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Mental health clinical services; a study of the children between 6 and 12 years of age examined by mental… Roberts, Evelyn Marie 1949

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MENTAL HEALTH CLINICAL SERVICES A study of the children between 6 and 12 years of age examined by Mental Health Clinics i n Vancouver from 1945 to 1947 inclusive by Evelyn Marie Roberts Thesis submitted i n Pa r t i a l Fulfilment of the Requirements for the Degree of MASTER OF SOCIAL WORK in the Department of Social Work 1949 University of Bri t i s h Columbia ABSTRACT There are 2 organizations in Vancouver, the Child Guidance Clinic and the Mental Hygiene Division of the Metropolitan Health Committee, which offer services to maladjusted children. No descriptive account of the work of these 2 clinics has been previously written, particularly from the view-point of the social worker. Accordingly, this study undertook a review of the clinic records of a particular group of patients, namely, children of elementary school age, to throw light on the problems and needs in this field. The criteria set for the selection of cases was threefold. (1) The examination took place within a 3 year period (1945 to 1947). (2) Patients were those between the ages of 6 and 12 years, with intel-ligence quotients of at least 80, who had lived with parents or r elatives at least until the age of 5 years, or were s t i l l living with them. (3) The children were confined to those residing in Greater Vancouver. The number of cases which satisfied these criteria was 257. These cases were classified into 4 groups on the basis of "problems" or symptoms of maladjustment which led to clinical examination. The classifications adopted distinguished (1) socially unacceptable behaviour, (2) personality reactions, (3) habit disorders, (4) disabilities in specific school subjects. The proportion which this group of 257 cases bears to the total number of cases examined by the clinics is examined, and an attempt is made to demonstrate to what extent the clinical population is a cross-section of the general population, but gaps in information in the clinic records make this possible in part only. A further sample was selected (on a one-in-five basis)from each of the four classifications, in pro-portion to the number of cases examined by each clinic, as well as to the number of boys and girls in the total survey. More detailed information was obtained from the clinic records on the 52 cases which comprised this sample. An analysis of this material, with the use of case illustrations, throws light on the work of the clinics, and on the factors of disorganiz-ation existing within the family and the community which contributed to the maladjustment of the children. The clinical recommendations for the treatment of children are outlined, and so far as possible an evaluation of the outcome of treatment is made. There is evidence that emotionally disturbed patients might be better served by the clinics i f more adequate community resources for mentally retarded children existed, thus reducing the number of clinical examinations of such children. More awareness on the part of parents of the availability of clinic services would undoubtedly lead to the earlier referral of many children requiring this kind of help. Improvement of the working relationships between the 2 clinics and between the Child Guidance Clinic and the schools would be beneficial. The enlargement of the Mental Hygiene Clini c staff to include social workers would result i n a better integrated c l i n i c a l service. A third psychiatrist on the Child Guidance Clinic staff would overcome some of the present lacks i n c l i n i c services. A treatment and observation centre for emotionally disturbed children i s greatly needed in this community. In many instances, staff members of social and health agencies responsible for the preparation of social histories would benefit from brief c l i n i c a l orientation and discussions with the members of the c l i n i c team on the subject of history taking. The addition of a group worker to c l i n i c teams would enhance the services to maladjusted children. ACKNOWLEDGEMENTS I wish to acknowledge great indebtedness to Dr. &.L. Crease, Provincial Psychiatrst, and Dr. C.H. Gundry, Director of the Mental Hygiene Division of the Metropolitan Health Committee for their per-mission to u t i l i z e the c l i n i c records for research purposes. I am also indebted to Dr. U.P. Byrne, Director of the Child Guidance Clinic, and to Dr. C.H. Gundry for their help through interviews regarding c l i n i c a l services. Special acknowledgement i s made of the helpfulness of Dr. L. C. Marsh, of the Department of Social Work who gave generously of his time and professional advice during the preparation of this study. TABLE OF CONTENTS Chapter 1. Child Guidance Clinics The development of child guidance.Contributions of Meyer, Freud, and Rank. Varying conceptions of the role of the c l i n i c i n relation to parents of children. Goals and methods of treatment. Chapter 2. The Clinics i n Vancouver Policies, functions and procedures of the Child Guidance Clin i c and the Mental Hygiene Clinic. Work loads of each of the c l i n i c s . Chapter 3. The patients and Their Families Sources of referral. Distribution of cases according to symptoms presented, and age, sex, intelligence, etc., of patients. Family disorganization factors. Racial origin, religion, residence of -parents. Size of families and ordinal position of patients. Chapter 4. Social Histories The purpose of a social history. Data concerning children and their parents revealed i n the histories. Gaps i n the social histories. Chapter 5. Socially Unacceptable Behaviour Incidence of symptoms i n various age groups. Social disorgani-zation factors. High incidence of unfavourable circumstances i n f i r s t three years of patients 1 l i v e s . Case ill u s t r a t i o n s . Chapter 6. Unfavourable personality Reactions Various age groups showing these symptoms. School and group adjustment of patients. High incidence of harsh or r i g i d parental discipline. Case ill u s t r a t i o n s . Chapter 7. Children presenting Habit Disorders Various age groups represented. High incidence of patients from larger families. Marked parental discord as a contributing factor. Case illustrations. Chapter 8. Children Showing Disabilities i n School Subjects Incidence i n various age groups. Less evidence of family and social disorganization factors. High incidence of unfavourable c i r -cumstances during the f i r s t three years. Case il l u s t r a t i o n s . Chapter 9. Recommendations and Results Five classifications of approaches to treatment. Results as indicated i n c l i n i c records. Chapter 10. Future Goals Clinic expansions during the post-war period. Need for improved community resources. Public relations of c l i n i c s . Social case work i n the schools, and i n the Mental Hygiene Clinic. Extension of treatment services. Group work representation on c l i n i c teams. Appendices: A. Mental Health Clinics i n Canada B. Forms i n use by the Child Guidance Cl i n i c C. Forms in use by the Mental Hygiene Clinic D. Schedule used i n collecting information from c l i n i c records E. Bibliography TABLES AND CHARTS IN THE TEXT (a) Tables Page Table 1. Distribution of Cases by Examining Clinic and Problem Referred 28 Table 2. Distribution of Cases by Source of Referral 29 Table 3. Boys and Girls i n Various Groupings 32 Table A. Distribution of Cases by Age 35 Table 5. Distribution of Cases by Intelligence Level 36 Table 6. Distribution of Cases by Family Disorganization Factors 4-0 Table 7. Distribution of Cases by Other Contributing Factors 41 Table 8. Distribution of Cases by Size of Family 42 Table 9. Distribution of Cases by Ordinal Position i n Family A3 Table 10. Distribution of Cases by Length of B r i t i s h Columbia Residence AA Table 11. Religious Denominations 46 Page Table 12. Parents' Formal Education 50 Table 13. School Record 63 Table 14. Frequency of Types of Recommendations Made at Clinic Conferences 122 Table 15. Adjustment Status of Patients 131 (b) Charts Fig. 1. Distribution of Cases in Both Clinics According to Age 26 Fig. 2. Proportion of Cases in This Study to the Total Number of Children Examined 27 Fig. 3. Distribution of Cases by Intelligence Levels 37 Fig. 4-. Theoretic Distribution of Intelligence 37 Fig. 5. Distribution of Intelligence of Child Guidance Clinic Cases. (All private cases 6 to 12 years - 1947) 38 1 CHAPTER 1. CHILD GUIDANCE CLINICS Psychiatric c l i n i c s for children on this continent have passed through three main phases of development. The f i r s t of these was the early work of mental hospitals and schools for the feeble minded. This was concerned chiefly with reducing the number of admissions to i n -stitutions. The c l i n i c opened in 1897 under the direction of Dr. Walter Channing at the Boston Dispensary marking the beginning of c l i n i c a l work with children. Dr. Channing was particularly interested i n the problem of feeblemindedness. Other state hospitals began to offer c l i n i c ser-vices, and by 1914 i n both New York and Massachusetts, provision was made for the establishment of out-patient departments and c l i n i c s i n each hospital. Each of these was to serve as the mental health centre in i t s d i s t r i c t . However, most of these early c l i n i c s regarded mental disorders as organic diseases. A second development was the opening of c l i n i c s for juvenile delinquents. These c l i n i c s , which numbered more than 100 i n the U.S.A. by 1914, were concerned with the prevention of crime. To William Healy and his associates i s given credit for the inauguration of the f i r s t coordinated effort i n child guidance i n 1909. This was i n connection with the Chicago Juvenile Court. Healy's work created a wide-spread interest i n child l i f e and there was rapid growth i n the number of c l i n i c s functioning with courts, schools, general hospitals, medical schools and mental hospitals. Most of these i n their early years were 2 l i t t l e more than mental testing laboratories. Gradually, the procedure and point of view of these clinics was influenced by clinical psychiatry and genetic-dynamic psychology, and by 1921 the general public was ready to respond to the search for better ways of dealing with the health and conduct of childhood. In the early twenties, a new stage was marked by the Common-wealth Fund's program of demonstration child guidance clinics which waa itself, in part, a fusion of the interests of the two first mentioned developments. This program was under the direotion of the National Committee for Mental Hygiene, through its Division on Prevention of Juvenile Delinquency. During the five-year program which was under-taken from 1922 to 1927 almost 500 clinics serving about 40,000 children were set up. These were distributed throughout most of the United States and one was established in Canada. The plan included not only the training of members of the clinic team, i .e . , psychiatrists, social workers, psychologists and nurses, but also the promotion of visiting teacher services in the public schools. The aim of child guidance today has been stated to be the offering of help to children who are handicapped chiefly by emotional difficulties. The delinquent and the potentially psychotic patients are s t i l l served, with varying degrees of success; but children whose maladjustments are not severe, yet serious enough to hinder them from the full utilization of their capacities, also come within the scope of the clinic's services. Psychiatrists, psychologists, social workers and nurses work as a team in the study of the children. The generally 3. recognized proportion for a clinic team is: one psychiatrist, two psychiatric social workers, one psychologist and one nurse. On this continent and in Europe, several scientists studying child psychiatry have contributed much to present-day child guidance. Adolph Meyer's emphasis on the uniqueness of each individual, and the importance of studying his total l ife history, his intellectual and physical equipment in order to understand his disorder, was an impor-tant contribution. To Freud, child guidance owes three important con-cepts, namely, the theory of the dynamic influence of the emotions (both those of the patient and of his family) on human behaviour,- the view that a l l behaviour is purposive, though its motivation may be un-conscious and non-rational} and the belief that each individual has some capacity for self-direct!on and that therapy and education can only provide a favourable setting for the development of latent abilities. Otto Rank, a Viennese psychoanalyst, elaborated on this last-mentioned concept and gave i t a somewhat different theoretical basis. He empha-sized the constructive capacities of the human wi l l , but stressed the necessity of working with the patient with regard to his present feelings rather than to his past experiences. Common to the systems of psychiatry developed by Meyer, Freud and Rank is the concept that behaviour is meaningful. The symptoms of a patient represent his attempts to solve his internal and external dif-ficulties. He may meet conflicts by striking out at himself or at his environment; he may try to deny them by withdrawing from reality and man-ufacturing a dream world of his own, or he may become over-conf orming in 4 an effort to propitiate the forces which he considers to be the cause of his frustration. Of course, many patients present symptoms which are a combination of two or more of these methods of making l ife more endurable for themselves. Symptoms, therefore, cannot be regarded as disorders in themselves. Dr. Ernest Jones describes them as "products of an attempt to heal the underlying disease."