t i l l through donations, an isolation unit was provided and furnished, equipment for electro-therapeutic work was installed, an ambulance was made available to take the children to Victoria, a new dental treatment room was built and equipped, improvements were made in the splint shop, new wheel chairs were provided, and so forth. All through the development of the Solarium,, two main attitudes have been apparent on the part of those responsible for its operation. The fi r s t lies in what was to be the function of the Solarium. Was hospital care alone what these children required? Should hospital routines and techniques be carried out? The attitude of the staff was that the Solarium was not to be a hospital only, but was to be the home of these children until they could return to their own homes—a home in which they would be allowed 19 . as much freedom as possible to grow and learn, to make their mistakes and experience from them, and to make friends. The fact that a child was more than simply a crippling condition was recognized and an effort was made to understand the children's emotional needs and to allow them the stimulation and satisfaction necessary for their growth. The second attitude is also in connection with the function of the Solarium. It had been established originally as a center for long term treatment. There was no rush to discharge a patient before he was ready to leave, although i t meant that a child might be a patient for many years. The original function had been maintained, but some difficulties arose be-i cause of the fact that i t was here only that a patient could remain for what may have seemed an indefinite period. There were children with in-curable handicaps that offered no hope with treatment, and as there were no facilities for looking after these children, their admission to the Solarium was often sought. However, i t was felt that the most expedient plan was to continue to admit children only who would benefit from treat-ment. This attitude was maintained for two chief reasons, namely, to ensure complete treatment for the child when prolonged treatment was required, as well as to relieve his family of the almost Impossible burden of maintain-ing him in other institutions. A limited amount of out-patient services were provided since the opening of the Solarium but these were not extensive, partly because of the small staff and partly because of the distance of the Solarium from the larger cities. The Children's Hospital and the Queen Alexandra Solarium, then, are the two main institutions for caring for and treating crippling condi-tions in British Columbia. Both were started for the same reasons and 20. both have grown and developed in spite of a depression, which decreased their income substantially, and a war, which decreased the staff and equip-ment needed for this work. Other facilities for the care of crippled children are available now, which supplement the institutional services given, and the plans suggested so long ago by these "voices in the wilder-ness" are again being picked up, with the object of bringing them to pass in the near future. CHAPTER III LONG-TERM HOSPITAL CARE The Children's Hospital and the Queen Alexandra Solarium have been nearly twenty-five years in their development and, today, are the two main institutions for the care and treatment of crippled children in this Province. However, since the end of the War, the suggestions of many years past, have ; again been taken up and concentrated efforts are being made to formulate and carry out a more complete program for the children's care. The prohibitive cost and the effect of long hospitalization on the child has resulted in more clinical work than ever before being done. At the Children's Hospital there is an out-patient department serving hundreds of youngsters, while the Health. Centre for Children, ( a part of the Vancouver General Hospital) also makes treatment available to out-patients from a l l over the Province. The only institution, as was previously noted, offering long-term care for crippled children in British Columbia, is the Queen Alexandra Solarium, which is situated in a semi-isolated site on the sea-shore about thirty miles from Victoria. Dr. Glenn Simpson, the Medical Superintendent and Pediatrician, whose services are voluntary, is in f u l l time attendance at the Solarium, but is not resident there. Dr. Starr of Vancouver, and Dr. Stark of Victoria, perform the orthopaedic surgery. A dental surgeon, Dr. W. N. Westwood, was placed in the Hospital by the Victoria Dental Association. In addition, there are eighteen medical men, each a specialist in his own line, to serve as consultants. The nursing staff consists of the Lady Superintendent, Miss S.D. Andrew, R.N., six graduate nurses, nineteen nurses' aides, one laboratory technician, one X-ray technician, one physio-therapist, a dietition, a full-time bracemaker and an assistant bracemaker. The Solarium has received provincial and municipal grants during the past few years but the bulk of the income and improvements are donated by private organizations and individuals. The Queen Alexandra Solarium Junior League and its affiliate in Vancouver, the Thetis Club, have under-taken as their chief projects to raise funds for the further equipping of the Solarium. The donations are received from many business firms on the Island as well as from those on the lower mainland. • 'ICot donations" are solicited, that is, the sum of $250.00 given toward cot maintenance in any one year. For those who cannot afford to give this much, other suggestions are made for smaller amounts, such as $2.00 to supply a pair of crutches and $5.00, a brace for a child. There has been a steady and consistent effort on the part of private citizens and organizations to keep the Solarium operating and this is certainly shown in the fact that the turn-over of funds in 191+7 and 191+8 was well over the $130,000.00 mark. The members of the Women's Auxiliary who have been working for the Solarium children since 1926, make clothing for the children from materials purchased with the proceeds of various functions. The Solarium, i t is well understood, is primarily a charitable institution, to enable the children of parents in poor or modest circum-stances, to receive the long course of treatment necessary for the cure of bone disease and for the victims of infantile paralysis. A man earning $100.00 to $150.00 pennmonth cannot pay $1200.00 for a year's treatment 1 for his crippled child. Not only is treatment at the Solariumi available 1. Queen Alexandra Solarium, Annual Report, 191+2, p. 5. 23. to the crippled child, but also to the child suffering from other handicaps such as asthma, eczema, rheumatic heart disease, and others. Referrals are made, for the most part, through the doctors, but in many cases, well-infor-med people who are aware that the local physician has been supplied with application forms,inform the parents of this resource. Further referrals are made by the different branches of both departments of the Health and Welfare Branch of the Provincial Government. Children are accepted from infanthood up to fourteen years of age, i f girls, and up to twelve years of age, i f boys. However, i f the child was admitted before the age limit and treatment is required beyond the age limit, arrangements are made for the treatment to be completed at the Solarium. The hospital, itself, is a bright building of one-storey, to f a c i l i -tate movement, with a bed capacity of seventy-five. However, during the winter months, i t has been found that more efficient service is given with a population of nearer to sixty-five children. The beds are regulation hospital type and, during the summer months, are easily rolled out onto the ramp which runs along in front of the wards. The wards each contain several beds and the children are placed according to their age, physical condition, temperament, and treatment required. In the small children's ward the furniture, tables, chairs, and cupboards are made for the young-sters' comfort. The furniture becomes gradually larger in size according to the size of the children in the ward. Dining room furniture for those who are able to move themselves to the dining room, is built so that the children can move into the chairs with the greatest ease. In 19U6, Dr. Glenn Simpeon, Medical Superintendent, was requested to make a study of the possibility of the co-ordination of services for physically handicapped children in British Columbia. Miss Andrew, the 2k. Superintendent, in order to make the study as worthwhile as possible, started with the name of the fi r s t patient admitted to the Solarium and worked out a classification of the children's handicaps, that permits her to give much information at a moment's notice. These cards give the causes of the handicap, the treatment received, and the results of the treatment. From 1928 to 19U3, i t was found that ninety-three children, crippled from infantile paralysis, had been given treatment; in the same period of time, ninety-six cases of congenital club feet, and one hundred and forty-one children who suffered from chronic, crippling, and allergic conditions had been treated. The Solarium is becoming increasingly well-equipped to give treatment in most areas with the exception of surgery. Surgery is s t i l l performed in Victoria at the Royal Jubilee Hospital, which means a trip of thirty miles each way for the child. Of considerable interest and advan-tage is the method of providing celluloid splints, which are made right at the Solarium. The man who is in charge of the brace-making at present was one of the fi r s t patients at the Solarium and s t i l l wears a jacket. The splints and braces are made over moulds taken off the children's body in plaster of paris. The maker is well aware of the discomfort suffered by the wearing of the old heavy braces and jackets, and for this reason, takes a keen interest in the work. The celluloid braces are light, f i t the body snugly, cause very few sores, and are airy. Built-up shoes and other like equipment, are made in this shop, also, for the patients, as well as for those outside the hospital who require them. Mien the staff was fi r s t planning the procedure with the children, i t was necessary to make one of two choices: whether the routines should be those of the hospital or, whether the Solarium should, indeed, be a home 25. for the child. The latter course was decided upon with the result that the children seem to have a sense of belonging, a sense of loyalty to the . institution. The youngsters are encouraged to take early responsibility for themselves, to accept their condition and to work within their limita-tions . The result, on seeing the youngsters who are under treatment, is that they appear to be happy children with no trace of illness. At the time of admission, there is a feeling of strangeness as the child is placed in the isolation ward, a ward of twelve beds, for the f i r s t two weeks of his stay, so that he can be observed by the staff, as well as to prevent him from spreading any infection he may have had at the time of his admission. Although this would appear to be a very difficult time for the child, some of the problems are alleviated as the nurses and staff get better acquainted with him, and he in turn, forms new and pleasant rela-tionships. Although the facilities for rounding out the child's personality are not of the latest quality or most abundant number, every possible opportunity is used. The children's education was considered to be a very important part of their training, in part, because numbers of children will be bed-ridden or at least sedentary for a good part of their lives, and the ability to read opens new vistas to them. The Department of Education has supplied three teachers for the Solarium. The children who can, sit up at tables, and the class is centered so that those who are bed-ridden can attend. Some of the difficulties in keeping the children up to the level of the children outside the Solarium arise because, for one thing, the greater number of these children are in need of rest, which results in shorter hours of lessons. In addition, the children have l i t t l e possibility of being permitted to do homework or outside study along with 26. their lessons. There are no cupboards in which they may keep their books and supplies, which are stored in separate bags in the teachers' room. Thus- even i f an older child desired to read his books while lying down, he would not be able to get them. It has been proved unwise to leave the books around loose because there is a tendency for them to be torn. As part of the educational program, the teachers instruct the children in handicrafts. Most of the children take an interest in this work, but the same drawbacks are met as with the school books; there is no locker where the child may put his work. The girls are taught to knit and sew, while the boys, as well as the girls, are instructed in leather-craft. There is a library of books for the children to read at leisure but, as the case is usually in regard to donated books, many are out of date, and unsuitable for the children to read. There are few, i f any, books that would interest a child in handicrafts. Some years ago the teacher at the Solarium brought out the thought that in the Bpecial Schools in England, which include day and residential schools for physically defec-tive children, blind, deaf and dumb, and mentally retarded, that handiwork was an essential aid toward the development, and even the cure of these children; particularly the spastic cases, and others which have their 2 origin in brain disorder. It was realized then at the Solarium that, although i t was an impossibility to make a training center there, the children would some day be called upon to take their place in the world, and that some might eventually find a vocation mf a wide range of handiwork subjects was offered. 2. Queen Alexandra Solarium, Annual Report, 193li, p. 5. 