(1) No diagnosis can be static, since the patient wil l respond to the new internal situation after each suc-cessive attempt to satisfy his needs. Treatment of symptoms, without alleviation of either the in-ternal or external stress, is of l i t t l e avail. Therapy must take into consideration not only the relieving of stress, but also the patient's feelings about taking help. There is general agreement in these various schools of child psychiatry that the basic requirement for therapy is bringing to light, and accepting in a non-judgmental way, the patient's feelings about his present situation. Psychiatrists differ in the use which they make of this information after i t is obtained. There are two types of child psychiatry outside of child guidance. One is an out-growth of non-Freudian adult psychiatry. This method, of which Leo Kanner is an exponent, assesses after careful four-fold examination (social, psychological, physical and psychiatrid), the patient's strengths and weaknesses, and then sets out to develop and correct them by strengthening the patient's conscious desires. In some (^Jones, Ernest, "Psychoanalysis and Psychiatry", Mental Hygiene Vol. XIV, 1930, p. 393. 5 instances the psychiatrist works directly with the child, and in others through information and advice given to the parents. Parents are ex-pected to "do something directly for their offspring or more indirectly work on themselves in their behalf. • (1) The second method, that of psychoanalysis, endeavours to allay unconscious conflict, but leaves the child free to choose his own way of l i f e . Generally speaking psychoanalysts consider the parents either as persons whose cooperation is required in order for the child's treat-ment to continue or as sources of information. Early in its development, in contrast to these two approaches to child psychiatry, child guidance began to regard the parents as well as the child as patients. More and more emphasis was placed on services to parents, and this entailed great changes in the role of the social worker, because work with the parents was chiefly her responsibility. In 1932 a survey of the New York Institute for Child Guidance, revealed that two-thirds of the children under nine years of age classified as "treatment cases" had less than three interviews with a psychiatrist. In two-thirds of the "full-study" cases, the parents were not interviewed by a p s y c h i a t r i s t . ^ similar survey of the Judge Baker Guidance Centre the next year revealed that treatment there, also, was carried on largely by social workers, through work with parents, teachers, social agencies, and in some cases with the children themselves. (•^ Kanner, Leo, Child Psychiatry. Springfield, Illinois, Charles C. Thomas, 1946 p. 126. ^Witmer, Helen Leland and students, "The Outcome of Treatment in a Child Guidance Clinic", Smith College Studies in Social Work, Vol III, 1933 p. 378-380. 6. Child guidance was begun with the viewpoint that the social worker's role was that of making the social history as complete as pos-sible, for the psychiatrist's use, and after his examination of the patient seeing that his recommendations were understood and carried out. As i t became more apparent that many of children's problems could be traced to unhealthy parental attitudes, the work of treating the parents was left to the social worker. Out of this came the recognition that the principles of dynamic psychiatry apply to parents as well as to children. Social workers then had to learn from psychiatrists about theory and techniques for the treatment of parents. There are two distinct types of clinics, classified according to the way in which they regard their function of working with parents. In one of the social worker's help is made available to parents because they are likely to be worried about their children, and wish to have an opportunity for discussion of problems with a professional person. This type of clinic makes no attempt to help parents solve their own.person-ality problems. Clinics of the second type see their function as working toward a change in parental attitudes, in particular those of the mother, in order to achieve better mental health for the child. In the first type, the parents' wishes become the focal point of treatment. The social worker becomes the psychiatrist's colleague rather than his assistant, when work with several members of a family is involved. Dr. Witmer in her study of psychiatric clinics for children describes cleavages within the child guidance field as having two 7. characteristics.^) Some may be based on differences of opinion concer-ning the goal of treatment. Others grow out of differences i n the matter of treatment methods and lead to divergent conceptions about the relation of a c l i n i c to the various agencies with which i t works and even about , the basic function of the c l i n i c i t s e l f . The goal of treatment. Mental and penal institutions have traditionally operated more for the benefit of society than for their patients. Their social ob-jectives are the protection of society from further inconveniences and damage. Early c l i n i c s became another part i n the institutional apparatus of schools, churches, courts, etc., which moulds the individual to soc-iety's needs. The f i r s t c l i n i c s dealing with mentally defective and anti-social patients placed emphasis on those who needed treatment rather than those who wanted i t . In consequence, the i n i t i a l decision to en-l i s t the c l i n i c ' s help was not l e f t to persons most immediately concer-ned, namely, the patients and their parents, but came usually from those who found the children troublesome, such as schools, courts, and social agencies. Therefore, many came to c l i n i c under authoritative pressure and consequently were not inclined to be cooperative. The c l i n i c was interpreted i n terms of the removal of objectionable behaviour. I t i s hard for such c l i n i c s to reinterpret their objective, because patients and parents s t i l l f e e l that they have no choice as to whether they attend c l i n i c or not. (•^Witmer, Helen Leland, Psychiatric Clinics for Children, New York, The Commonwealth Fund, 1940, PP. 353-366. 8 An alternative point of view about child guidance work i s one that sees the treatment process as aiming so to strengthen the patient that he w i l l be able to work out his own kind of adjustment, less hand-icapped by emotional turmoil. This approach recognizes that there are many ways i n which individuals find satisfaction i n l i f e . It also recognizes that there are many circumstances beyond the c l i n i c ' s con-t r o l which influence the patient's a b i l i t y to desire professional s k i l l s of clinicians and to benefit from them. This i s based on the belief that under reasonably favourable circumstances each individual human being contains within himself forces that favour social adjustment. According to Freud, the demands of society are not alien to the child exposed to favourable conditions, but rather early i n his l i f e become an integral part of his personality. Dr. Rank holds that the patient can only be helped to find his own solution to his d i f f i c u l t i e s , and that the therapist "must refrain from moral evaluation of every kind". Clinics which accept these theories of individual needs and capacities do not become a part of the network of regulative institut-ions which attempt to adjust children to accepted social standards. Such c l i n i c s seek recognition i n the community as the agency of those individuals who desire their help. Methods of treatment Four general types of approach have been distinguished by Dr. Witmer. The f i r s t i s that of c l i n i c s whose work centres chiefly around attempting to make the environment an easier or pleasanter place i n which the patient may l i v e . These may either provide a new environment by 9. means of foster homes or institutions, or attempt to remodel the old onej the l a t t e r may be done by modifying parental attitudes or relieving their tension, interpreting the child to his teachers and other adults, and ameliorating the school environment. A second approach i s used by those c l i n i c s which attempt to find new outlets for the patient's energies or capacities, by the building up of new recreational interests, fostering of undeveloped talents, encouraging of a c t i v i t i e s i n which he i s l i k e l y to find sucdess. A third method i s that of remedying the patient's specific d i s a b i l i t i e s , physical and intellectual, that i s , of removing certain specific internal obstacles so that he i s put on a par with his fellows. A fourth pro-cedure i s that of direct dealing with the patient's psychic problems, the methods varying with the different therapists. This approach i s based on the assumption that the patient can make his own adjustment i f he i s helped to overcome to some extent his anxieties and his fears. In practice most c l i n i c s use a combination of these four approaches. Those who tend to emphasize self-direction for the patient tend to favour psychotherapy. Clinicians of most schools agree that the f i r s t alm i n therapy i s to create a situation i n which the patient i s free to express what he w i l l without the usual danger of incurring disapproval. Modifying en-vironment i s the traditional mental hygiene method. The Mental Hygiene movement originally aimed at providing a more understanding environment for the psychotic patient, and eventually moved into the f i e l d of child guidance because i t found that some of the conditions presumably leading 10 to psychoses were to be found in the misunderstandings and other envir-onmental deficiencies by which children are surrounded* The educational aspects of clinic work were always stressed by mental hygienists. Early clinics were set up as demonstrations, not only of what they could offer their individual patients, but especially of what the mental hygiene point of view had to offer the professional persons who were responsible for the care of children. Staffs gave numerous lectures and representatives of schools, courts and social agencies were invited to conferences, partly in order that they might learn to handle the problems themselves. This was forced, too, by the recognition that clinics could never hope to serve a l l the children who were maladjusted. Clinics basing their work on changing the individuals's en-vironment are necessarily interested in social and educational reform. Each patient may be regarded as a sample of community neglect. The alternative approach of clinics to their work is that of accepting the world as i t is (or at least holding that reform of the community does not l ie within their function) and concentrating attention upon helping patients make their adjustment to i t . Therapy for clinics with this approach is mainly for the patients and not a means of serving society's ends. They do not aim at reforming courts, schools, etc. The help they can give to other agencies is limited to what these clinics consider their specific task - understanding the child1s feelings and desires. Members of other professions dealing with children are accepted by such clinics as persons capable of making their own decisions as to what use 11. they s h a l l put the information given them about pa t ien ts . The c l i n i c a l in tegra t ion of the contr ibutions of psychiatry, phys ica l medicine, psychology and s o c i a l work i n the study of maladjusted chi ldren was i n s t i t u t e d i n Canada i n 1919. The f i r s t c l i n i c was estab-l i shed i n Toronto through the Canadian branch of the National Committee for Mental Hygiene. I t was a part of the Commonwealth Fund program of se t t ing up demonstration c l i n i c s . Since then, c h i l d guidance or mental heal th c l i n i c s have been established i n a l l provinces i n Canada except Prince Edward Island and New Brunswick. (1) A universa l handicap of these c l i n i c s was the shortage of s t a f f during the years of World War I I . The r e su l t i ng curtailment of services during a time when many chi ldren as w e l l as adults were exposed to greater emotional s t ra ins created an increased demand on c l i n i c fac-i l i t i e s as the nation emerged in to the post war per iod. Undoubtedly experience of s ta f f members who had been engaged i n psych ia t r i c work i n the armed services was invaluable i n that the r e su l t s of childhood maladjustments were demonstrated again and again i n deal ing with service personnel who needed treatment for psych ia t r i c disorders . Reject ion as w e l l as discharge revealed a high percentage of severely maladjusted adul t s . In the words of Dr. J.H.W. van Ophuijsen, Chief of the Psychiat-r i c C l i n i c of Lenox H i l l Hospi ta l "the war has shown with c r u e l c l a r i t y how s i ck a nat ion can be and has unmistakably indicated that after the f i g h t against tuberculosis , venereal disease, cancer, e t c . , our next. (•^A l i s t of the c l i n i c s i n Canada, w i l l be found i n Appendix A . 