2 7 . Much of the time that is not spent by the child in receiving treatment or education, is available for recreation. It is difficult to ensure continuous entertainment in an isolated situation, such as that of the Solarium, and the children must make some of their fun themselves. However, for those who are bed-ridden, and for the others i f they wish, there are radios available, and these children, as any children, have their favourite programs of which they are very fond. There is a moving picture show every week, and the beds are rolled in for this. Other inside recreations include parties and do's held for the children by outside organizations, often on their individual birthdays, and nearly always on the different holidays. The facilities for outside recreation are good and include, beside swings, teeter-totters, slides, a salt water pool, and a pool in which the children may wade. The setting of the Solarium is good as far as the out-door activities are concerned. There is sufficient space and forest to challenge the children's imagination, and to spur them on to their limit physically. Through the Girl Guide and Boy Scout organizations, to which many of these children belong, they are taught to shift for them-selves in the woods, how to help look after others, and to participate in an organized group activity. Because of the distance from the rest of the Province, and the time and expense involved in making a trip over there, many of the parents are unable to visit the Solarium or the children. Efforts are made by those in charge to keep the parents of a l l children informed, with regard to the children's progress. The parents are free to write to the Institution at any time for information, and an effort is made to keep the parents inter-ested so that i f , after the children are discharged, any complications should arise, the parents would move quickly to obtain further treatment. 28. The children who are able to write communicate with their parents by-letter, and the receiving of letters means much to them. After discharge, apart from those who live near-by on Vancouver Island, there is l i t t l e follow-up work done. The staff has always been happy to have patients return when necessary, because i t is apparent in these cases that close attention has been paid to the child's physical condition. It has been realized for many years that there should be a travelling clinic to cover the outlying districts in the following up of cases. Added to this, there i s no organized out-patient department, and i t is in this area, perhaps, that the.location of the hospital might be criticized. To have a satisfactory out-patient department, there must be a number of patients living close by, with an adequate foster home program to accommodate those children who must come from a distance. The distance from a medical center is also a drawback that is becoming more of a prob-lem, especially in view of the fact that a medical school has now been opened at the University of British Columbia. The doctor, who f i r s t re-ferred the patient to the Solarium, is notified when the child returns home, but from that time, the parent is responsible for taking the i n i -tiative to see that the child receives adequate medical attention. Often in poor and border-line families, funds are not laid aside for this pur-pose, and as a result, the child may have a set-back or a new development in his condition, and have previous treatment invalidated because he does not receive the necessary additional treatment in time. From the point of view of the social worker, the interest lies not only in the fact that the child is offered treatment, but also in how the child as a whole reacts to his illness; what his emotional problems are; how they are being met; at what place he wil l be in his adjustment 29. when he leaves the institution, and how he has been prepared to face l i f e as he returns home. There is no social service department at the Solarium and the result is that there is no person available who has been trained to understand the children's reactions or the reasons for many of their actions that appear to be so out of place and uncalled-for. It has been mentioned that unless the child's home is near, his parents do not usually visit. This means that a child who has already suffered separation from his playmates because of his handicap, must face, with adult maturity,, the further separation from his parents and siblings. It has been reported that children who have been admitted to the Solarium, for example, suffer-ing from asthma, have responded quickly to treatment while in hospital only to suffer a further breakdown when they return home. At present, the child does not obtain complete benefit from hospital treatment when, in many cases, he returns to the environment that was a major factor contribu-ting to his condition. The same principle operates, although not so plainly, in crippling diseases and the lack of a social service department means that the utmost in treatment cannot be given to the child because there is no social worker to help the child to accept hospitalization, to work through hisproblem, and to ensure him proper care after discharge. Very careful and skilled planning is necessary to prepare the child for discharge, to prepare the parents or foster parents for his coming, and to refer the case to the proper social agency, so that the work might be carried on with the child and his parents and siblings as long as i t is needed. It is only in this way that the child will respond to the greatest extent to treatment. There is much discussion, at the present time, in connection with the expansion of the existing institutions to meet the needs that will be 30. uncovered by the British Columbia survey, now in operation. After much careful thought by the Board, the staff, and those interested in the Solarium and its work, i t is their opinion that some of the needs could be met most satisfactorily by extending their program to include adolescents over the ages of twelve and fourteen years. An alternative would be to expand to take incurable children, but this would appear to be another problem altogether. There is much feeling in many places in British Columbia regarding the total absence of facilities to care for incurable children, but to incorporate this group into the present set-up of the Solarium would be to f i l l most of the beds available now for long term treatment, and taking in incurables permanently. There is a considerable interest in chronically handicapped children who require hospital or insti-tutional care, and there is a willingness in evidence to make arrangements i f possible, for them, as soon as the present program is geared to serve children who require active treatment, from babyhood through adolescence. A further matter for discussion is the part that the government will take in helping in the expansion of the facilities. The opinion held by several people is that, i f the Government participates, the Solarium will be taken over and that policies will be dictated. It is possible to see how great are the numbers of contributors to this Hospital, and its work, and the fear that these contributors would be denied the satisfac-tion that they receive from giving, should not be taken lightly. This is a very real problem that is being faced by the Solarium at this time. CHAPTER IV GENERAL HOSPITAL CARE In contrast to the long-term treatment services given at the Solarium, the Children's Hospital (for sick and crippled children), lo located at 250 West 59th Avenue, Vancouver, B.C., has in the past years extended its services to become an acute illness hospital for children. It is supported as other general hospitals are, by grants and payments from the Hospital Insurance Commission at current rates, which entails the discharging of patients within a maximum period of ninety days. The two institutions, though starting from almost common sources and only four years apart, seem to have followed very diversified paths. However, the need for long-term care for many children is extremely serious and the Solarium is meeting this need within its limitations. The Children's Hospital, situated as i t is in a heavily populated area, has emerged as a general hospital with government support to serve a l l children. It would almost seem that private contributions and drives for funds would be no more necessary for this hospital than for any local hospital, but this as-sumption is based on the opinion that only hospital services are given, an opinion which is quite out of line with reality. A greater part of the population is served now through the out-patient department of the Children's Hospital. Further, a travelling clinic has been established to go outinto the province, thereby reaching a maximum number of children and finally, the services of a school for cerebral palsied children, as well as a. dental clinic for a l l children attending as out-patients, are offered to the children of British Columbia. Hospital Insurance does not cover the costs of these services or of capital 32. expenditures, and the choice was made to extend the services into these specialized fields with the voluntary contributions, rather than to use them for the maintenance of hospital facilities only. As the picture of institutional care is completed for this Province, then, there are two institutions, the Solarium and the Children's Hospital, which both offer treatment and care to orthopaedic cases. The Active Staff at the Children's Hospital consists of forty-one specialists, while the Visiting Staff is made up of sixty-one specialists. There are thirty-six graduate nurses, some of whom, have special training in children's care and treatment. Five dentists donate their time to the care of the children's teeth. A physiotherapist, laboratory technicians, three school teachers, a speech therapist, an occupational therapist, and nurses' aides, and orderlies complete the staff. INhile an occupational therapist is made available for the spastic children, occupational therapy to the in-patients is given by the teachers as part of the educational program. Until last year there was a medical social worker on the staff. The social service department is a definite part of the hospital, but no social worker has yet been obtained to f u l f i l the function of this depart-ment. Under the new regulations, children coming into the hospital as in-patients for treatment, are a l l covered by Hospital Insurance, and the services of the hospital are made available to a l l children up to fourteen years of age, without regard to how high or low the parents' income may be. However, the services of the out-patient department are available to those children whose parents' income is too low for them to meet the cost of having the child treated by a private physician. All cases are referred to the Pediatric Clinic by their family physician, public health nurse, or 33. social service agencies, including Metropolitan Health, Children's Aid Society, and Catholic Children's Aid Society. The Children's Hospital itself is a two and one-half storey building situated in a quiet area of town, but not too far away, and close to a school. Clinics are held in the basement rooms, where there are also facilities for physiotherapy, hydrotherapy, laboratory work, dental treatment, and a school room for spastic children. Hydrotherapy is made pleasant for the children and re-laxing to their bodies in the modern indoor heated pool, into which the nurses can lower the youngsters on stretchers. Administration offices, wards, an occupational therapy room, and operating rooms are located on the upper floors of the building. There is •> modern and up-to-date equipment for the treatment of most children's sicknesses and handicaps apart from those for orthopaedic cases. Some splints are made on the premises. The atmosphere of the wards is more or less that of a hospital, but i t must be remembered that the average patient stay in this hospital is in the neighbourhood of fourteen days. There are one hundred beds in the Children's Hospital, eighty-three of which are available for a l l c ases of illness, whether acute or of longer duration; none of these are set aside for special use. In the summer time, most of the beds are tolled out to a ramp on the southern side of the hospital. When the child is able to study there are two teachers available for in-patients, supplied by the School Board, and these teachers work fu l l time in the Hospital, but are part of the staff of a nearby public school. The children's work is kept up as much as possible always keeping in mind that though the youngsters are incapacitated in hospital, they will be returning home and to school, and i t would be a negative treatment that would allow them to return to their playmates with the experiences they 3k. have gone through affecting them, and far behind in their school grades. Many of these children do not face the difficulty of a long adjust-ment in hospital, and many of those who are in-patients for several weeks are not cut off from their relatives and friends. Part of the day is spent with relatives frequently and this takes the place of recreation for the child. Where the child is able, or requires, for physical reasons, to use certain hand movements, facilities for occupational therapy are provided. There are numbers of handicrafts offered: making stuffed j animals, leatherwork, art and painting, weaving and others. For those who are interested in reading library books are available. Perhaps one reason that the children's adjustment in hospital is made easier is based on the fact that when the hospital i§ fully staffed the social worker is there to help with family relations, referrals to other agencies for service, to give the child the reassurance and help he might need with his emotional problems. This department facilitates the movement of the patient into and out of the hospital. As a result, when i t is necessary for a child to be discharged either to his own home or to a foster home placement, the parties concerned are prepared for any prob-lems that might arise and are, therefore, apt to be less upsetting to the child. After discharge, follow-up work is continued and those crippled children who require out-patient care, and are eligible, can carry on there. For those who return home to localities near the hospital, visits to the out-patient department may be arranged as necessary. To meet the needs of those who have returned to distant parts of the Province, there is a travelling clinic provided. Full records of a l l cases are kept for quick referral when necessary as well as for the basis of a study of 35. children's diseases. These services are available to a l l sick children and will be discussed along with the wing constructed for the treatment of children suffering from cerebral palsy who are of interest in this thesis. The out-patient department holds clinics on different days for the treatment of different conditions. Pediatric and orthopaedic clinics are held on the same day so that specialists in both departments are available for the examining of patients. The medical record of each patient is con-fidential, and includes a comprehensive and detailed history of the patient. A complete report is made by the specialists of each child examined and as intimated previously these records are of value as a cumu-lative history used during during treatment of patients, and i f and when they return to hospital from time to time for further treatment. Records of this type are frequently responsible for the advance of medical science. During the past year the number of out-patient visits was nearly twelve thousand while the daily attendance at the spastic unit was over two thousand. Dental treatment is carried on for in-patients after their dis-charge, at the clinic. A plan is being made to make available complete orthodentic services and this is important from the point of view of the wider definition of the word "crippled" which includes malaclusiori, a con-dition requiring expert service in this line for its treatment. Physio-therapy, hydrotherapy, and speech therapy are offered to a l l out-patients but i t is necessary to narrow the scope of the work to meet the needs of those cases being discussed, namely, orthopaedic and cerebral palsies. In 19U7, British Columbia's f i r s t spastic unit was established at the Children's Hospital. According to Dr. C.A. Ryan, cerebral palsy is generally the result of a birth injury, the result of minor or major brain 36. hemhorrages at or after birth. Cerebral palsy does not only affect the motor areas of the brain, but may occur anywhere at a l l in the brain. There are tests to show just what area is affected but in the case of in-volvement in a sensory or thought area there is difficulty in picking out the area. Where there has been definite damage done to an inaccessible part of the brain there is difficulty in correction. A hemorrhage to the brain always leaves a small scar tissue, and because the arteries in the brain are generally end arteries, a small shut-off will destroy the part of the brain supplied by that artery. Treatment, then, is concerned largely with the problem of making these children self-sustaining and not a burden on the family, by re-educating a different group of muscles to perform the same function by picking up an accessory tract in the brain whereby impulses may be carried around these small hemorrhages, so that the child may function in a normal manner. The children suffering from cerebral palsy are brought daily through the week to the hospital in a station wagon, manned by a group of volunteer firemen, who help the children just as much as is required, but allow them, at the same time, to move as much as possible on their own. The children arrive at the hospital by nine o'clock each morning and they are encouraged to do everything they possibly can for themselves. During the mornings they are taught by a teacher supplied for their education by the Vancouver School Board. Whereas nine of the thirteen spastic patients attend the school at present, because of the individual attention required by spastic children, a teacher is not able to teach more than six children at any one time adequately. The school room is a large room equipped with collapsible desks and furniture well-suited to the requirements of the spastic child. The teaching-training program is extremely individualized 37. because of the great difference in the capacity of each child to do things for himself. In order to meet the needs of the children in part, the teachers have ingenuously devised varied gadgets so that the spastic stu-dents may learn to hold objects and so forth. For example, i t was a phy-sical impossibility for many of these children to pick up a pencil, but by attaching a small rubber ball over the eraser end of the pencil, manipu-lation was made easier. The trouble that the children had in drinking their milk because, when they raised the glass to their mouths, their hands shook so that the milk was mostly spilled, was overcome by covering the glass and having a lip put on the side. Nov/, regardless of how much his handltrembles, the spastic child is s t i l l able to drink his milk.with-out assistance. For those who cannot write at a l l , a special typewriter with large letters is provided. The class ranges in age from seven to about fifteen years, and in school experience, from kindergarten to grade eight. In the school the emphasis is on having every child do things for himself and making every effort within his capabilities, remembering that development comes from within the child himself, the ability arising from the child's own efforts, but assisted by those in charge of the Unit. Dr. Ryan, mentioned above, has explained that the earlier the start of re-education of a group of muscles or nerve tracts, the more favourable is the prognosis. At three or four years of age some direction could probably be given in the use of muscles but this would require the establishment of special kindergartens. Because of certain limitations in his mentality that prohibit normal experiences, the spastic child misses these experiences and i t is felt that a proper kindergarten could give them to him. As a result of the lack of experiences the mentality of spastic children is lower than that of normal children of the same age, and their schooling must be curtailed. Any child who has had cerebral palsy is extremely vulnerable to fresh experiences and strangers are unable to work with them. Their concentration is so extremely limited in some cases, that the children cannot be handled adequately as a group; many of them, indeed, would require individual cubicles to keep them from being distracted from outside. During the day the patients receive treatment and the therapy prescribed. Speech therapy is an important factor and may include anything from imitating the noise of a motor boat, in order to form the putt-putt sound, to blowing horns and bubbles. Speech disorders are frequently the lolling type. Sounds that require the lifting of the tongue are defective and the essential task is to free the tongue from its tendency to move in conjunction with the lower jaw. Breathing exercises are also given. Chil-dren in need of physiotherapy, after examination by the::specialists, are given treatment under the direction of trained personnel, while children who have never walked before, are encouraged by means of walkers, parallel bars, and special underwater exercises carried out in the hydrotherapy pool. At noon there is a lunch period during which the children's lunches are served. Again the youngsters are taught to do for themselves and i t is with many movements and great difficulties that they clear away the tables in preparation for lunch. After the meal there is a rest hour, and i t is for this that the seventeen out of the hundred beds are used._ The tables and chairs are moved and these beds can be lowered from behind the panel-ling of the walls, thus obviating the change of environment to which these patients are so susceptible. After the rest hour the periods are taken up by handicraft instruction or musical appreciation. At two-forty-five in 3 9 . the afternoon the children are ready to leave for their homes and the volunteers again are ready to help them. The approved way of handling the social l i f e of these children, numbers of whom are from homes with limited incomes, and where the parents1 understanding of cerebral palsy is not complete, is to t e l l the parents the truth about the condition, that i t is incurable, and that the efforts made must be pointed toward re-education which is a co-operative effort between the family, hospital, department of education, and other profes-sional groups. In order to educate the mothers of the children to carry out the necessary exercises and care at home, every effort is made to have the mothers attend the physiotherapy treatments with the children so that they may be aware of what is being done. From the social point of view i t is necessary that the living conditions surrounding the child be modified so that he may function up to his maximum capacity. It has been noted in passing that there is a Social Service Depart-ment at the Children's Hospital, but that there is no social worker on the staff at present. There is l i t t l e advantage, really, in telling the parents the truth about cerebral palsy, or any crippling condition, i f i t cannot be ascertained that the parents are going to accept the information given. The only method of being at a l l sure that there will be acceptance is to precede and follow this telling with a good deal of interpretation. The guilt and shame and hostility, felt toward the handicapped child by his parents, is too often overlooked, and the parents, willing to make up in any way, whether beneficial or not to the child, will often b_3 very accept-ing of anything that is said. There may be rejection of the information but this cannot be too quickly discounted either and the timesspent with the parents in working through their acceptance or rejection of the child and his handicap, treatment, and the interpretation given, is invaluable. It is not invaluable only to the parents as i t frees them from their feelings to see their child as he is, but most of a l l , to the child, as the environment in which he lives is modified, and his parents are able to allow him to grow and develop in a mature way, i f they accept him. How-ever, where the rejection has been worked through and continues, construc-tive plans can be made to remove the crippled child, who has been so un-happy, from his unfriendly environment, to one that is more friendly before too much harm has been done to him and while he i s _ s t i l l able, emotionally and psychologically, to benefit from the services available. Such service is invaluable to the hospital also because as the child is freed to accept treatment and education he responds more quickly and successfully to treatment. To believe that these social services can be carried out by members of other professions in conjunction with their own work is to believe in a false premise. Even from a realistic point of view, the doctor is unable to spend the extensive time required even i f he had social work training. The physiotherapists and others at different institutions have admitted their inability to do so. The teachers are already overburdened by their teaching duties alone and their orientation toward the children is different and for a different purpose. The result is that at the Children's Hospital where one social worker would be less than the minimum required to maintain services, there is none. This is a serious lack in view of the fact that any program offered is only success-ful insofar as the children receive the maximum in treatment and services to help in their future adjustment. Springing from the first twenty-five dollars put aside in 1923 towards establishing facilities for the care of crippled children, there hi. is now a well-equipped general hospital giving service to a l l children, with an out-patient department serving hundreds of children whose parents have not sufficient money to pay for the services of a private physician, a special spastic unit where treatment and education are available, and a travelling clinic to bring specialized services to every part of the Province. This hospital, as a result of the needs of the community has developed into a two-way institution, serving children in hospital and children in their own homes; through these channels of service there is a spreading out to meet the needs of more children. General hospital services are also offered in different hospitals on a smaller scale, but at the Vancouver General Hospital, with the expec-ted bed capacity of nearly two hundred in the Children's Ward, and at the Royal Jubilee Hospital in Victoria, where there is a large well-equipped ward for children, extensive services are offered to crippled children who do not require care for longer than the legal limit of stay in hospi-tal. The Vancouver General Hospital has developed a children's program from one that was set up originally to give care for acute illness to people of a l l ages. Because of the large numbers of children who were at-tending the out-patient department, usually on Saturdays for the most part, services were delayed. There was a growing awareness that a method of giving adequate services to the children would be to remove from the out-patient department a l l the children under a certain age and to set up sepa-rate facilities for their care, but under the one administration. As a result of this, there is now the Health Centre for Children which offers services to a l l children whose parents have a limited income. There is a good social service department at the General Hospital and the Health 1x2. Centre, as part of the General Hospital staff, is able to extend these services to the children who attend. > CHAPTER V CLINICAL AND OTHER FACILITIES For the most part care for crippled children has been provided through the Children's Hospital and the Solarium, and as the new and greater needs of crippled children have become evident, expansion has been confined to these institutions to a considerable degree. However, there are other facilities to care for children who are handicapped: the Health Centre for Children, which, as part of the out-patient department of the Vancouver General Hospital, offers outpatient services for a l l illnesses; the Children's Hospital through its Travelling Clinic brings services to the crippled children throughout the Province; and the Junior Red Cross Society, in addition has a division in its program for crippled children. While no treatment is provided by the Society itself, i t is made a v a i l a b l e to the children in such a way that discussion of the Society's contribu-tion, i f omitted, invariably would be missed because of the effect the giving to the crippled children has on the young donors. The Health' Centre for Children was opened in 19U7 in a building rehabilitated for the purpose and was financed by the Rotary Club. To this Centre were automatically transferred a l l the children who were in attendance at the out-patient department of the Vancouver General Hospital. The objects of the Health Centre are to act as a diagnostic center for the diseases of children, for the instruction of internes and residents, health visitors, nurses, and social workers. According to Dr. Donald Paterson, Pediatrician-in-Charge, the experience of an out-patient departr-ment shows that i f i t is well conducted and investigations are made there-by sufficiently skilled and interested staff, a great many children who would otherwise require to be admitted for investigation or treatment, need never become hospital in-patients. The out-patient department is, therefore, an essential screen for a hospital and prevents the abuse of hospital beds. This program is interesting from the point of view that the child-ren, when they are too old for attendance at the Health Centre, will auto-matically be transferred to the regular out-patient department of the General Hospital, and the entire program for a l l ages is carried in this way, through the one institution. This is a children's program in a gener-al hospital setting and is a part of approgram of treatment for handicapped people generally. However, where hospitalization is required, i t is some-times felt by those who are interested in children and their crippling conditions, that a large