1 2 . enemy i s going to be the psych ia t r i c d isorder , i n the f i r s t place i n the form of psyche-neurosis.1 1 ( 1 ) ^ J e w i s h Board of Guardins, The Caseworker i n Psychotherapy. Jewish Board of Guardians, New York, 1 9 4 7 , p . 1 4 - . 13. CHAPTER 2. THE CLINICS IN VANCOUVER Mental health has been defined as "the adjustment of individuals to themselves and the world at large with a maximum of effectiveness, satisfaction, cheerfulness and socially considerate behaviour, and the ability to face and accept the realities. «(D The home, the school and the community each have important roles in helping children along the path of mental health to emotional maturity. In Vancouver, (2) parents and guardians, teachers, nurses, social workers and others, have access to two clinics when children show symp-toms of unsatisfactory deviation in mental and emotional development. The Provincial Child Guidance Clinic was opened in 1932. Four years later, the Mental Hygiene Division of the Metropolitan Health Committee, through the appointment of a mental hygienist began serving children whose emotional disturbances were apparent in the school situation. Both clinics have had many patients; at times many more than limitations in number of staff made i t possible to serve as adequately as they de-sired. Other than surveys of work loads for annual reports, there has been no research in- either clinic. Directors of both services welcomed a study of clinic cases, and files were readily made available for this purpose. ^White House Conference on Child Health and Protection quoted by Nat-ional Committee for Mental Hygiene, Mental Hygiene Bulletin. January-February 1931, page 1. (2)ihis refers to Greater Vancouver, throughout this study unless other-wise indicated. 14. The P r o v i n c i a l Chi ld Guidance C l i n i c This c l i n i c was formed i n Vancouver after a request by the P r o v i n c i a l P sych ia t r i s t t o the National Committee for Mental Hygiene for help i n a program for the prevention of mental i l l n e s s . The Committee was instrumental i n obtaining the services of the f i r s t p sych ia t r i c soc i a l worker and paid her sa lary for one year . A psychologist was added to the c l i n i c team f i v e years l a t e r . At f i r s t the c l i n i c was open for half-days only. The services have expanded great ly i n the intervening per iod . The Vancouver Ch i ld Guidance C l i n i c operates throughout the week. Usually 18 complete examinations per week are made. The patients come from Vancouver, North Vancouver, West Vancouver, and Burnaby. Pat ients from New Westminster, referred by Soc ia l Welfare Branch only, are a l so examined. During the years 1945-47 inc lus ive the number of pat ients given f u l l c l i n i c a l examinations at t h i s c l i n i c was 1,895. Of t h i s number, 1440 were under 18 years of age. The chi ldren who are given c l i n i c a l examinations range between the age of 6 months and 18 years. Adults whose maladjustments may con-t r ibute to emotional disturbance of ch i ldren are frequently the subject of consul tat ive conferences between the r e fe r r ing agency and the c l i n i c . In a l i m i t e d number of cases, such adul ts are examined at c l i n i c . The chi ldren studied at Chi ld Guidance C l i n i c can be c l a s s i f i e d i n three g r o u p s : ^ The f i r s t group i s made up of those ch i ld ren who express t he i r lack of adjustment i n symptoms of various k inds , i n the home, the school or the community. These symptoms may take the form of undesirable habi ts , personal i ty t r a i t s or behaviour. In the second group, ( 1 )Byrne, U . P . , " C h i l d Guidance C l i n i c s n typewritten interdepartmental paper. 15 a r e t h e "dependent" c h i l d r e n , who b e c a u s e o f i l l e g i t i m a c y , abandonment o r n e g l e c t o f p a r e n t s , o r homes b r o k e n b y d i v o r c e , d e s e r t i o n o r d e a t h w i l l d u r i n g t h e i r c h i l d h o o d be p l a c e d i n a d o p t i o n homes, i n s t i t u t i o n s o r f o s t e r homes . L a s t l y , t h e r e a r e c h i l d r e n who show r e t a r d a t i o n i n i n t e l -l e c t u a l deve lopment s u c h t h a t t h e y a r e u n a b l e t o compete s u c c e s s f u l l y i n t h e o r d i n a r y t y p e s o f i n t e l l e c t u a l work r e q u i r e d o f t h e m . The s e r v i c e s g i v e n b y t h e C h i l d G u i d a n c e C l i n i c a r e d e s c r i b e d i n t h e A n n u a l R e p o r t o f t h e S o c i a l W e l f a r e B r a n c h (1947-48) a s (1) t r e a t -ment (2) d i a g n o s i s (3) c o n s u l t a t i o n . T r e a t m e n t c a s e s a r e . t h o s e i n w h i c h a f t e r d i a g n o s i s , p a t i e n t s a r e s een b y t h e p s y c h i a t r i s t on a t r e a t m e n t -i n t e r v i e w b a s i s , o r b y c l i n i c s o c i a l w o r k e r s and p s y c h o l o g i s t s u n d e r t h e d i r e c t i o n o f t h e p s y c h i a t r i s t . T h i s s e r v i c e i s a v a i l a b l e f o r t h e c l i n i c ' s p r i v a t e p a t i e n t s ^ ) o r f o r p a t i e n t s r e f e r r e d b y a g e n c i e s on a c o - o p e r a t i v e b a s i s . ( 2 ) C h i l d G u i d a n c e C l i n i c c a s e s r e f e r r e d t o t h e c l i n i c b y s o c i a l a g e n c i e s o r b y m e d i c a l a n d h e a l t h a g e n c i e s a r e g i v e n d i a g n o s t i c s e r v i c e . E a c h " c h i l d and h i s s i t u a t i o n i s s t u d i e d i n whole o r i n p a r t , a p s y c h i a - * t r i e and p s y c h o - s o c i a l d i a g n o s i s i s made and p o s s i b l e s o l u t i o n s t o p r o -b lems c o n t a i n e d w i t h i n t h e s e a r e a s a r e t h e n p r e s e n t e d . T h e C h i l d G u i d a n c e C l i n i c , however , h a s no a c t i v e p a r t i n t h e s u b s e q u e n t p r o g r e s s o f t h e (1)Private p a t i e n t s a r e t h o s e r e f e r r e d t o c l i n i c n o t b y s o c i a l o r h e a l t h a g e n c i e s b u t b y t h e i r p a r e n t s , p r i v a t e p h y s i c i a n s , s p e e c h t h e r a p i s t s , k i n d e r g a r t e n s , e t c . (2) C a s e s p r e s e n t e d f o r c l i n i c a l e x a m i n a t i o n and f o u n d t o b e i n need o f i n t e n s i v e p s y c h i a t r i c t r e a t m e n t , a r e i n some i n s t a n c e s , i n t e r v i e w e d r e g u l a r l y a t t h e c l i n i c . The a g e n c y m a k i n g t h e r e f e r r a l may c o n t i n u e t o g i v e o t h e r s e r v i c e s t o t h e c h i l d a n d h i s f a m i l y i n s u c h c a s e s . 16. case. The value of this service depends on the responsible agency ade-quately equipped to make the social study, to make use of the c l i n i c ' s findings, and to carry out the c l i n i c ' s psychiatric recommendations. In the diagnostic service, treatment i s delegated by the c l i n i c psychiatrist i n conference to the referring agency. A consultative service i s one i n which the c l i n i c ' s services are given to any person interested i n the child, but where there may be no actual contact on the part of the c l i n i c with the child. Social and health workers have used the service to discuss the psychiatric problems of their clients with the psychiatrist and the other members of the c l i n i c team. One afternoon each week i s set aside at the Child Guidance Clinic for Family Welfare Bureau or Children's Aid Society consultations. Such conferences are arranged for other agencies when requested. (2) There are five procedures within the Child Guidance Clinic, i n the study of patients, namely, the social history, the physical, psycho-logical and psychiatric examinations and the conference. In the social history a vi v i d picture of the child l i v i n g with his parents or foster parents, i n his home, school and community i s desirable. A psychiatric social history outline^) i s provided by the "Annual Report 1947-48", Welfare Branch of the Department of Health  and Welfare. King's Printer, Victoria, 1948, p. 128. (2)During the f i s c a l year 1947-48, 198 consulting conferences were held at the Vancouver Child Guidance C l i n i c . (^Appendix B (1) 17. c l i n i c as a guide. The c l i n i c requests that four copies of each history (one for each member of the c l i n i c team) should be received at c l i n i c at least 2 days prior to the examination. In compiling the social history, the social worker describes the various aspects of the c l i n i c a l examin-ation, i n order that the parents may prepare the child for the new ex-perience of attending c l i n i c . Private c l i n i c patients, i f they are apprehensive about the examination, are shown through various parts of the c l i n i c , and meet the nurse, psychologists, and receptionist several days before their appointment date. The physical examination(^) i s necessary i n recognizing those cases i n which the disturbance i s due to organic lesion within the central nervous symstem. In other cases, i t frequently aids i n under-standing the behaviour and may disclose defects such as dental caries, birth marks and other disfiguring features which may have a damaging psychological effect on the child. The c l i n i c nurse prepares each patient for the physical exam-ination, explaining f u l l y the doctor's procedures, and assuring the patient that nothing discomforting w i l l be done. Vision testing (Snellen Scale), hearing test (speaking voice or audiometer), weighing, measuring, and urinalysis are done by the nurse. Following these tests, the nurse assists the psychiatrist with the physical examination. The physical room at the c l i n i c i s set up to appear less austere than a general hospital examining room. The psychiatrist does not don the traditional white coat and the nurse wears a colored smock, (^Appendix B (2) 18. rather than a uniform. Parents and familiar adults are invited to remain with the child during examination i f he appears at a l l insecure. There are no hard and fast rules regarding lying f l a t on the examination table, undressing completely, or saying "ah". When treatment of physical defect i s recommended, the child's parents or guardians are referred to the . family physician or school health services. The public health nurse makes play room observations0-) of patients. In preparing each patient for the physical examination as well as i n observing him i n the play room or waiting room the nurse has an opportunity to see many aspects of his behaviour. These observations which are usually made over a longer period of time and under circum-stances different from those of other members of the c l i n i c team and are valuable i n supplementing their reports on the child's behaviour. The psychological examination^) i s concerned with the eval-uation of the child's innate a b i l i t i e s , educational achievements and special aptitudes. In making this evaluation the c l i n i c a l psychologist may use standardized intelligence tests, tests of special a b i l i t i e s , personality schedules and interest blanks.^) The results of these tests enable the psychologist to predict within certain limits the maximum school achievement to be expected of a particular child; and the child's chance for success i n some vocations. Having discovered any special d i s a b i l i t i e s , the psychologist may recommend special tutoring and treat-(1) Appendix B (3) ( 2) Appendix B U) (^Appendix B (5) l i s t s the tests used by psychologists at the Child Guidance Cl i n i c . 