adult hospital is not the best place for these children because i t is. generally geared to give adult services, with the result that there is the strictly institutional feeling, so depressing to a sick child that is not usually so intense in a hospital serving sick children exclusively. At the Health Centre an orthopaedic clinic is held on Tuesday mornings along with a pediatric clinic. Three certified orthopaedic sur-geons are in attendance to see the various congenital and acquired defor-mities, fractures, infections and other crippling diseases. Referral is made and cases sent to the hospital where i t is necessary. From June, 19h& to May, 19k9, attendances to the orthopaedic clinic numbered 362, showing a very low attendance at the beginning of the period with a steady increase throughout the year. This pattern was consistent with that in other clinics and bears out Dr. Paterson's theory that the service creates the demand so that even though the need for this service was hidden, i t was here a l l the time. In addition, another clinic that is of use frequently to the crippled child, who may be maladjusted, is the Child Psychiatry Clinic, where beha-viour problems and other psychiatric disturbances are dealt with. There are programs in the Centre for rheumatic fever cases and for hearing con-servation and a program for cerebral palsied children is being planned. Two f u l l time social workers are available at the Health Centre. They are members of the staff of the Vancouver General Hospital Social Service Department, and their work covers both out-patient and in-patient work and includes the Psychiatric Clinic. The social worker considers, on an individual basis, the income of the child's family which, for the child to be eligible, must be not more than $110.00 monthly for a man, wife and one child, rising by $ 2 0 for each child thereafter, over and above Family Allowance. However, financial hardships and debt, illness and other con-siderations alter eligibility. There appears to be ample work and scope for the social workers at i t has been estimated by those in charge that at least three-quarters of the out-patients are from broken homes and need case work treatment in addition to treatment for their physical conditions. The out-patient departments of the Children's Hospital and the Vancouver General Hospital are the chief facilities for diagnosing and treating children living away from the hospital. It was necessary, until a few years ago, for the children to be brought in to these centers, many times at great expense and from long distances. However, there has been, through the years, in both the Solarium and the Children's Hospital, an awareness of the need to make the required treatment available to every crippled child in the Province regardless of how distant his home is from the institution itself. The Children's Hospital was able to meet this need, to a great extent, by the institution of a travelling clinic. In 19^7, the f i r s t Travelling Clinic left the Children's Hospital to go into the out-lying districts. It was in charge of orthopaedic and pediatric specialists who, after examining cases referred to them, in turn referred the children to hospital or for treatment as needed. Since that date the Travelling Clinic has made eight trips throughout the Province and has seen a total of 857 children, I4.8I of whom were new patients and 376 rechecks of existing patients who have been in hospital. The actual purpose of the Clinic was to recheck patients who had been in hospital and who now lived in remote areas. Many times in the past, parents had failed to have their children sent back to hospital for the recommended rechecks because of lack of money. At other times, the parents seeing that the child had been helped a good deal, could not see the benefit of his being returned to hospital. Thus the Travelling Clinic was established to visit these cases, and while the Clinic was in the outlying districts i t was felt that a further service could be extended in case-finding and consultations. As a result, i t is only when necessary that children are sent down to hospital- and a good screening system has been set up through this means. If the specialist should recommend care at the Children's Hospital and the parents are not financially able to meet the cost of the child's transportation, then the Junior Red Cross or a service club is usually willing to meet this cost. The Junior Red Cross is one of the many organizations that contri-butes funds for the care of crippled children as well as acting in the capacity of a case-finding agency. As a matter of fact these other organ-izations are too numerous to mention, although their work and efforts are no less appreciated. The reason for selecting the work the JuniorKRed Cross Society performs in this field is because of its effect on the children who give. The Junior Red Cross program is, f i r s t and foremost, an educa-tional program but the social effects of this education are sufficiently far reaching so that i t could truly be said that there is treatment in giving to those who need treatment. The Junior Red Cross makes available to the young people of the community vast resources to give them practise in meeting citizenship responsibilities, locally, nationally, and inter-nationally; to develop within themselves a desire to render voluntary service; to promote personal habits of health and safety; to acquire a sense of responsibility for the health and welfare of others; and to create an understanding and an appreciation of the cultures of a l l peoples and a 1 belief in the dignity of mankind. No funds are requested from the students, but in order to raise funds the students, who are members of the Society, are guided into making self-sacrifices for the fund, on the one hand, but mainly into projects which will supplement what they are learning at school. Although raffles are a good source of income the children do not receive anything of educa-tional value from such a method, whereas in the case of a sale of work they would earn less but would have gained much in experience as they them-selves made the articles to be sold. One of the two centralized funds, that is, a fund administered Provincially by the Junior Red Cross, is the Crippled and Handicapped Children's Fund. Donations to this Provincially administered fund are used to help physically handicapped children within the Province, who have no other means of support. This includes, besides crippled cases, children suffering from numerous other defects. It provides for the supplying of T~. Junior Red Cross, Suggestions for the Use of the Junior Red Cross  in High Schools. UQ. orthopaedic appliances, hearing aids, glasses, wheel chairs, or other aids. Through this fund, Junior Red Cross pays transportation costs and medical bi l l s for cases accepted by the organization. Those eligible for treatment of physical defects must be under eighteen years of age; must, in the opinion of a licensed physician or surgeon, have, hope of benefit from treatment; must have been accepted for treatment by the Junior Red Cross Committee. Treatment is defined to in-clude medical and surgical treatment (where not otherwise provided), trans4? portation, foster home care while awaiting or undergoing treatment, i f under recognized supervision, and other treatments, such as physiotherapy, massage, orthopaedic appliances, and so forth, as ordered by the physician in charge of the case. In order to qualify for treatment the children must not have other means of treatment nor must the responsibility for their assistance, and treatment have been assumed by official or other organiza-tion. Applications for treatment are made through the public health nurses and social workers connected with the Provincial Department of Health and Welfare. Frequently the public health nurse does not visit the out-lying schools over a long period of time and the onus is then on the school teachers to watch for physical handicaps in their pupils, and where i t is apparent that the families may be in need of financial assistance for treatment of the handicaps, the teachers contact the public health nurse. During treatment in a hospital or other institution, or foster home, in a locality other than that in which the family physician is located, i t is desirable that the family physician be kept informed through the receipt of medical reports from the physician in charge of the case. Where the attending physician does not submit reports directly to the h9. family physician, the Junior Red Cross assumes the responsibility for send-ing these reports through its own office. Notification of the child's return to his home is sent to the public health nurse with a copy to the district office of the Social Welfare Branch. With these three resources then, the facilities for a l l types of care of crippled children are completed: the long-term care offered by the Solarium; the combination of hospital, out-patient and travelling clinic services made available through the Children's Hospital; the out-patient setting of the Vancouver General Hospital in the Health Centre for Children; and the case finding and making arrangements for treatment carried on by the Junior Red Cross. However, treatment alone is not enough and i t is neces-sary, in order to bring any treatment to a successful conclusion and to continue to give the child his rights, to follow i t up by rehabilitation and training so that even with limitations, the child might be able to take his place in the community as a citizen whom the community'is grateful to count among its members. CHAPTER VI REHABILITATION AND TRAINING "The goal of rehabilitation i s to achieve the maximum function of the individual and to prepare him physically, mentally, socially and vocationally for the f u l l e s t possible l i f e compatible with his a b i l i t i e s and d i s a b i l i t i e s . " —Baruch Committee on Physical Medicine. Until 19U9 there was no institution active i n the f i e l d of reha-b i l i t a t i o n of crippled children and the one under discussion now i s not exclusively for children but covers the training of children and adults. The new Rehabilitation Centre, opened in January, 19k9, by the Western Society for Physical Rehabilitation, i s the f i r s t of i t s kind i n Canada and one of the few on this continent b u i l t for this purpose. The opening was the result of the interest evinced, i n 19U7, of a group of professional medical men and laymen i n the problems of rehabilitation of paraplegics and similar cases. A good deal of research was done to determine the best method to handle the rehabilitation program for those requiring i t . The Society was incorporated under the Societies Act of British Columbia. The Directors solicited information from the Baruch Committee on Physical Medicine, New York, one of the leading committees i n this area i n the world. Conferences were held with the Department of Veterans Affairs, who have four rehabili-tation centers throughout Canada, and with plans and advice received, a re-habilitation center was designed and a campaign for finances was instituted which raised $200,000.00 to build and equip the present Unit. The Medical Director spent two years i n Eastern Canada and United States under a Federal grant on an educational tour of centers arid hospitals, and while on this tour, conferred with the leading medical men i n the f i e l d . 51. The Centre is operated as a school for physical rehabilitation of the orthopaedically disabled, including paraplegics, polios with permanent paralysis, cerebral palsy and kindred cases. The services of the Centre are available to those who, in the opinion of the attending physician and the Medical Director of the Centre, would benefit from this training. Trainees are referred usually by their own doctors. Many have learned of the Centre through the press and communicate directly. Those accepted are taken on for a term of three months and their application is renewable at the option of the Medical Director. The aim, however, is to give training for as long as the case is progressive and the average length of stay is from three months to nine months, depending on the person's age, disability, and desire for physical rehabilitation. Trainees come from al l the areas of the Province and numbers have been admitted from Alberta and Saskatchewan. A one-storey structure with al l entrances on street level, the Centre is designed to meet a l l the requirements of people in wheel chairs. The door-ways and halls are sufficiently large to accommodate the wheel chairs without difficulty. The large dining room is attractively furnished but, at the same time, the tables are of a height to accommodate wheel chairs. In addition to the dining room service there are six semi-private rooms and a private room with bath, the bedrooms and bathrooms specially designed, the beds low, with frames which the trainees may raise and lower themselves on, the toilets and wash basins and light switches also lower than normal, for the disabled. As a result of the problem with which the Directors were faced in connection with those cases coming from out of town, this living-in accommodation was provided for the disabled. Hotel accommo-dation for a person in a wheel chair, because of the difficulties of move-ment, was impractical and the high costs were also taken into consideration. 