1 9 . ment to overcome them. Recommendations regarding school grade placement may be made by the psychiatrist, when the results of the psychological examination indicate that the child is misplaced. A program of remedial reading is carried on by the psychological department of the clinic for a limited number of the children found to be in need of i t . In the psychiatric examination, the psychiatrist through his special training is in a position to view the inter-relationship of the physical and the mental. The psychiatrist's special contribution in understanding the child is the discovery and elucidation of the child's inner motives, as these are revealed by his behaviour in the interview situation. The ini t ial interview paves the way for treatment interviews later on, i f these are considered necessary in the staff conference. The psychiatrist also interviews both parents, either separately or together, in a l l cases in which the parents accompany the patient to the clinic. In many instances the mother only, comes to clinic with the patient. The understanding and co-operation of both parents is considered so important by the clinic that time schedules are adjusted to make possible at a later date, interviews with fathers who were unable to attend clinic at the time of their children's examination. At the conference which is held after the completion of the four procedures outlined above the psychiatrist acts as chairman. The other three members of the clinic team as well as the worker from the social or health agency participate in the conference. In private clinic cases, i f the parents have given consent, the school principal and the patient's teacher, • as well as the public health nurse in the school, are 20. invited to attend the conference. In some instances these persons axe invited to conferences on cases presented by other agencies. The aim of the conference is to define reasonable treatment objectives and the pros-pects of attaining them. This may involve a decision to use direct therapy, treatment of one or both parents, manipulation of the environ-ment or a l l three. Al l plans are subject to revision i f changing circum-stances indicate the need for this. Further conferences may be held in such cases, with the workers responsible submitting additional histories or progress reports covering the intervals between conferences. The Mental Hygiene Division of the Metropolitan Health Committee In this division, formed in 1936, much of the mental hygien-is t ' s^) time was at first devoted to the establishment of clinical services for public school pupils. The School Health Service program, which at that time was under the jurisdiction of the Public School Board, was thus supplemented by the Metropolitan Health Committee. The mental health program which developed was curtailed for nearly three years during World War i i because the services of a psychiatrist could not be obtained. In January 1946, the clinical work was resumed. During the years 1946 and 194*7 the total number of patients examined was 426. Of this number, 9 were adults, 41 were pre-school children, and 376 (88 per cent) were between the ages of 6 and 8.^) The following description of the clinics' policy and procedures (^The term "mental hyglenist" rather than "psychiatrist" is generally used by the Metropolitan Health Committee. ^Based on statistics quoted in Annual Reports of The Division of Mental Hygiene, Metropolitan Health Committee, Vancouver for years 1947 and 1948. 21. i s based on information found i n the two sources acknowledged below.^ The object of the program of the Mental Hygiene Division i s the promotion of mental health. Types of problems suitable for study by the c l i n i c are outlined as follows: "Poor group adjustment - timid, insecure children -the nervous child. Poor attitude toward authority - dependent, unres-ponsive children, disturbing behaviour. Physical disturbances associated with emotional tension - t i c s , speech defects, unco-ordinated movements. Presence of neurotic symptoms - tendencies to make use of symptoms to evade challenging situations. Delinquency problems - stealing, lying, truancy, begging, etc.'! School nurses are expected to consider that problems of be-haviour and signs of undue emotional tension demand attention just as urgently as do physical defects. Early personality problems are to be brought to parents' attention i n the same way as other defects, and the correction of early faults i s emphasized as a means of safe-guarding future health. Parents, school medical officers, teachers, and others as well as nurses may make referrals to the c l i n i c . Clinics are held i n the offices of the Health Units and the schedule of appointments i s arranged by the Unit Supervisors of Nurses. Usually one c l i n i c per month i s held i n each unit. (2) Teachers wishing to have children examined at c l i n i c discuss the matter with their principals. (1) Nurses' Manual "Metropolitan Health Committee F a c i l i t i e s for Diagnosis, Treatment or Consultation". Gundry, C.H. - Memorandum for Directors of Units, Metropolitan Health Committee, and School Principals. Re Mental Hygiene Clinics, Vancouver 1946. (^There are 6 Health Units i n Greater Vancouver. 22 In each case in which a decision is made by the teacher and principal that a pupil requires clinical examination the school nurse is asked by the principal to visit the child's parents to obtain their con-sent and co-operation. Having done this, the nurse clears the case with the Social Service Index. If the case is under the active supervision of a social agency, an appointment with the case worker is made for the pur-pose of discussing information for the social and family history.(-0 If the case has been closed by the social agency, the nurse requests a resume of the agency's previous contact. The nurse then prepares the social and family history. The child's teacher prepares the school history^) in duplicate, one copy for the principal's records and one for the clinic. Unless there is an individual intelligence test rating or a recent group test score that is consistent with the child's general performance, i t is recommended that referral to the Bureau of Measurements be made, before examination at the Mental Hygiene Clinic. The school nurse then makes an appointment with the unit supervisor for the child to be seen at the clinic. The parents, or one of them, or the person in loco parentis are asked to come to the clinic at an appointed time arranged with the Unit Supervisor of Nurses. If a child is under the care of a private physician the Unit Director (School Medical Officer) or the Unit Supervisor consult him regarding the clinic study and invite him to attend the conference. (•^ Appendix C (1) (2)Appendix C (2) 23. « It is the responsibility of the school nurse to notify the parents of the time and place of the child's psychiatric examination. Usually only three patients (2 in the morning and 1 in the afternoon) are examined on a clinic day, the last part of the afternoon being used for conferences. Those persons legitimately concerned with a case are invited to the conference. These might be any or a l l of the following: school principal, teacher, psychologist (Bureau of Measurements), school counsellor, school attendance officer, social worker, private physician, public health nurse, Unit Director, Unit Supervisor, School Medical Officer (if other than the Unit Director). The school nurse notifies interested parties of the time and place of the conference. These conferences are considered to be the Division's most important method of teaching mental hygiene. "The Public Health Nurse and Unit Supervisor, should grasp every opportunity to interpret the value of the conference, stressing that members attend not only to secure information, but also to contribute to the round table discussion. The place of the Mental Hygienist should be that of consultant and advisor. "(1) Written reports of clinic study are sent by the mental hygienist to the Unit Director, - (attention of Public Health nurse referring the case) and to the School Principal - (attention of the teacher and coun-sellor) . Written reports are also sent to social agencies and to private physicians in cases in which they are concerned. Six months after the. in i t ia l examination, the school nurse is expected to submit a progress (!)Nurses' Manual "Metropolitan Health Committee Facilities for Diagnosis, Treatment or Consultation". 24. report^) to the mental hygienist. A copy of each progress report is kept in the Unit files. Methodology of this study. Because this survey is a pioneer in research in these two clinics, i t must necessarily be broad in many aspects. Several criteria were set up as a basis for selection of cases. Age limits set were six to twelve years inclusive, the minimum being school beginning age, and the maximum the average pre-adolescent period. Only cases in which pa-tients had intelligence of at least slow normal or above were included. Children of unmarried mothers were omitted in this survey except where they remained with their mothers, grandparents or other near relatives until they were at least five years of age. Adopted children were also excluded. These groups as well as mentally defective children were omitted not because they are immune to maladjustment or because they are less important than those considered. "Average" children in "normal" families were selected on the grounds that the children in excluded groups showing maladjustment wil l need a l l of the services discussed in connection with the "average" children. Besides these they may need additional ser-vices. In the course of the selection of the 257 cases which comprise this study, numerous records of illegitimate, adopted and deficient children were scanned. They are not the main subject matter of this in-quiry, but may be referred to where relevant. A detailed study of fac-i l i t i es in use, and additional facilities needed for any one of these MAppendix C (3) 25 excluded groups might well be the subject of another thesis* The total number of cases examined by the two c l i n i c s during the years 1945-47 inclusive, which met c r i t e r i a outlined above was 257* In this general survey, the following points were noted: age of child, pre-senting problem, address, length of child's residence i n B.C., source of referral, intelligence rating, number i n family, ordinal position i n family, ra c i a l extraction, religion, and marital status of parents (married, common-law, divorced, separated, deceased), absence of father from home i n military service, poor l i v i n g arrangements, (crowded or bad housing) and presence of grandparents, aunts or uncles i n the home whose attitudes contributed to maladjustment. These 257 cases were classified according to the problems which led to the patients being referred to the c l i n i c s examination. The classifications were (1) socially unacceptable behaviour (2) personality reactions (3) habit disorders (4) school d i s a b i l i t i e s . One out of every five cases i n each of the above-mentioned categories was selected at ran-dom, and a more detailed s t u d y ^ of this 20 per cent sample was made. (•^The schedule used i n collecting data from c l i n i c records of 52 cases (20 per cent)sample w i l l be found i n Appendix D. 2 6 . H P . 1 . C.G.C. 19Af> - LI D i s t r i b u t i o n o f Cases i n Pott; C l i n i c s According to Ape. Chi l d r e n ( 1 U 0 ) Adults U ] ( i n c l u s i v e ) M l d ( U 7 ) A d u I t s ( 9 ) M.H.C. 1 9 ^ . 6 - a ( i n c l u s i v e ) Figure 1 shows the number of cases examined by each of the clinics. The year 194-5 was included in the study in order to make possible some comparison of the cases in which the fathers of patients, were s t i l l away from home because of war service with those cases in which the fathers had returned. Another reason for considering the Child Guidance Clinic cases of a three year period was to effect a more even balance between the number of cases studied from each clinic. The Mental Hygiene Clinic was not in operation in 1945. Relatively fewer cases per year were examined by this clinic, because the director of the Mental Hygiene Division of the Metropolitan Health Committee was the only psychiatrist in this division and part of his time was spent in giving lectures to students at the University as well as at the Normal School. 27 F i g . 2. P r o p o r t i o n o f Cases i n This Study-t o t he T o t s ] Number o f ^ h i I d r e n , Examined. , > 11. ' ' ! 11 (116) (141) Legend (1600) C h i l d G u i d a n c e C l i n i c M e n t a l H y g i e n e C l i n i c Cases o u t s i d e l i m i t s o f s u r v e y Figure 2 shows the proportion of children surveyed i n this study to the total number of children examined by both c l i n i c s . I t shows that only 13.7 per cent of the patients 18 years of age and under, came within the scope of the c r i t e r i a set for this study. 28 CHAPTER 3. THE CLINIC PATIENTS AND THEIR FAMILIES In the period covered by this study (1945-1947 inclusive) the number of elementary school children of at least normal intelligence who received c l i n i c a l psychiatric examinations was 2 5 7 * O f these, approx-imately 55 per cent were examined at the Ment al Hygiene C l i n i c . Because the bulk of this c l i n i c ' s work was concerned with school-age children, i t i s understandable that i n the course of two years, a larger number of children between the ages of 6 and 12 years were examined there than at the Child Guidance Cl i n i c i n a period of 3 years. Not only because the Child Guidance Clin i c examines children as young as 6 months, but also because much of i t s time was devoted to "dependent" children, there were comparatively fewer Child Guidance Cl i n i c cases which came within the scope of this study. Table 1 DISTRIBUTION OF CASES BY EXAMINING CLINIC AND PROBLEM REFERRED Examining C l i n i c Socially Unacceptable Behaviour Personality Reactions Habit Disorders School Disabilities Total p.c. M. H. C. 42 48 23 28 141 54.86 C. G. C. 58 32 16 10 116 45.14 Total 100 80 39 38 257 100.00 In considering these 257 children, i t i s well to keep i n mind (•^This number includes only those cases which came within the limits of the c r i t e r i a for selection outlined i n the preceding chapter. 