52. If trainees live a great distance from the Centre, living-accommodation is also provided because of the inconvenience and expense of commuting. How-ever, the bulk of the trainees come in by the day and are brought in by a car and driver supplied by the Centre, and returned home at the end of the day. •;' The training program extends from nine o'clock in the morning until four-thirty in the afternoon daily. It involves group exercises, group games, and individual exercises in addition to ambulatory retraining, physiotherapy and swimming. There is a large, fully equipped gymnasium for most of the activities. Facilities for the measuring and prescribing pros-thetic appliances are available as there is a Brace Shop for the making or alteration of bracks and so on at the Centre, the staff consists of the Manager, a f u l l time Medical Director, who screens a l l applications where necessary, three graduate physiotherapists, two remedial physical training instructors, a chauffeur, and administrative and domestic staff. In order to make the f u l l use of his capabilities, vocational training with a view to later placement of the trainee is planned. Such provision of vocational guidance involves the psychological assessment of native abilities and interests. So far, however, there is no institute for vocational training that is geared to the trainees of the Centre and al-though i t is not satisfactory in many ways, the Centre has arranged to have this obtained through the Vocational Institute and other such schools in the City of Vancouver. It is the desire here that placement and follow-up services will be available. Entertainment for the trainees living in the Centre has been kept to a minimum for two main reasons. In the fi r s t place, when the trainees, return home they will be living in a different environment where they cannot 53. be entertained regularly or frequently. Secondly, i t is the aim of the Centre to train the clients to take their place in their communities and to this end, they are encouraged to train themselves to go out for entertain-ment to shows, beaches, sports events, and so forth. This plan is followed out as a result of the experience during the War at Lindhurst Lodge in Eastern Canada where the men were literally showered with entertainment. The contrast to their normal home l i f e after their discharge was so great that they were dissatisfied to live at home. In the Centre there is also a program for the management of the spastic child, sponsored by the Spastic Paralysis Society of B.C. There are facilities, at present, for the training of approximately twelve child-ren and the program involves physiotherapy, speech therapy, formal educa-tion (the teacher is not supplied by the School Board), psychological assess-ment, prescribing of prosthetic appliances and ambulatory training. A transportation service is provided to bring the children to school and to take them home. The services are limited in this field because of the small quarters available at present, but with the expansion of the Centre, and the building is in the process of being erected now, there will be much larger accommodation for this work. At present i t is not possible to have the children stay for the day because there is nowhere for them to rest in the afternoon and no provision is made for providing lunches for them. Private contributions, fees paid by trainees, and a government subsidy are the means by which the Centre is financed. By subsidies and fees i t is hoped that the budget will be met. However, there is a scale of fees charged those who are able to pay only. The monthly charge for the physical re-education program is $60.00. The charge for living'in is $6.00 a day in addition to the re-education program. Federal funds from the 5U. National Department of Health and Welfare may be allocated through the Provincial Government but these funds are not for capital expenditure. All paraplegic cases for the Workmen's Compensation Board are handled at the Centre. The function of the Centre i s to act as a stepping stone between the hospital and the home. Numbers of trainees have been in hospital for from one to two years or over-protected at home for years, and have developed inhibitions to varying degrees. Some are backward about appearing in public on crutches or in wheel chairs. Their inhibitions must be broken down while they are in the Centre. As they gradually become acquainted and mix with others at the Centre, there is some breaking down of the reserve, but the aim is to have them able to face the public by the time they are discharged because i t is realized that the Centre itself offers much shelter. To this end, those who can walk and are ready for discharge are taken out and into town where they do their walking among the crowds of people in order that their self-consciousness might be lessened. The psychological adjust-ment of a l l trainees is given careful consideration and individual attention is necessary in different conditions, for example, the polio patient handles much easier with his few bowel or bladder complications than does the para-plegic who faces a serious problem in this connection. The present building is only the f i r s t unit of the ultimate Centre and expansion is even now under way both in facilities and-in services. The $120,000.00 required for the new wing has a l l been donated by private citizens and business organizations in the Province. When this wing is completed i t will provide more than double the present floor area. There will be an additional twenty beds for in-patients, more room for physio- • therapy, a much greater working area and facilities for the management of 55. the cerebral palsied. There will also be rooms for diversional therapy, institutional training, more patient examining for the Medical Director. Further facilities to be provided are two Hubbard baths and an indoor remedial pool, specially designed to be used for ambulatory retraining, measuring twenty feet by fourteen feet, with the water two feet deep at the shallow end and five feet at the deep end. The Hubbard tanks are to be used for leg and arm exercises on a horizontal plane. In addition to physical training services there is to be an expansion in vocational guidance and placement. Where the trainees are able to take competitive employment there is not a serious problem. When selective em-ployment is necessary i t is a l i t t l e more difficult to,arrange. But when sheltered employment is required i t is a virtual impossibility to place a trainee. A social service department is being established to work extensi-vely in the field of placement and the social worker will be responsible for the referrals of employment and men. Vocational training will be available shortly and the Centre expects to send the trainees to the new Vocational Institute project in the aid of the physically handicapped which is now in the process of being planned. Perhaps a few words could well be inserted here on this project as i t will offer a complete training to the handicapped and facilitate the type of placement in jobs necessary to the trainee. The Vocational Institute is the project of Kitsilano's Canadian Legion Branch and the $60,000.00 building which will house i t will be supplied by the Lions Gate Branch 79. The Institute is expected to open in the f a l l of this year. It will offer aid to handicapped people that they cannot get anywhere else and will provide free training in handicrafts for those requiring i t while for those already trained, i t will give a place to work under expert supervision, with good equipment, and with an assured 5 6 . market for what they produce. Workshop facilities will be installed for weaving, basket making, leather work, woodwork, costume jewelry manufacture and other handicrafts. All will be offered free to the handicapped both ex-service men and civilians, with a priority on a basis of need. Work will be marketed through the Vetcraft Shop now run for the Legion Branch. Even the first floor of the new institute is expected to accommodate from x':i. f i f t y to seventy-five learners. The question may well be raised regarding the use of these new facilities for crippled children, but i t must be borne in mind that child-ren do grow up and treatment without vocational training and employment within his limitations will not make the crippled child develop into a well-adjusted independent adult. CHAPTER VII REVIEW AND ACTION The program for crippled children in British Columbia, then, has been in the process of developing for roughly one-quarter of a century, a quarter of a century in which there has been considerable progress made in medicine and in this particular field, in diagnosis, treatment, and preven-tion. The importance of the human personality in handicaps has also been brought to the fore with the discovery of the effects of the emotions and environment on the physical conditions of the body, and on the ability of the person to accept treatment. In addition, there has been considerable stress laid on the welfare of the child in a l l phases of development and, because of the special problems associated, of the handicapped child. Col-lections have been made by many different agencies, the governments have or have not participated, treatment centers and services have sprung up in localities where they were needed or not needed so much. The picture gen-erally, at the present time, is one of attempting to take the different independent paf/ts of the scene and place them in a frame so that there will be a picture with no gaps, no overlapping and showing a service available to a l l crippled children that will meet their needs. This does not mean that an end may be reached, but that co-ordination will lead to that place where further research into conditions may take place when the present needs are being met satisfactorily. Experimentation and research must continue as long as there are crippled children. As a result of the many studies made in the United States in connection with the care of crippled children and adults, a standard for a well-integrated program was published in the Social Work Year Book of 19H9. Such a program would include at least several major requirements in order to be complete. Because the needs and requirements seem to be so similar in many of the current programs, i t might be of more value at this point to measure the facilities and services offered in British Columbia with the standards thus set as a result of study of a l l major programs rather than with those offered by other local programs. In the fi r s t place, physical facilities and adequate medical supervision are needed, with a sufficient number of personnel, to insure every crippled child of the most advanced treatment possible. The special-ists in the Province on children's conditions have co-operated whole-hear-tedly in the children's program and there are very few who are not on the staff in some children's center. With a good staff there would appear to be sufficient medical men interested and willing to handle a f u l l program. This will be helped by the fact that when the Children's Ward at the Vancouver General Hospital is opened as a teaching center there will be a training program whereby the medical students will be able to offer much. There is a shortage of trained physiotherapists, occupational therapists, technicians, special teachers, social workers, and nurses who have special-ized in children's conditions. This shortage appears to be fairly general, however, and should be relieved as more people are trained in these special fields. One of the difficulties in evaluating thefprogram in British Columbia in this regard is the fact that there have never been any reliable statistics obtained or published of the actual numbers of crippled children in the Province. Dr. Glenn Simpson, who is the Medical Superintendent of the Solarium, in his brief on co-ordination of services to crippled child-ren in British Columbia in 19U7, felt that to accept statistics from out-side, for the present, was one way of judging the extent of this problem here. He found that the ratio of physically handicapped children per one thousand of the general population most frequently quoted has been derived from sources from the United States of America. The findings of state-wide and local community surveys covering a. period of twenty-five years has shown, considering a l l variations, that the ratio is five per thousand which would give an estimated total of four thousand five hundred handi-capped children in British Columbia. However, i t must be borne in mind that the term "physically handicapped" takes in a larger group of children than this discussion-includes. At the same time, this figure is usable in that a l l the facilitie with the exception of Queen Alexandra Solarium offer services to a l l children with a l l types of illness. For these handicapped children there is a maximum of about two hundred beds in the general hospitals; another hundred beds at the Children's Hospital; and sixty-five to seventy-five beds at Queen Alexandra Solarium. These facilities are broadened to meet the needs of those children not requiring hospitalization by the extensive out-patient services offered at the Health Centre for Children and the Children's Hospital. However, there are limitations, apart from financial ones, that reduce the numbers receiving services. For example, the Children's Hospital and the Queen Alexandra Solarium do not accept children over fourteen years of age, and in the latter hospital, boys over twelve years are not accepted. This may not seem to be too serious a. -lack in view of the fact that former surveys have shown that sixty per cent of the cripples under twenty-one years were cripples under the age of seven years; but, indeed, many of these have not been actively treated until the child is much older than seven years. side, for the present, was one way of judging the extent of this problem here. He found that the ratio of physically handicapped children per one thousand of the general population most frequently quoted has been derived from sources from the United States of America. The findings of state-wide and local community surveys covering a period of twenty-five years ha.s shown, considering a l l variations, that the ratio is five per thousand which would give an estimated total of four thousand five hundred handi-capped children in British Columbia. However, i t must be borne in mind that the term "physically handicapped" takes in a larger group of children than this discussion includes. At. the same time, this figure is usable in that a l l the facilitie with the exception of Queen Alexandra Solarium offer services to a l l children with a l l types of illness. For these handicapped children there is a maximum of about two hundred beds in the general hospitals; another hundred beds at the Children's Hospital; and sixty-five to seventy-five beds at Queen Alexandra Solarium. These facilities are broadened to meet the needs of those children not requiring hospitalization by the extensive out-patient services offered at the Health Centre for Children and the Children's Hospital. However, there are limitations, apart from financial ones, that reduce the numbers receiving services. For example, the Children's Hospital and.the Queen Alexandra Solarium do not accept children over fourteen years of age, and in the latter hospital, boys over twelve years are not accepted. This may not seem to be too serious a lack in view of the fact that former surveys have shown that sixty per cent of the cripples under twoenty-one years were cripples under the age of seven years but, indeed, many of these cases have not been actively treated until the child is much older than seven years. 