29 that they represent only the number in whom the need for psychiatric help was recognized. The question then arises: Which persons or agencies saw this need? Table 2 DISTRIBUTION OF CASES BY SOURCE OF REFERRAL Source of Referral Socially Unacceptable Behaviour Personality Reactions Habit Disorder School Disabilities Total p.c. Parents 20 21 5 7 53 20.61 Nurse 11 8 12 4 35 13.61 School doctor 1 4 3 4 12 4.67 Attendance Officer 0 1 0 0 1 .39 Teacher 8 20 3 11 42 16.34 School Principal 7 5 I 6 19 7.39 B. of M.* 3 1 0 3 7 2.72 Family Doctor 4 3 1 2 10 3.89 Juvenile Court 7 1 0 0 8 3.04 Children's Aid Societies 17 8 3 1 28 11.28 F.W.B.** 11 4 10 0 25 9.73 Other Social Agencies 11 2 1 0 14 5.45 Health Agencies 0 2 0 0 2 .78 Total 100 80 39 38 257 100.00 ft Bureau of Measurements. ±k Family Welfare Bureau 30. It is encouraging to note that parents referred 20 per cent of these children. This is the highest percentage among 13 sources of refer-ral . However, i f persons connected with the school system, namely, prin-cipals, teachers, public health nurses, school medical officers, Bureau of Measurements and attendance officers are grouped together, 45 per cent of a l l referrals can be credited to this source. Social agencies referred 25 per cent of the children who were examined. Juvenile Court referrals led to 3 per cent of the total number of cases. Since support of parents is invaluable to treatment, i t would be hoped that parents were the instigators in seeking clinical help. Although parents made direct referral for examination in only one out of every five cases, social histories indicate that in a much larger percentage of cases, they were aware that their children were showing symptoms of mal-adjustment. However, these parents did not know where psychiatric help could be obtained until they had discussed their problem with a doctor, teacher, nurse, or social worker. There may, of course, be opposition to examination on the part of some parents. A few of the social histories indicated that there was some parental opposition when the schools or social agencies took the in-itiative in suggesting psychiatric help. Such examinations were not made until parents' consent had been obtained. In private cases at the Child Guidance Clinic parents make direct referrals. In each case of this kind, i f one parent is unwilling to accept the services of the clinic, no exam-ination is undertaken until this resistance has been over-come sufficiently that some cooperation from both parents in treatment plans may be expected. 31. The interpretation of clinic services which is required in such cases is done by a social worker. Logically, the next question to be answered is: Why were the children of this study referred to the clinics for examination? In other words, what were the symptoms of their maladjustment which led parents, school authorities, social agencies and others to request clinical exam-inations for them? These symptoms may be divided into four categories, as follows: (1) socially unacceptable behaviour (2) personality reactions (3) problems in habit formation and ( 4 ) special school disabilities. Symptoms of maladjustment which may be classified as socially  unacceptable behaviour are numerous. Some of these are: temper tantrums, teasing, bullying, rebellion against authority, cruelty to persons or animals, destructiveness, bragging or "showing off", seeking bad compan-ions, precocious sex activities, lying, stealing and truancy. One hundred of the 257 children examined, (38.91 per cent) presented symptoms of this kind. Among the chief personality reactions which are manifestations of maladjustment, the following may be listed: seclusiveness, timidity, sensitiveness, fears, cowardliness, excessive imagination and fanciful lying, "nervousness", excessive unhappiness and crying, stubborness, res'fc-lessness, selfishness, overactivity and unpopularity with other children. Eighty of the children who were examined, (31.12 per cent) were referred because of symptoms of this nature. Problems in habit formation include sleeping and eating diff i -32 culties, speech disturbances* thumb sucking, nail biting, masturbation, prolonged bed-wetting and soiling. Thirty-nine of the children examined, (15.18 per cent), were referred because they had difficulties of this kind. Special school disabilities occur, particularly in reading and arithmetic. "Mirror writing" (writing backwards) is also a special dis-ability. Thirty-eight of the children, (14.78 per cent) were examined because such difficulties prevented their progress at school. As has been pointed out previously, children frequently manifest symptoms which may be classified under two or more of the 4 categories described above. In this study, cases in which a combination of 2 cr more types of symptoms occurred, were classified according to predominating symptoms. For example, a boy who stole, and was untruthful, destructive, and disobedient would be included with the group showing socially un-acceptable behaviour, although he may also have presented a habit dis-order such as enuresis or nail-biting. Table 3 BOYS AND GIRLS IN VARIOUS GROUPINGS Mental Hygiene Clinic Boys p.c. Girls p.c. Total Socially Unacceptable Behaviour 33 78.67 9 21.43 42 Personality Reactions 31 64.68 17 35.42 48 Habit Disorders 20 86.95 3 13.05 23 School Disabilities 21 75. 7 25. 28 Total 105 74.56 36 25.54 141 33. Child Guidance Clinic Boys p.c. Girls p.c. Total Socially Unacceptable Behaviour 39 67.24- 19 32.76 58 Personality Reactions 22 68.75 10 31.25 32 Habit Disorders 8 50. 8 50. 16 School Disabilities 8 80. 2 20. 10 Total 77 66.38 39 33.62 116 Slightly.over 70 per cent of the children examined were boys. This higher preponderance of males was more marked in the Mental Hygiene Clinic where boys comprised about three-quarters of the cases. However, two-thirds of the Child Guidance Clinic patients also were boys. There is no doubt that the uneven distribution between male and female patients in the Vancouver clinics cannot be accounted for on the basis of a sim-ilarly disproportionate number of boys in the school population.^ Moreover, this survey of Vancouver's clinic patients bears a marked sim-ilarity to the findings of two larger studies of clinical populations. In a statistical analysis of 500 cases examined at the Michigan Child Guidance I n s t i t u t e * 7 8 per cent of the patients were boys. A sample (^Canada Year Book, 1947, p. 113-114. According to 1941 census figures in Canada the excess of males over females is 2.56 per 100 of the pop-ulation. The sex distribution in British Columbia, in 1941 showed a somewhat higher preponderance of males, namely, 6.36 per 100 of the population. (^Hewitt, Lester E. and Jenkins, Richard L . , Fundamental Patterns of Maladjustment. State of Illinois, 1946, p. 19. 34-of 500 children examined by the Institute of Juvenile Research in Chicago^) included 62 per cent boys. "Delinquent" populations, as reflected in juvenile court stat-istics, reveal an even greater disparity between the sexes in social ad-justment. In Canada, in 194-5, 88 per cent of the children brought before the courts were boys.^) The United States Children's Bureau^) in its summary of juvenile delinquency cases reported from 28 juvenile courts during the year 1937 found that boys constituted 85 per cent of the "delinquency population". There are 2 possible conditions for this showing. Either cul-tural norms tend to protect girls from court appearances} or girls tend toward greater conformity to social mores. The latter condition may account to some extent for the fact that only about 30 per cent of the Vancouver clinical population were girls. (•^Ackerson, Luton, Children's Behaviour Problems. University of Chicago Press, 1931. (2) v 'Canada Year Book, 194-7, p. 251. Ratio of Boys and Girls Brought before the Courts, Years ended September 30, 1936 - 194-5. (^Children ± n Courts, Juvenile Court Statistics, Year December 1931, 1937 and Federal Juvenile Offenders, year ending June 30, 1937. United States Children's Bureau Publication No. 250, Washington, D.C., 1940. 35. Table 4 DISTRIBUTION OF CASES BY AGE Ages of Patients Socially Unacceptable Behaviour Personality Reactions Habit Disorders School Disabilities Total p.c. 6 yrs.* 10 17 4 9 40 15.56 7 yrs. 22 9 9 7 47 18.29 8 yrs. 17 17 7 7 48 18.68 9 yrs. 18 14 9 6 47 18.29 10 yrs. 13 13 5 5 36 14.00 11 yrs. 20 10 5 4 39 15.18 Total 100 80 39 37 257 100.00 ft Up to 6 years 11 months, and similarly for succeeding groups. Considering the Vancouver patients on the basis of age children between 8 and 9 years constituted the largest proportion, (18.68 per cent). An identical number of children in the 7 to 8 year and the 9 to 10 year group were examined. The age group presenting the lowest incidence of maladjustment was the 10 to 11 year (14 per cent)• The above table indicates that the age distribution of patients is fairly even. However, Vancouver (1) Public School Board statistics show that there was an aver-age of over 550 more pupils per year in Grade I than in Grade II during the years under consideration in this study. Assuming that some of these pupils were repeating Grade I, some of the 550 would be 7 years or over. Allowing for this, there would s t i l l be a larger number of 6 year olds than of other ages, since there has been a steady increase in the number of births in Vancouver from 1936 to 1947. (2) (l)Vancouver proper only. (2) Births in Vancouver 1918-1948 inclusive. Bulletin 121, Bureau of Measurements, Board of School Trustees, Vancouver, B. C. Jan., 1948. I c 36. The adjustment entailed in beginning school has long been re-cognized as a difficult one for many children. The question then arises: Why were there fewer patients of 6 years of age compared with those of 7, 8 or 9 years? A survey of the 20 per cent sample of 257 cases reveals that the average period of time between the first serious symptoms of malad-justment and clinical examination was 2 years and 10 months. It would appear that early symptoms frequently receive too l i t t l e attention; too often, not until the child's problem has become intensified to a degree that his behaviour is irritating or even objectionable to those about him, is there any concerted effort made to refer him to a clinic. Table 5 DISTRIBUTION OF CASES BY INTELLIGENCE LEVEL Intelligence Quotients Socially Jnacceptable Behaviour Personality Reactions "Habit Disorders School Disabilities Total p .c Near Genius (140 & over) 2 2 1 0 5 1.95 Very Superior (120-139) 9 1 3 0 13 5.06 Superior (110-119) 6 15 1 1 1 8.95 Average (90-109) 56 41 20 24. 141 54.86 Low Average (80-89) 25 14 12 13 64 24.90 Not Stated (but appar-ently average) 2 7 2 0 11 4.28 Total 100 80 39 38 257 100.00 37. The intelligence quotients of the patients ranged from 80 (the lower l i m i t set i n selecting cases) to]Sl. The 4-28 per cent of the cases, i n which the intelligence was not stated, but was apparently at least average, were cases examined by the Mental Hygiene C l i n i c where routine psychological tests were not always given. In summary then, approximately 84. per cent of the patients had average intelligence. The distribution of various intelligence levels of c l i n i c cases shown i n Figure 3 bears a marked contrast to the theoretic dis-tribution of intelligence as shown i n Figure 4. Fig. 3. I.Q. 140 & overt 120 - 139 110 - 119 90-109 . 80 - 89 not stated Distribution of Cases by Intelligence Levels. 10 p.c. 20 p.c. 30 p.c. 10 p.c. Legend C Child Guidance Clinic Mental Hygiene Clinic 50 p.c. Fig. U. I.Q. 1/.0 & over • 120 - 139 • 110 - 119 • 90-109 • 80-89 m 70-79 • Below 70 • Theoretic Distribution of Intelligence. 10 p.c. 20 p.c. 30 p.c. IO p.c. 50 p.c. 60 p.c. 38. The proportion of children of "above average" intelligence to those of "average" and "low average" then is 20:74. The proportion in this study is 16:84. Reducing these figures to percentages, reveals in the clinical population under study the distribution of proportions in the superior range were only 70 per cent of the expected normal distri-bution. A comparison of the proportion of children of "low average" in-telligence to those of "average" intelligence shows that the former com-prise 193 per cent of the number of "low average" cases expected in the theoretic distribution of intelligence. Therefore, i t cannot be said that these patients of the Van-couver clinics represent a cross-section of the general population with regard to intelligence. There is a marked tendency toward a larger-than-expected grouping at the lower end of the intelligence distribution. A survey of the intelligence quotients of school a&e patients privately referred to Child Guidance Clinic for examination during the year 1947 reveals a marked contrast to the above findings. These child-ren tended toward both the upper and lower extremes of intelligence, as illustrated in Figure 5. F i g . 