60. For the chronically crippled child who will always need a certain amount of institutional care there is nothing in British Columbia. The Provincial Infirmary, known as the Home for Incurables, has been used rarely for these cases because of the feeling, on theppart of many people, that the cases referred there are hopeless, and that these children should have more than merely institutional care. The Infirmary is mentioned as the one facility for the care of these chronically crippled children but there are limits to how many people the Infirmary can give service and there are long waiting l i s t s of older chronically i l l cases. As a result, i t can be seen that there are two groups of crippled children who cannot be assured of service; namely, those of over fourteen years to twenty-one years, and the chronically crippled who require some type of institutional care with nursing services. For the former group facilities are definitely needed, as they are for the latter, but in the case of the former, much may be done to see that the sixty-per-cent who are crippled before the age of seven years are treated as quickly as possible, by a good case finding arrangement. This leads to the discussion of the next requirement for a f u l l program, that of good case finding, which is necessary for preventive and remedial measures. It is most important according to these standards, that in the case of congenital defects,' the location and proper reporting of the child at the time of the original diagnosis should take place. Until last year there was no system of reporting to a center any crippling conditions, and i t was the very fortunate or the very crippled child who was referred for early treatment. Like the rest of the program, case finding has been done on a more or less individual and independent basis. Reports and referrals came into the different centers through the workers 61. in both branches of the Provincial Department of Health and Welfare; the Junior Red Cross and the Travelling Clinic of the Children's Hospital have located numbers of cases; and citizens, doctors and private organizations have made referrals. In line with the trend to co-ordinate the services to crippled children in the Province, a survey of crippling conditions throughout British Columbia has been instituted. One of the bases for this survey is the fact that in order to know how best to use the dominion grant for crippling diseases of children, which amounts to $i|.2,000 yearly for the next five years, i t is necessary to know just how great the problem is, that is, the number of crippled children. Once the information has been obtained a check can be made by the Sub-Committee on Crippling Diseases of Children, who is in charge of the survey, as to whether there is suffic-ient staff, equipment and accommodation to help the crippled children. All the doctors in the Province, as well as the following agencies, have been contacted: al l hospitals in Vancouver with an orthopaedic department, the Health Centre for Children, Grace Hospital, for congenital malforma-tions, Western Society for Rehabilitation (spastic unit), Queen Alexandra Solarium, the Provincial Mental Hospital (also for spastic children), the Children's Hospital, Public Health Nurses of the Department of Health and Welfare, and Metropolitan Health Nurses. This survey has been going on for several months now, and is an excellent means of locating, as soon as possible, every child in the Province suffering from crippling conditions. Whether reporting continues after the survey has been completed is a question of importance to every-one interested. The Ontario Society for Crippled Children, along with other agencies, believes that one of the fi r s t steps in the prevention of crippling diseases is the indexing and early diagnosing of these condi-tions. That Society has maintained a partial index, but has proved by experience that this is most unsatisfactory and has maintained that i f the problem of the crippled child is to be faced squarely, there should be a complete index that should be geared in on one side with annual county surveys and birth registrations and on the other side with local Seryice Club efforts to provide treatment. In this way the chances of overlook-1 ing thousands of needy cases would be greatly reduced. The compulsory reporting of such conditions has been suggested as a means of overcoming laxity because of the many forms medical men find i t necessary to complete in their daily routines. There has been done, at Queen Alexandra Solarium, by Miss D. Andrew, a complete indexing of a l l the cases ever admitted there and, as far as could be ascertained, this is the one complete index in the Province. Apart from this there has been very l i t t l e done in the way of systematic indexing. Of course, crippling conditions in children, by their very-nature, draw upon the emotions of most people for sympathy and because i t has been realized that much more is involved in many conditions beside an outstanding cure,' for instance, that i t might take many years of inten-sive work and treatment to bring a child to the place where he is not cured, but able to do some things for himself, i t is necessary to interpret the services required and the fundamental issues at stake. To do this there must be a knowledge of the conditions, how many crippled children there are, what treatment has been used, the length of treatment and the results. Good case finding without adequate service is of l i t t l e value. 1. Ontario Society for Crippled Children, Annual Report, 191+9. The standards set up advance as a further means to a well-integrated pro-gram a competent diagnostic service and screening with a referral system to ensure adequate care for a l l crippled children. In addition to medical care withhospitalization and surgery along with competent medical super-vision of a l l phases of the complete program, physical, occupational, and speech therapy should be given when needed as part, not only of the medical care, but also of the educational program. There are many referrals through individual means and children are referred to the different ortho-paedic centers for hospitalization and treatment through the out-patient and general hospital departments. In British Columbia, the Travelling Clinic diagnoses and refers its cases to the Children's Hospital. Queen Alexandra Solarium has endeavoured to obtain diagnoses and referrals by keeping the out of town doctors supplied with- application forms. This unco-ordinated method of referral means that often children who need hospitalization and treatment are denied them because there is no center to which they can be referred, where a second choice could be made for their accommodation, when the first choice may be unable to take them for lack, temporarily, of room or some such reason. The linking up of physical, occupational, and speech therapy with the educational program has not been done in British Columbia except "in the case of the Spastic Unit at the Rehabilitation Centre. For academic training the Vancouver School Board has supplied one teacher for children, who, for physical reasons, are unable to attend regular .schools, and are taught in their homes; and during the past year twenty-five orthopaedic cases as well as forty-eight otherwise physically handicapped children were taught in this manner. Teachers are also supplied by the Vancouver School Board to institutions; three to the Children's Hospital, one of 6U. them a specialist in handling spastic children, two to the Preventorium, and one to. the children's ward at the Vancouver General Hospital. The Department-of Education, Victoria, also supplies three f u l l time teachers to the Solarium. Outside of Vancouver when a child has been discharged to his own home he is study under the Correspondence Courses which are offered by the Department of Education. These courses are said to be self-explanatory but except in the cases of older children, who have already been well-started on the road to education and have the desire^ to study, the courses have been found to be more than the average child is able to manage. Where the parents are unable or unwilling to help, the child soon slips back into just being crippled and into a state of dependency. The spastic child who is, for purposes of classification, in the trainable group, is also in need of extremely intensified education. At the Children's Hospital a school for spastic children is held daily, and efforts are made with the small staff to extend the benefits to as many spastic children as possible. There has been considerable discussion by those interested in the problem of crippled children regarding the place where the spastic child should receive his education. During the discus-sions i t has been maintained that for the child's well-being he should not be brought to a hospital setting for this purpose, but that special schools should be set up. The Rehabilitation Centre also offers f a c i l i -ties for the education of spastic children and is, at present, using volunteer teachers. It is felt, that the children respond in the Centre because they do not feel that they are sick but know that they are coming for training and education. There are approximately seventy-three spastic children registered at the Centre. The Vancouver School Board is consider-65. the possibility and advisability of establishing as soon as possible a special school for handicapped children, adequately constructed and equipped for physically handicapped children. There are two of these schools in Toronto which, have f i l l e d a great need. Children are brought and taken home in special cars and i t is a. fairly costly service but is considered to be very worth while. The Research Consultant for the Social Welfare Branch of British Columbia was unable to say whether such a school would be warranted here, but was of the opinion that i f a. center is set up for the training of spastic children in the Province, there may be an 2 urgent need for some type of special school. Dr. Glenn Simpson has mentioned in his brief and as a result of his study that the care of physically handicapped children does not differ from the accepted standards in health and educational programs for normal child-ren, for whom training and education of mind and body go hand in hand, but to attain them for crippled children involves specialized services a l l 3 along the line. In looking over the educational facilities there would appear to be much to be done but at least, at present, there is a solid foundation on which a f u l l program of education can be built and which is satisfying part of the present requirements. There is a definite need for a school for handicapped children from other parts of the Province. Not only are teachers required for the children but a teaching program is needed for parents where the children are living at home, so that the work done in the training centers and special schools will not be undone in the 2. Harvey, Isobel, Resources in British Columbia for the Physically - Handicapped Child, Social Welfare Branch, British Columbia, 19U9, p. k. 3. Simpson, Glenn, A Brief on the Co-ordination of Services for Physically Handicapped Children in British Columbia, 19U9, p. 2. 66. home. Closely allied with academic education, is rehabilitation or education for living. No program for crippled children is nearly complete without some plans for rehabilitation. In British Columbia there is a certain amount of therapy given at the Health Centre for Children and a good deal for spastic children at the out-patient department of the Children's Hospital. However, the Western Society for Rehabilitation has opened its unit and is the fi r s t step here towards a complete rehabilitation program. When the building is completed i t is felt that there will be facilities for rehabilitation of a l l handicapped people. The Centre is, in reality, a school where people do not learn the three R's exclusively but learn to see the limitations in which they live, and to live with others. It has been said of the crippled child that i t is vitally important that he should learn to live with others; that his social attitudes are always k warped by his personal handicap. The Centre strives to ensure that iso-lated and home-bound cases are brought into the activities in the effort to give them contacts with other people. However, the adjustment of the crippled child to himself does not end with rehabilitation unless that rehabilitation prepares him to make the maximum use of his existing faculties, both in an effort to enjoy l i f e and to be as self-supporting as possible. To do this, the standards set, suggest a good vocational training program. At present there is no way of placing the trainees from the Rehabilitation Centre or other crippled children in jobs because there is no vocational school established to meet the special needs of crippled children. The existing facilities, including the Vancouver Vocational Institute, have been used by the Centre, but U. Ontario Society for Crippled Children, Annual Report, Toronto, Ontario, 19U9. 67. grudgingly because they are already over-crowded and are not set up for handling handicapped children. Placements in competitive employment have been made without too much difficulty in comparison with those in selec-tive and sheltered employment. Until the new vocational school for the handicapped is opened there is actually no way of giving adequate voca-tional training to these people. This gap is felt by leading American authorities, to be a great one in an integrated program for crippled children. They know that em-ployment services are essential to the goal of good economic self-sufficiency by the handicapped adult. In addition to vocational testing, counselling, training, placement and adjustment represent the f u l l series. Further services are needed in the form of sheltered workshops and cura-tive workshops for rehabilitation of the handicapped to provide a com-plement of services for a l l types of handicapped persons, many beginning with services for the pre-school child recognizing that early treatment is economical, not only in financial terms, but in terms of human value. The present trend in British Columbia is to f i l l the gaps that are hold-ing back an integrated program and i t does not appear that these further services will be available for some time. A good program for crippled children would also include such services as social services, psychiatric and psychological counselling, programs of recreation and group activities, as well- as special parent or family counselling. The social service aspect will be discussed later and there is l i t t l e to be said for the facilities in the other areas at present. The Health Centre for Children has, as part of its program, a psychiatric clinic open to a l l sick or handicapped children, which is in line with the development there to give a well-rounded service to a l l children. 68. Most of the recreation at present consists of entertainments in the hospitals but there has been l i t t l e in the way of organized or co-ordinated plans for recreation for crippled children in the Province. At the Solarium the boys and girls are encouraged to join the Boy Scouts and Girl Guides. They are fortunate, as far as outdoor facilities are concerned, because they are allowed to go camping in the woods in the summertime without involving too much expense or long moving. The children are allowed to develop their resourcefulness in the near-by woods and beaches. This gives them an opportunity for a certain amount of self-government and to be away from adults for a while at least. They learn here to depend on themselves for their amusements and to find out by trial and error methods just how much they are able to do for themselves. Those children situated fight in the City face a different l i f e both in institutions and in their own homes. In the latter there is the tendency, i f the child should be taken to camp, to overprotect him so tha.t he cannot hope to discover l i f e for himself. It is nowhere nearly impossible in a well-integrated program to have good recreational facilities. Camps have been held in many areas in United States with much success. In Ontario there are three camps where crippled children can spend a three-week period in the summer time. These' camps serve a dual purpose as they are used for convalescence as well as for recreation. The danger with the crippled children, where recreation is not well planned, is that they become too accustomed to being enter-tained and are thus left untrained in the art of looking into themselves for resources in this area. There is an almost complete lack in the Province of facilities to train the child to help himself and others in the field of recreation. 69. To complete the program, institutional and residential care is set up as a requirement for the normal severely handicapped child. There is nothing along this line in British Columbia. The Superintendent of Child Welfare has used foster homes from time to time for these children but this is not the answer as the foster parents are apt to request the child's removal in times of stress, when removal presents the worst possible threat to the child. The two obvious effects on the child are that he mistakenly believes that he has no place in the normal world, and this belief is en-forced as he is rejected time and again. Only a special type of institu-tion or specially built residence where the child can do as much as he is able vdth his severe handicap, is the answer to this problem. It was suggested that a good program for crippled children requires good social services and this is borne out in the following statement of the thinking in United States along this line: "Even the finest programs of medical care and education are ineffective in the face of social malad-justment. Therefore, provision of added medical social services to programs for the handicapped is required to meet the problems of personal and family adjustment and a myriad of other difficult situations faced by the handi-capped and their families." That there has been an awareness of this fact in British Columbia has been shown in the past by the instituting of social services in some of the institutions and in the present by making available to the crippled children, social services that have not been available before. However, i t is open to question how deep this awareness is in view of the fact that, at present, the Vancouver General Hospital is the only institution maintaining adequate social services in the children's field. The Vancouver General Hospital has been able to set up an adequate social service department, which is a. particularly important part of the 70. Health Centre for Children and its function is to deal with the broken homes of patients, the meeting of costs of appliances and necessities for the children, and the necessary visiting of these homes so that the domes-tic and emotional problems might be considered along with the physical 5 problems of the children. Referrals are made to and from the various social agencies. At the Children's Hospital there is also a social service department that is a regular part of the hospital, but there is at present no social worker to give the services. However, an excellent service has been given through this department in the past and those in charge of the institution seem to be aware of the need to have its continued opera-tion but are of the opinion, which is not entirely correct, that there' is a shortage of social workers especially in the medical field. The Junior Red Cross Society uses the Department of Health and Welfare faci-l i t i e s to report cases returning to the districts as well as for taking applications. Western Centre for Rehabilitation has employed a social worker whose job will be, in the beginning, at least, chiefly in the field of job placement. At the Solarium also, the effects of not having a social service department have been seen and there is a consistent effort being made there to expand, in this area. There is l i t t l e to be said at this time in this connection in view of the fact that expansion of the facilities of the Solarium in the near future will solve the problem of this lack as well as of others. Out in the districts the Social Welfare Branch offers a generalized social service to a l l residents, but unless there is some systematic means of referral, the workers, with their heavy 5. Paterson, Donald, "Children's Health Centres and Their Uses", Canadian  Medical Association Journal, Vol. 62, 1950, pp. 39-U3. 71. case loads and often extensive distances to cover would not be able to do efficient work in this area. The social services for crippled children in the Province also have grown up in an independent manner as has the whole program, with some services more effective than others and some even yet, non-existent. Like the other services they fully cover some crippled children and leave others, who have equal needs, absolutely without help. Tb' clarify the situation, there is a picture of coverage of some standards to varying degrees of partial coverage, with complete lack of others. There is a good supply of medical personnel and hospital f a c i l -ities to. meet the present need and to build on in the future as the f u l l need is made known. There is one Travelling Clinic reaching to al l parts of the Province in its work of case finding and reporting to one center. There are educational facilities and rehabilitation services set up. However, the needs number at least as many, i f not more than the facilities. The lack of co-ordination of the present services renders a l l the available facilities less efficient than they could be. There is the lack of any service for crippled children from fourteen years to twenty-one years of age, who need long-term care and for those children of a l l ages, who are s chronically crippled and need full-time care. There is a need for an educational center for all handicapped children, as well as for a vocation-al center and facilities for job placement. CHAPTER VIII TO FULFIL THE RIGHTS OF  CRIPPLED CHILDREN This brief study of the existing facilities for crippled children shows that there has been adequate development in some areas and very poor development in others. The survey now taking place will reveal definitely the extent of the needs and just how useful the present facilities will be to meet them. However, whatever the results bring out, definite steps must be taken to improve the present program before i t can operate with effic-iency, regardless of the situations to come. In the f i r s t place, co-ordin-ation of the present services must be undertaken. Every agency interested in caring for crippled children hasmaintained province-wide jurisdiction and none seems to accept limits in this respect or that the other agencies might be offering a duplicate service. Co-ordination could take place in a variety of ways. There could be a continuation of the use of service clubs in their present capacity as has been done in Ontario. This would enable i the participation of the government to the extent of giving lands arid build-ings for the furtherance of the program, while the program itself would be administered by an association of representatives from the different service clubs. An alternative would be much the same but would entail the co-opera-tion of the existing facilities to set up a program, having a group selected from the different agencies now in operation to dispurse funds and incorpor-ate the facilities so that there would be the least amount of duplication of services. The third alternative, and the logical recommendation, in the writer's opinion, after study of the matter, is a complete provincial pro-gram for physically handicapped children which would extend specialized care to crippled children also. The Department of Health and Welfare is organized in such a way that this could be managed without too much re-organization. This recommendation will no doubt bring down cries of objec-tion because of the extensive activities of private organizations in the field; however, there is no wish to depreciate the exceptional achievements of the private organizations nor the fact that they were, in the first place, responsible for the development of any program at a l l , but with the growth of population along with the increase of interest in the problem, and. the resulting increase in case finding and reporting, the field has grown by leaps and bounds. The Department of Health and Welfare should be able to offer much to the program by the co-ordination and supervision of an all-over plan, while the agencies themselves, through this co-ordina-tion, could decide the most efficient means of giving service to every child. This, for example, would mean the sharing of the. existing f a c i l i -ties in such an effort. The Travelling Clinic would s t i l l go out into the districts and report to a central agency. The social workers already em-ployed by the Provincial Government could add much in the way of eligi-bility requirements for fares, treatment and case work services to the children in their own homes, while the Public Health Nurses would likewise be available for follow-up care of the child after his discharge to the district. The interest of the private agencies would be maintained by having discussions, by representatives from a l l over the Province, on an-ticipated moves. There is s t i l l much under this scheme for the private agency to do. Funds are always necessary for education and training of personnel; new buildings are always required before the government is able to budget for them; research always goes on, and actually the private ag-ency would have as great a part in this program, but would be aware that what was being done was going into a consistent, co-ordinated program and being used to a maximum. The private organizations have always striven to see that the rights of crippled children are extended to a l l crippled children, and, under such a structure, they would receive assurance that this is so. An example of such organization is that of the B. C. Tuberculosis Society which originally took on the responsibility for the control of tuberculosis in British Columbia and now works in close co-operation with the Division of T. B. Control of British Columbia. Because the crippled child is so frequently moved from his home for treatment and care, i t is necessary that he should, in the absence of his parents, come under the care of some social agency so that there will not be indiscriminate moving which is upsetting to every crippled child. The Child Welfare Division could offer through the other social agencies, child placing, family work, and medical social work ones, services to crippled children in the field of case work as well as in planning for placement. Foster home placement for out-patients, i f carefully handled, would be an advantage over keeping the children in hospitals when there is such a need for hospital beds. However, i f because of the type of population and like factors, this is not feasible, then residences built for such children would come under the supervision of the Child Welfare Division. In this same area and in order to integrate the program fully, there should be participation on a dominion level. The problem of crippled children is one that affects the whole country and co-ordination is neces-sary between a l l the provinces. A thorough country-wide study of handi-capped children could be carried out, and some arrangements made, as they are in United States. In that country, the Children's Bureau of Federal Security Agency has been charged with the responsibility for administering grants to the States i'or the crippled children's programs; and has as-signed this task to the Division of Health Services, which also administers the maternal health and child program. Where the States have an approved program for crippled children, annual appropriation supplements are given for the operation of diagnostic clinics, hospitalization and surgery, medical social services, provision of aids and protheses and allied ser-vices. In Canada, the Dominion Government could have the funds allocated, administered on a provincial level. However, even government participation to a great extent will not relieve the private organizations of their responsibility in a field such as that of caring for crippled children, because there is so much to be done. Assuming that this recommendation were carried out, the others may then f u l f i l the rights of crippled children in this Province. At the same time, to be certain that every crippled child possible will benefit from treatment, there must be good case finding and reporting -facilities. It has been found that, in order to be certain of the imme-diate reporting of crippling conditions, legal action is necessary and the Protection of Children's Act could be altered to protect these children from physical neglect by making compulsory the reporting of a l l crippling conditions as soon as the doctor sees them. In congenital conditions, s speedy arrangements could be made for the child's care and treatment. By treating the children early, in many cases, the anxieties suffered by the families as well as the defeatism, hopelessness,. weakened morale and devel-opment of personality deviations, which so frequently result from neglected handicaps, could be prevented. The second recommendation, then, will concern the right of the crippled child to have as vigorous a body as human sk i l l can give him. This, of course, involves the physical facilities here from which the child may receive care and treatment, which would, in turn, involve the working together of the present hospitals and institutions for the most efficient operation. Dr. Glenn Simpson in his study has, on the basis of the cases at the Solarium, classified the types of care necessary as follows: short hospitalization with out-patient or follow-up services; long hospitaliza-tion with treatment and training; treatment and care in the home; care in a convalescent or foster home; permanent institutionalization; and nursing and educational care with physiotherapy and general medical supervision. He