5. D i s t r i b u t i o n of C h i l d Guidance C l i n i c Cases. ( A l l p r i v a t e cases, c h i l d r e n 6 to 12 years - 19A7) I.Q. 10 p.c. 20 p.c. 30 p.c. AO p.c. 110 6 over • • • • 120 - 139 ••••»•• 39. This suggests that children whose problems are apparent to their parents^) tend toward both extremes of intelligence. Keeping in mind that more than 2 out of every 5 (45 per cent) of the 257 children in this study were referred by school authorities, one reason for the deviation from the normal distribution of intelligence suggests itself. Children of superior intelligence, although maladjusted, are less likely to arouse the concern of teachers than are those of lower intelligence whose mal-adjustment may show up in poorer academic progress. This theory can be substantiated by the Child Guidance Clinic case records of numerous pri-vate patients, in which can be found instances of a principal or a teacher expressing surprise that a child is to have a psychiatric examination. Frequently they make such comments as - "He's not a problem in school", "He's an average student, doing satisfactory work", or "He's in the lower third of the class, but seems to be doing his best". Such pupHs often are found to have I.Q.'s which classify them as superior, very superior or above, and therefore have intellectual capacity, i f freed from emotional disturbances, to be "better than average" students or in the "upper third" of the class. Although group intelligence tests are given routinely in grade 1 and grade 6, and sometimes in grade 3 or 4, in Vancouver Public Schools, the maladjustments which cause some children of superior intelligence to make only average academic progress may also operate in the test situation. In one instance, a nine year old g i r l , doing mediocre work in school, had (1) The majority of private Child Guidance Clinic cases are referred at the instigation of parents, although actual referral may be through family doctors, speech therapists, public health nurses, etc. AO, -scored 120 i n a group intelligence test i n the classroom. In an ind i v i -dual test given after several v i s i t s to the Child Guidance C l i n i c , she was found to have an I.Q. of 155. One of the outstanding features of the study of the families of which the 257 patients were members i s that, i n one out of every 3 serious factors of family disorganization were considered by the examining psy-chiatrists to have affected the personality development of patients. Table 6 DISTRIBUTION OF CASES BY FAMILY DISORGANIZATION FACTORS Factors Socially Unacceptable Behaviour Personality Reactions Habit Disorders School Di s a b i l i t i e s Total Marked Parental Discord 7 7 7 3 2A Divorce 11 A, A 1 20 Father Deceased 6 3 1 1 11 Desertion 6 1 - - 7 Separation 3 2 - 1 6 Common Law Marriage(1) 3 3 - - '6.., Mother i n Mental Hospital 2 3 - - 5 Mother Deceased 1 1 1 - 3 Father i n Prison 1 2 - - 3 Father i n Mental Hospital - 1. - - 1 Total AO 27 13 6 86 (1) Only includes cases i n which mother's insecurity about t h i s type of marriage affected children. a. Leading the l i s t i n frequency of occurrence was marked discord between parents. In 9.33 per cent of the cases this factor was noted. In 7.78 per cent parents were divorced. In many of these, there were in-dications of marked discord preceding the divorce. Families which were incomplete because fathers were deceased represented 3.28 per cent of the cases. In 2.72 per cent desertion, i n 2.33 per cent separation, and i n 2.33 per cent common-law marriages resulting i n mother's insecurity, con-tributed to childrens' maladjustment. Other factors were mental ill n e s s of mothers, mothers deceased, fathers i n prison, mental i l l n e s s of father. Table 7 DISTRIBUTION OF CASES BY OTHER CONTRIBUTING FACTORS Contributing to Maladjustment Socially Unacceptable Behaviour Personality Reactions Habit Disorders School Di s a b i l i t i e s Total Inadequate housing (poor or very crowded) 16 18 5 3 42 Father's absence while serving i n the Armed Forces 11 12 9 4 36 Interference by relatives l i v i n g i n the home 18 8 5 3 34 Total 45 38 19 10 112 Although boys comprised over 70 per cent of the 257 cases, they represented only 56 per cent of the 86 cases i n which there was evidence of family disorganization such as marked discord, divorce, desertion and separation. Similarly, boys appeared to be less vulnerable than g i r l s to such environmental factors as the fathers' absence while serving i n the 42. Armed Forces, inadequate housing, and interference of grandparents and other relatives living in the home. Of the 112 cases in which these fac-tors were present, boys comprised only 61 per cent. According to the social histories, 51.75 per cent of the parents were of Anglo-Saxon descent. In 20.62 per cent of the cases, racial origins were not stated. This high percentage makes i t impossible to draw any accurate conclusions as to the extent to which various nat-ionalities were represented in the clinic cases, or to compare this group with the general population. The social history outlines of both clinics suggest that information regarding racial origins should be obtained. Table 8 DISTRIBUTION OF CASES BY SIZE OF FAMILY Number of Children in Family Socially Unacceptable Behaviour Personality Reactions Habit Disorders School Disabilities Total p.c. 1 24 19 8 9 60 23.35 2 21 37 10 19 87 33.85 3 28 9 7 7 51 19.84-A 15 7 5 3 30 11.67 5 1 2 3 6 2.33 6 5 A 5 - 14- 5.4-5 7 2 1 1 A 1.56 8 1 1 - - 2 .78 9 - - - - - .00 10 3 - - - 3 1.17 Total 100 80 39 38 257 100.00 43 The largest percentage of patients (33.8 per cent) were members of families i n which there were only two children. Sibling r i v a l r y , re-sulting i n a feeling of i n f e r i o r i t y on the part of the disturbed child occurred i n various degrees of severity, i n many families, but appeared to be more marked where there were only 2 children. "Only" children repre-sented the second largest group (23.4 per cent). Eighty-eight per cent of a l l children considered i n this study came from families i n which there were not more than A children. [fable 9 DISTRIBUTION OF CASES BY ORDINAL POSITION IN FAMILY Ordinal Position i n Family Socially Unacceptable Behaviour Personality Reactions Habit Disorders School Disabi l i t i e s Total p.c. Only Child 24 19 8 9 60 23.35 Oldest 37 28 8 8 81 31.51 Middle 27 12 12 4 55 21.40 Youngest 12 21 11 17 61 23.74 Total 100 80 39 38 257 100.00 With regard to ordinal position, there was a higher incidence of maladjustment i n oldest children i n families, 81 of the patients (31.5 per cent) being i n this group. Youngest children comprised the second largest group. Sixty-one children (23.7 per cent), were i n this category? while 60 (23.4 per cent) were "only" children. "Middle" children numbered 55 (21.4 per cent). Mobility of families does not appear to be a significant factor in the emotional disturbances of children who were examined at c l i n i c s . 44. Twenty-three per cent of the patients were born outside of Br i t i s h Col-umbia. The population of this province has increased by over 35 per cent since 1939. Allowing for natural increase, within the province, there i s no doubt that more than 23 per cent of the increase i n population may be attributed to immigration from other parts of Canada and elsewhere. In one quarter of the cases i n which the patients were born outside of British Columbia, the records contained no information about the length of residence^ 1) i n this province. Table 10 shows the d i s t r i -bution of cases i n which the length of Br i t i s h Columbia residence was stated. Table 10 DISTRIBUTION OF CASES BY LENGTH OF B.C. RESIDENCE lesidence i n British Columbia Socially Unacceptable Behaviour Personality Reactions Habit Disorders School Disab i l i t i e s Total p.c. L0 yrs.* 0 1 0 0 1 2 .33 3 yrs. 1 0 1 0 2 4.65 6 yrs. 5 0 0 :,, 1 6 13.95 5 yrs. 7 3 1 0 11 25.58 4 yrs. 2 0 0 0 2 4 .65 3 yrs. 2 0 0 2 4 9.30 2 yrs. 2 0 0 1 3 6.98 1 yr. 3 4 4 0 11 25.58 Less than 1 yr. 2 1 0 0 . 3 6.98 Total 24 9 6 4 43 100.00 ± Up to 10 years 11 months, and similarly for succeeding groups. (l)used i n the non-legal sense of the term. 45. The foregoing table shows that of the patients who had migrated to British Columbia, a high incidence of maladjustment occurred among those who had lived in the province for 5 years. There were children whose families moved to the Pacific coast during the early years of World War II. An equally high incidence was also found among patients who had resided in the province for only 1 year. These were children whose families moved to British Columbia as the war was drawing to a close, or in the first 2 post war years. Socially unacceptable behaviour as a symptom of ma]adjustment was found in higher proportion (56.8 per cent) among the patients born outside of the province than in the total clinical population (38.9 per cent). Information regarding the religious denominations of the parents of clinic patients was omitted in 6 per cent of the cases, although in this matter, too, social history outlines of both clinics recommended that i t be obtained. The following table compares the religious denom-inations of the general population with that of the parents of the clinic-al population. Table-ill RELIGIOUS DENOMINATIONS Population of Vancouver according to 1941 census-*-Parents of c l i n i c a l population2 per cent per cent Protestant 81.67 86.77 Roman Catholic 10.92 5.06 Buddhist and Confucian 3.88 . -Jewish .99 .78 Greek Orthodox .64. 1.16 Other and not stated 1.90 6.23 Total 100.00 100.00 ^-Based on Table 17 Religious denominations of the populations of 9 c i t i e s over 90,000 - Canada Year Book 194-5, p. 109. ^Only the section of the c l i n i c a l population included i n t h i s study. Immigration laws respecting Orientals have tended to cause the B r i t i s h Columbia population of A s i a t i c o r i g i n to be predominantly adult males. This i s a p a r t i a l explanation f o r the absence of patients from families adhering to the Buddhist and Confucian r e l i g i o n s . Patients from Roman Catholic f a m i l i e s comprised only 5.06 per cent of the c l i n i c a l population although adherents of t h i s r e l i g i o n com-prised 10.92 per cent of the t o t a l population of Vancouver i n 1941. Of the Roman Catholic patients examined, only one was attending a parochial school. The r e f e r r a l i n t h i s case was made by a non-denominational s o c i a l agency which had contact with the child's family through a request of the Dependent's Allowance Board. This showing raises the question: Why are children attending 47. parochial schools not referred for psychiatric examinations? One evident reason i s that the services of the Mental Hygiene Division of the Metro-politan Health Committee are not available to parochial or other private schools. Although provincial and municipal funds pay the bulk of the financial costs of Metropolitan Health Services, a grant from the Van-couver School Board r e s t r i c t s the school health services to public schools. At present, 2 school nurses, whose salaries are paid through Community Cest Funds, are administering to the health needs of over 4,800 children i n attendance at more than 30 widely scattered parochial schools. One school dentist .attends to these pupil's dental needs. There i s no school medical officer. It i s understandable, that under such circum-stances, emotional illnesses of pupils might be overlooked. However, the services of the provincial Child Guidance Clinic are available to those attending parochial and private schools. None of the 257 children i n this study was attending a non-sectarian private school at the time of referral for examination. Both c l i n i c s examined a number of children who had attended private schools earlier. A study of the addresses of the 257 patients revealed that the maladjusted children came from a l l sections of Greater Vancouver. The distribution of cases i n the various areas was f a i r l y even. School authorities and social agencies referred nearly a l l of the cases i n the parts of the city which on the basis of Juvenile Court reports are clas s i f i e d as "delinquency areas". 