has suggested that three or four types of institutional care would be necessary, namely, a diagnostic center and a short term surgical unit, a hospital-home-school for long-term treatment cases, a convalescent home, a hospital-school-vocational center for incurable patients. From this i t would appear that the necessary recommendations would be that the Solarium be extended to give long-term care to children up to eighteen years of age at least, and that for facility of treatment the in-stitution be moved nearer to the medical center at Victoria and s t i l l main-tain its close affiliation with the Royal Jubilee Hospital. The Children's Hospital, in view of the fact that i t is the best equipped orthopaedic center in the Province, could give an extremely valuable service by treat-ing chiefly orthopaedic cases. The out-patient department has been well-deyeloped and could s t i l l serve in this capacity as an out-patient clinic for all orthopaedic cases and for other conditions from which their pa-tients would suffer. Facilities should be increased, here also to include the adolescent child for treatment. Diagnosis and referral might be carried out in conjunction with the Health Centre for Children before re-ferrals are made. This would leave the Health Centre to offer facilities 77. for the care of other than orthopaedic cases or chiefly short term surgery for these cases. This s t i l l leaves the chronically handicapped children who require permanent institutional care with nowhere to go. Two suggestions have been made. The first is that the Infirmary be extended to care for such child-ren and this could be done by adding to the present facilities and setting up a program to cover all ages, or to erect new facilities under" the same administration for the care of children only. The other is that separate facilities could be founded for these children in connection with one of t the present institutions caring for crippled children. It is extremely important that facilities be made available for this type of case as soon as possible. There do not appear to be large numbers of such chronically handicapped children yet, but even a. few of these constitute quite a prob-lem in the family as well as in the community. The effects on the mother and father, as well as on the other children of the family, as they try to do the impossible for a child who is too heavy to be lifted and cannot help himself, are devastating. The effect on the child himself is equally so. Dr. Simpson's suggestion for a hospital-school-vocational center for these patients appears to be a good one in that i t provides for the child instead of just moving him somewhere—anywhere. The establishment of a convalescent home or a foster home program to care for crippled children is an absolute necessity. At present child-ren are kept in hospital when-only out-patient care is required or they are returned home without the assurance of continued care. In the case of a good foster home program which, ideally speaking, would be what is de-sired, i t would be wise to enlist foster parents for a program for handi-capped children. Although the difficulties in obtaining foster homes at a l l constitute an ever-present problem, this problem is not insoluble by any means, and has been overcome in other places. In Boston, for instance, a private social agency has been concentrating its efforts for more than half a century in the field of placing convalescent children from hospitals into foster homes. It is true that more than one child is placed in the home but the children do have a mother and a father both interested in them. There are specialized home-finders to make the plan more successful and social workers complete the plans by their working with and interpret-ation to the foster parents, the child, and the child's own parents, where they are involved. The expense involved in this plan may appear to be high in terms of dollars and cents. In terms of the hospital days i t saves and the services i t provides to the child, in addition to the satisfaction i t gives to the foster parents and reassurance to the child's own parents, the cost fades almost into insignificance. However, until such a program could be worked out and sufficient staff trained, a. temporary solution might l i e in the erection of convales-cent homes in different centers where medical facilities are available; but i t would be necessary for these to be staffed by good foster parents who could care for the children. There should be adequate grounds for recreation and the location should not be too far away from other people. In this respect, the present Solarium facilities could be used as a summer camp and for convalescent care during the summer months. Such an arrange-ment could be the foundation on which a good program for recreation could be built, as i t would be a means of providing the children with camping privileges. In this way there would be a further rounding-out of the pro-gram to build the child's body. A third recommendation is made in connection with the facilities for the crippled child's education. At least one school should be made available for crippled children of a l l ages along the lines of the School for the Deaf and Blind, under the direction of the Provincial Department of Education, serving crippled children from every part of the Province. This school should be located near a vocational school and training center and should work in close co-operation with them. Training for spastic children should be included in the school, the rehabilitation center and the vocational school. These are expensive programs to operate and i t i s in this area, for one, that government participation is most necessary be-cause i t is in the interest of the community at large that these people be made as self-supporting as possible. In addition, there could be voca-tional training carried on in the Children's Hospital and the Solarium for in-patients so that the youngsters might start to develop their faculties as early as possible while their bodies and minds are s t i l l pliable. After the results of the survey have been studied and made known, i t is likely that teachers should be made available for those home-bound children in the districts at. least until the youngsters are of an age where they can cope with the Correspondence Courses, after which time the teachers could visit but infrequently and as the child required. There is l i t t l e point in educating and training any person, and this applies to the crippled child also, i f he is not going to be able to use that education as a means to self-support and future enjoyment of l i f e . In discussing employment services the question is likely to arise as to how, when there is an abundance of labour on the market, is employment going to be made available for cripples. Good work is being done in this connection for the blind. The training should be geared to take in a l l a.ges from the very young to the older crippled child as should the voca-80. tional center. There is a special placement division at the National Employment Service, but this service is limited when there is an over-sup-ply of labour,' and for this reason a. social service department would be a. necessary part of any rehabilitation or vocational center offering help to crippled children or adults, to offer proper placement of the trainees. In addition, however, i t is recommended that when a. vocational school is opened, curative work-shops be provided for the crippled child and that employment in the form of sheltered work-shops and for the home-bound be found. - In this connection, i t has been said that there is l i t t l e that is worse for a handicapped person than to be kept occupied merely with busy work-, because, i n all likelihood, i t brings back to him his early memories of being overprotected and rejected, when he is willing to make articles and they are not wanted, or when he is willing to accept as much responsi-bility as possible and is not allowed to do so. The last involves a program that is more embracing than that which the carrying out of these recommendations would bring about. They deal with parts of the child; the care and treatment of hisphysical body, the education of his mind, the training of his faculties, and the use of these faculties, later in l i f e , through employment. But there is more to the child than his body, his mind and his faculties. There is thai inner self around which these a l l revolve, that self that alone is responsible for and capable of seeing thai any services given to alleviate or cure any defects of its outward manifestations are used. It is .the most important part of the person, the part that must be developed, the part that must have its pity towards itself dissolved because its distorted view of the world has been straightened as the dust of environmental cruelties, of de-privation, of the jeers and scorn of enemies and friends alike, are removed. It would appear that i t is because of the knowledge of this inner part of the child, and its importance has been proved over and over, that the quot-ation maderearlier, was stated: "Even the finest programs of medical care and education are ineffective in the face of social maladjustment, there-fore, provision of medical social service to programs for handicapped children is required to meet the problem of personal and family adjustment and a myriad of other difficult situations faced by the handicapped and 1 their parents." It is true that some of the severely maladjusted children suffer-ing from crippling conditions will require psychiatric care, but the majo-rity of them will require, at the most, skilful casework services i f these are offered soon enough and with sufficient intensity to meet their needs. This is even more so with crippled children, than with other children as a group, because many times the crippled child is forced, for the sake of treatment, to move out of his home, and removal from the home of a small, even healthy, child is usually accompanied by a somewhat difficult readjust-ment. More serious is the fact that everyone must face, even somewhat re-luctantly, that the parents of these children, with their out-dated ideas of medicine, their comparing what they call failures in treatment of other children with their own child, and their own fears, are constantly, even by their fears and insecurity, influencing the child, and increasing his in-security and confusion, which in. turn decreases his ability to use the services offered for his benefit. Let i t be taken for granted that social services facilitate the 1. Hodges, Margaret B., "The Crippled," The Social Work Year Book, JJ>!-9. Russell Sage Foundation, New York, 19U°, p. 161+. child's movement to and from hospital, that they save the hospital and the community money, and that they smooth rough relationships in many places. Nevertheless, these are not the most important functions of the social ser-vices. These are the results of the child's being brought, as well as his parents often, to the place where he knows himself, he knows what his con-dition is, the most harm i t can cause him, and that he has a. right to a happy, productive l i f e ; not only that he has a right to i t but that i t i s his for the taking. The institutions that care for crippled children in British Columbia have not extensive social services. The Children's Hospital could make use of at least one social worker for the in-patients and of probably more than one in the out-patient department. The Solarium also is offering incomplete service to the child because there is no worker to give the necessary casework from which the child would and should benefit. Because the social aspect of the child's l i f e is a major one, i t is necessary to have sufficient personnel to meet the needs in this field. There may be a shortage of medical social workers in the Province at pre-sent, but there is no reason why this shortage should continue. However, to channel social workers into the medical social work field, i t is neces-sary to offer them something worth while in the way of job placement. The fir s t consideration would be that there should be a realization that social workers are not employed to round out a service to meet modern standards only, but because they have their place in the institution or center, a place which only they can f i l l and a contribution to make to the care of crippled children that only they can make. In turn, the social worker should be given a chance to develop and. study in connection with the job and should be able to co-operate to good purpose with the other professions in the setting, secure in the knowledge that this co-operation is recipro-cated to the ultimate benefit of the crippled child. It seems that too often, in this study, the fact has been mentioned that without one service' or another the program would not be well-rounded. It is repetitious, but because i t slips in so naturally, i t seems to show that all. the services and facilities mentioned are extremely necessary to provide adequate care and treatment for the crippled child. From this emerges the most important recommendation of the study and that is, that starting with the present facilities, with their gaps and overlappings, co-operation between a l l the persons, agencies, and professions concerned with the meeting of the needs of crippled children, would almost double even the present services. It is here that a l l professions must work to-gether, even to the point of submerging their identity, while still'being aware of the function and contribution of each, so that the crippled child might be granted all his rights and be given an opportunity for a f u l l and happy and useful l i f e . 8U B I B L I O G R A P H Y 1. Children's Hospital (for sick and crippled children), Annual Report, Vancouver, B. C, 1925-19U9. 2. Department of Education, Junior Red Cross, Victoria, B. C, 191*6. 3 . Health Centre for Children, Annual Report, Vancouver, B. C, June, 19U8-May, 19U9. h. Hodges, Margaret B., "The Crippled," The Social Work Year Book, Russell Sage Foundation, New York, 19 U9. 5. Hopkirk, Howard W., Institutions Serving Children, Russell Sage Foundation, New York, 19UU. 6. Levy, Florence, "Meeting the Needs of Orthopedic Children," The Family, Vol. XXIII, No. 3, May, 19U2. 7. Junior Red Cross, Annual Report, Vancouver, B. C, 19^9. 8. Ontario Society for Crippled Children, Annual Report, 19U7, 19 U8. 9. , Variety Village, a paper. 10. Paterson, Donald, "Children's Health Centres and Their Uses," Canadian Medical Association Journal, Vol. 62, 1950. 11. Queen Alexandra. Solarium, Annual Report, Victoria, B. C, 1929-19U9. 12. Simpson, Glenn, A Brief on the Co-ordination of Services for  Physically Handicapped Children in British Columbia, Victoria, B. C, 19U7. 


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