4S. CHAPTER 4. SOCIAL HISTORIES In the preceding chapter, which dealt, with the 257 cases used as a basis for this study, i t was seen that some of the c l i n i c records lacked information which might be considered essential i n thorough exam-inations of maladjusted children. This chapter w i l l deal with 52 cases, which are a 20 per cent sample of the total number of cases surveyed. A more detailed study of the c l i n i c records of these 52 cases was made and reveals that other significant data, about parents, siblings and the patients themselves were also omitted. Not only w i l l these omissions be pointed out, but an analysis of the information contained i n the social histories w i l l be made. A clear picture of the family constellation i s important i n making an accurate psychiatric diagnosis of a child's i l l n e s s , and of equal importance i n carrying out the c l i n i c a l recommendations, which fre-quently involve treatment of the parent-child relationship. A l l of the children studied i n the 20 per cent sample were members of a family group. Nearly a l l were l i v i n g with their own families. A very small number were in foster homes with substitute parents, although u n t i l at least the age of 5 years they had lived with their natural families. Although social history outlines of both c l i n i c s suggest that the age of parents should be stated, i n 27 per cent of the sample cases this information was en-t i r e l y omitted. In another 13 per cent the age of only one parent was stated. 49 The average age of the mothers of clinic patients was 37 years and 8 months, while that of the fathers was 39 years and 2 months.^ The difference in age of parents in this sample group of the clinical pop-ulation, therefore, was one and a half years. This is a good deal closer than the average situation for Canada. In the group of children whose symptoms of maladjustment took the form of socially unacceptable behaviour, the differences between the age of parents were most apparent. In 43 per cent of these cases, mothers were older than fathers, the greatest difference being 11 years and the least 2 years. In another 30 per cent of these cases there was a marked difference between the age of the parents, the age of fathers exceeding that of the mothers by from 20 to 9 years. Whereas a marked difference in the age of a husband and wife does not necessarily presuppose a detrimental effect on their adjustment, in many instances i t may be significant in family difficulties. In selecting a marriage partner a woman may have a psychological need for a husband who represents to her a "father person". She may however, in developing emotional maturity later, become dissatisfied with the relation-ship which originally was a satisfying one. Similarly, a man may outgrow his need for a wife who during the earlier years of marriage had fulfilled a maternal role in his l i f e . The dissatisfaction with marriage and re-sultant tensions from such situations may occur even when there is l i t t l e (•^ Based on cases in which this information was available. (2)The average age of fathers of legitimate children is about 4 years greater than the average age of mothers. Canada Year Book, 1947, p.156. 50 or no difference i n the chronological age of marriage partners. However, this i s found much more frequently where there i s a marked difference i n the age of spouses. Information about the formal education of parents was entirely lacking i n 29 per cent of the sample cases. In 15 per cent of these cases the education of only one parent was stated. The education of both mothers and fathers ranged from grade 3 to post graduate work i n univer-sit y . On the basis of those cases i n which information was available, fathers of patients had a slightly higher degree of education than mothers. The average education of fathers was grade 9 .8 , while that of mothers was grade 9. The following table shows the average education of parents of children of each of the four classifications of symptoms. Table 12 PARENTS' FORMAL EDUCATION Children's Symptoms Mothers (Grade) Fathers (Grade) Socially Unacceptable Behaviour 8.4. 9.5 Personality Reactions 10 10.5 Habit Disorders 8 8.4-Special School Disabilities 9.6 10.2 From the foregoing table i t w i l l be seen that parents of child-ren whose maladjustments were classified as "personality reactions" had more formal education than those of children who were examined because of "socially unacceptable behaviour11, "habit disorders", or "special school d i s a b i l i t i e s " . The parents who had the second highest degree of educ-.51-a t ion , were those of ch i ld ren who had "spec ia l school d i s a b i l i t i e s " . Information about the occupations of the fathers of c l i n i c pat ients was contained i n 92,3 per cent of the s o c i a l h i s t o r i e s . Of the fathers whose occupations were stated, f i v e - s i x t h s were u n s k i l l e d , semi-s k i l l e d and s k i l l e d labourers . The other one-sixth were professional and business men. The ac tua l earning capacity of the fathers was stated i n only 11.5 per cent of the cases. The former or present occupations of mothers of c l i n i c patients was stated i n l e s s than h a l f (42.4 per cent) of the s o c i a l h i s t o r i e s . Twenty-five per cent of the mothers whose occupations were s tated, had been engaged i n c l e r i c a l work previous to marriage while 8.3 per cent had been members of professions. The remaining 66.7 per cent had been em-ployed at unsk i l l ed and semi -sk i l l ed labour . In 9.6 per cent of the sample cases mothers were engaged i n work outside of the home at the time of pa t i en t ' s r e f e r r a l for c l i n i c a l examination. More than h a l f of these mothers were working, because they were separated from t h e i r husbands by divorce or deser t ion. The other mothers were working to supplement the low incomes of t h e i r husbands. There were many omissions i n the s o c i a l h i s t o r i e s with regard to heal th of parents. The Mental Hygiene C l i n i c out l ine does not spe-c i f i c a l l y request t h i s information but there are headings under which i t might be included. In 28.8 per cent of the sample cases, there was no mention of the mother's heal th , while i n 59.5 per cent of the cases t h i s information about fathers was omitted. In 17.3 per cent of the cases mother's health was stated to be "good" or "excel lent" . In a s l i g h t l y 52. higher percentage of cases (19.2) the health of fathers was described i n the same terms. In the 53.9 per cent of cases i n which i l l n e s s of mothers was reported, tuberculosis was most prevalent. Other illnesses of mothers l i s t e d were: ar t h r i t i s , asthma, varicose veins, mental depression, neurodermatitis, hysteria, rheumatic fever, cardiac condition and venereal disease. In the 21.3 per cent of cases i n which there were reports of poor health of fathers, a r t h r i t i s was most prevalent. Other reported illnesses of fathers were schizophrenia, psychoneurosis, ulcers, defective vision, stomach disorder, hemorrhoids and venereal disease. Besides the diagnosed mental illnesses mentioned above, i n 25 per cent of the sample cases, mothers were described i n terms which in -dicated varying degrees of mental disturbance. Such terms as "unstable", "inadequate", "extremely tense", "immature", were used i n these social histories. In 19.2 per cent of the cases fathers were described i n simi-la r terms. Half of these fathers used alcohol to excess. -Several were chronic gamblers. The social history outline i n use for Child Guidance Cl i n i c examinations suggests that information about habits and social behaviour of parents should be obtained. Presumably this would include at least some description of the interests and recreation of parents. However, in the sample cases, there was no information on this subject for 80.6 per cent of the mothers, and 69.1 per cent of the fathers. Social hist-ories indicated that 7.7 per cent of the mothers and 5.8 per cent of the 53 fathers had no interests or recreation outside of their work. "Problem" children frequently have "problem" parents. Dr. M. Levine, Professor of Psychiatry at the University of Cincinnati College of Medicine, describes five types of problem parents as follows: 1. The perfectionist parent, whose own neurotic need to be perfect causes insecurity i n a child by over-emphasis on prestige and success. 2. The antagonistic or rejecting parent, who arouses fear and insecurity in a child. Such rejection may be concealed under the guise of over-solicitousness, over-prptectiveness, and "smother-love". 3. The over-indulgent parent, whose child faces inevitable frustration. 4. The dominating parent, whose attitudes may lead to undue submissions or undue rebelliousness i n a child. 5. The identifying parent, who acts as i f the child i s s t i l l a part of her body, making i t d i f f i c u l t for the child to learn independence. Numerous examples of each of these five types of "problem" parents were found i n the sample-cases. In many instances, social hist-ories indicated the nature of parental attitudes toward the patients. In others, this information was found in the psychiatrist's interview or i n the conference notes. Rejection, with varying degrees of ambivalence, (the combination of the opposing emotions of love and hate) was the most frequently noted negative attitude of both mothers and fathers. Mothers who were "over-protective" were as numerous as those whose rejection was more obvious. (•^Levine, Maurice, Psychotherapy i n Medical Practice. The MacMillan Co., New York, 1947 p. 276-279. 54 More fathers were "over-indulgent" i n their attitudes toward children than were the mothers. On the other hand more fathers tended to dominate their children. "Perfectionist" parents of both sexes were found. There were a few instances of "identifying" mothers. In some cases, one parent was extremely rejecting of the patient, while the other parent was over-in-dulgent. In other instances, one parent's attitude toward the patient was a positive one while that of the other parent was a detrimental one. In some cases, of course, the attitudes of both parents appeared to be favourable. Negative parental attitudes such as those described above have their basis i n the personalities of parents, which i n turn are the re-sult of parents' own heredity and environment. In a later chapter i t w i l l be seen that i n both c l i n i c s the recommendations for treatment are largely i n the nature of environmental manipulation. Frequently the most needed adjustment i n a patient's environment i s that of a changed attitude on the part of one or both parents. It w i l l be d i f f i c u l t , i f not impos^ sible, for this public health nurse or the social worker who i s respons-ible for follow-up work to help parents effect this change, i f she her-self has no knowledge of the etiology of their present attitudes. The Child Guidance Clinic social history outline suggests that information about paternal and maternal relatives should be included i n the family history. In one-third of the social histories of children examined at Child Guidance Clinic, clear pictures of family backgrounds shed considerable l i g h t on the reasons for parents being the kinds of persons they were. In the other two-thirds of the cases there were 55. varying degrees of information of this kind. In marked contrast to this, i n only one-quarter of the Mental Hygiene Clinic social histories was there information about the parents' family backgrounds. A small number of these were f a i r l y detailed. In the remaining three quarters of the Mental Hygiene Clinic cases, no i n -formation whatever was available about factors which might account for the parents' personality traits.(1) Another important aspect i n the study of families i s that of interpersonal relationships between patients and their brothers and sisters. Other than data on age and education, information about siblings was lacking i n more than half of the social histories. While a l l of the social histories of Child Guidance Clinic patients i n this sample of cases were prepared by social workers, only 17 per cent of the Mental Hygiene Clinic cases were prepared by members of this profession. Public Health nurses were responsible for the pre-paration of the remaining 83 per cent of the social histories of the Mental Hygiene Clinic patients. A partial explanation of the difference i n this matter between the social histories prepared by social workers and those prepared by public health nurses may be that more emphasis i s placed on family hist-ory i n the Child Guidance Clinic outline. The work of the Mental Hygiene Clinic according to i t s stated policy " i s to be considered a f i e l d of prevention rather than treatment", and "cases found to require repeated treatment sessions are referred to a private physician, Child Guidance (•^The Case of Tom Z. described i n Chapter 5, illustrates this lack of background information about parents. 56. Clinic, etc., following study by the Mental Hygiene Clinic." This may, in part, account for the less detailed social history outline of the Mental Hygiene Clinic. However, in actual practice, this clinic has as-sumed a treatment role greater than was evidently anticipated at the time the above-quoted policy was formulated. (1) It would appear, therefore, that the social history outline of the Mental Hygiene Clinic should be extended in order to serve more .adequately its expanding functions. Another explanation for the greater emphasis on family back-ground on the part of the social workers, is that by nature of their training, they are more aware of the meaning of behaviour and the im-portance of intrafamilial relationships in the development of personality. The acquiring of ski l l in the science and art of interviewing is also an important part of the training of social workers. A good social history, whether prepared by a social worker or a public health nurse should aid members of the clinic team to see the child from his earliest l i fe up to the present time. "The social case history supplies to the clinic staff a revealing story of the child in his social setting. The plot centres around his difficulties, which often come about through friction between his growth process and the demands of his environment. It is evident that whatever affects this (1)NO cases studied in the 20 per cent sample were referred to the Child Guidance Clinic by the Mental Hygiene Clinic, although in a number of instances children who had been examined by the latter became patients of the Child Guidance Clinic when referred by their parents or social agencies. 57. growth process or the environment i s of significance i n the story. «(D The e l i c i t i n g of an accurate medical history has been described as demanding "care, courtesy, time and patience".(2) This i s particularly applicable i n preparing a social history, where informants may have feelings of resentment, suspicion, apprehension, or gu i l t . Care, courtesy, time and patience are required i f parents are to be expected to give an accurate picture, as they see i t , of the child i n the family constellation. Parents, i n giving information about the child, often indirectly give much information about themselves. A ski l l e d interviewer learns to ob-tain and u t i l i z e this material. On her a b i l i t y to assess parental a t t i -tudes depends much of the success of the treatment plans which follow the' c l i n i c a l examination of the child. The social worker or the public health nurse i s i n most cases, the person who helps parents i n the carrying out of the c l i n i c recomm-endations. Gordon Hamilton i n her recent book Psychotherapy i n Child  Guidance calls the parent the social worker's "partner i n treatment". (3) With this i n mind, i t behooves the interviewer, whether social worker cr public health nurse, to aim toward establishing rapport between herself and the parent during their f i r s t contact. Not only w i l l this promote a (^Institute for Juvenile Research, Paul L. Schroeder, Director, Child  Guidance Procedures. D. Appleton - Century Co., New York, 1937. p. 40. (2) Professor Henry Cohen, Skinner Lecture 1943, cited by Hall, Muriel Barton, Psychiatric Examination of the School Child. Edward Arnold & Co., London, 1947. p. 23. (3) Hamilton, Gordon, Psychotherapy i n Child Guidance. Columbia University Press, New York, 1947. p. 34. 58. good working relationship i n the carrying out of treatment plans, but i t w i l l also insure a more complete social history. There w i l l be less with-holding of information i f the interviewer can help the parent realize that her opinions are respected, and that her relation to the c l i n i c w i l l be a participating one, a joint attempt to work out a clearer understanding of the problem. When a child i s referred to c l i n i c by a social agency, the school or the court, there i s particular need to help the parent as well as the patient, to understand that the purpose of the c l i n i c i s to con-sult with her and help her i n the care of her child. The interviewer, w i l l have d i f f i c u l t y i n establishing rapport i f she lacks time and i s over-anxious about obtaining i n one interview, a l l of the information suggested by the social history outline. Frequently parents are so concerned with the immediate situation which has arisen that they emphasize present symptoms rather than earlier ones and give no consideration to an underlying cause. Such parents have not thought in terms of a gradual process culminating in a group of symptoms. An opportunity to talk about the symptoms often has therapeutic value for these parents. At the same time the public health nurse or social worker may glean significant facts about both parents and patients. Gordon Hamilton i n her previously quoted study, writes thus on this subject: "The history t e l l s when some deviation started, and knowing when i t started, and under what circumstances we are in a better position to know what i t i s today. The history seeks knowledge of the past because i t i s a part of the present structure. 59. One can only treat "current" personality in i t s present circumstances, but one can understand the person best by knowing when deviations and fixations occurred and what were the traumatic incidents which are now scars and to which he i s s t i l l reacting. It i s the in-appropriate persistence of the past into the present d i f f i c u l t i e s as well as the precipitating cause of his coming for the cl i n i c ' s help i s an important part of a social history. S k i l f u l inter-viewing i s necessary i n order to obtain this information. It may be necessary for the person preparing the history to direct the interview toward discussion of earlier symptoms. In 15 .4 per-cent of the sample cases, there was a complete lack of information about the onset and devel-opment of the patients' d i f f i c u l t i e s . In 46 .1 per cent of the cases social histories gave some information on this subject, while i n the re-maining 38.5 per cent a clear, detailed description was given. Certainly "care, courtesy and patience" are required i n order to gain the cooperation of parents so that they w i l l unfold the detailed picture of their child's development from birth to the time of the c l i n i c a l examination. Parents may need help i n understanding the signi-ficance of the questions put to them before they are prepared or able to give a valuable account of their child's personal history. In giving this information parents may gain some understanding of the strains and stresses which have contributed to the creation of the patient's maladjustment. Parents may, for the f i r s t time, look at which A clear picture of the onset and development of the child's (•^Hamilton, Gordon, Psychotherapy in Child Guidance. Columbia University Press, New York, 1947. p. 35 . 6 0 . the t o t a l picture of their various methods of attempting a solution of the d i f f i c u l t y and arrive at some evaluation of these methods. At the same time the interviewer may gain information as to whether parental discipline has, on the whole, been sound and rational, or whether i t has been harsh, unreasonable, inconsistent or weak. Ideally, parents should be given some opportunity to talk about their child's problem soon after a re f e r r a l i s made for c l i n i c a l examination. This i s equally important whether parents have taken the i n i t i a l step, i n seeking the c l i n i c ' s help, or the school, court or a social agency have made the referral.. In actual practice, at ^hild Guidance Clinic particularly, there i s frequently a delay of one or two months between the referral and the f i r s t interview. Such delay, although unavoidable, often exposes the patient to parents' frenzied search for other methods of dealing with the problem. An enuretic child who has already received corporal punishment, dis-approval and ridicule may be forced to launder his own linen, eat salty sandwiches or to endure some other ineffectual or harmful "remedy". The large caseloads and manifold duties of social workers and public health nurses appear to be one of the chief reasons for this delay. Another reason i s that with the existing c l i n i c a l f a c i l i t i e s , appointments for examination are frequently f i l l e d for several months i n advance. In 28.8 per cent of the social histories information was given about birth, feeding, weaning, t o i l e t training, walking, talking, and teething. In 34*6 per cent of the cases, social histories gave f a i r l y detailed information about most of these factors. Information was very 61. meagre i n 13.5 per cent of the s o c i a l h i s t o r i e s . In some of these cases, mothers stated that they could not remember de t a i l s of the c h i l d ' s ear ly l i f e . In 23.1 per cent of the cases, no ear ly developmental information was given. In a number of the soc i a l h i s t o r i e s i n t h i s group the whole subject of developmental h i s to ry was summed up' i n two words, "apparently normal". S o c i a l h i s t o r i e s which lack information i n whole or i n part of the ear ly development of patients necessitate the examining psych ia t r i s t devoting a port ion of h i s interviews to t h i s subject. In many instances s ign i f i can t factors such as feeding d i f f i c u l t i e s , sudden weaning, ear ly and r i g i d t o i l e t t r a i n i n g were revealed to the p s y c h i a t r i s t . In nearly a l l of the sample cases, the medical h i s t o r i e s of pat ients were care fu l ly wr i t t en . The majority of the pat ients had had one or more serious i l l n e s s e s . Over one-third (34.6 per cent) had under-gone t o n s i l and adenoid operations. Several of these ch i ld ren had t h i s operation twice . A small number of pat ients had had appendectomy and mastoidectomy operations. Over 12 per cent of the ch i ldren had suffered fractured l imbs . The age at which a c h i l d i s hosp i t a l i zed for an oper-a t ion , h i s psychological preparation for i t , and h i s reac t ion to i t , are of importance i n a s o c i a l h i s t o r y . In over h a l f of the h i s t o r i e s one or more of these items of information were omitted. Pneumonia and bronchi t i s were reported i n 15.4 per cent of the cases. Other severe i l l n e s s e s mentioned i n h i s t o r i e s were rheumatic fever, eczema, nephr i t i s and r i c k e t s . In near ly a l l cases ch i ld ren had had one or more communicable diseases. A number of ch i ldren appeared to 62. be "accident prone". The health history of Tim J . , although somewhat extreme, wil l be quoted in Chapter 5, because i t illustrates the inter-relationship between physical and emotional factors. Another essential topic in the thorough study of clinic patients is that of formal education. The age at which these children entered school, their attitudes toward this new experience, their punctuality and attendance, their special interests, their difficult subjects as well as their academic achievements may be of significance in the clinical diagnosis and subsequent treatment plans. Both clinics, recognizing the importance of this aspect of children's lives request considerable detail in the educational histories of patients. In the Mental Hygiene Clinic a separate report, designated as the school history is prepared by the teacher and school principal jointly, or by either of them separately. On the whole, the school reports of the Mental Hygiene Clinic cases gave a clearer picture of the patients as pupils than did the education section of the social histories of the chil-dren examined at the Child Guidance Clinic. Another advantage of the use of the school report at the Mental Hygiene Clinic is that in many instances, teachers' attitudes toward "problem" pupils are evident. In the sample cases these attitudes ranged from the positive "He's an unhappy maladjusted child. Why? What can we do to help him", to the negative "She's a thief. I can prove i t . " In one case, a school principal's report (four type written pages in length) was devoted entirely to giving evidence in police court fashion, of a 63. l i t t l e g i r l ' s repeated thefts. Information about the school's attitude toward patients was given less frequently i n Child Guidance Cl i n i c cases. However, i n this c l i n i c ' s social histories, the parents' attitudes toward the school and toward their children's academic progress or lack of i t were more clearly delineated, than i n Mental Hygiene Cl i n i c cases. The marked tendency to omit such information i n the school c l i n i c ' s social histories may be attributed, i n part, to the absence of any specific reference to school i n the outline. Table 13 i s a summary of the school histories of the sample cases i n both c l i n i c s and shows that the percentage of patients whose school records were good was only slightly higher than the percentage who had failed i n one or more grades. Table 13 School Record p.c. Excellent 3.85 Good 26.92 Fair 17.31 Poor 21.15 Failed i n one or more grades 23.07 No report 3.85 Not i n school 3.85 Total 100.00 64 This summary also indicates that less than one-third of the patients who were in school were making satisfactory academic progress. Although there was a wide range i n the quality of the descrip-tions, a l l of the social histories i n this sample gave some account of the patient's current personality t r a i t s . In some instances i t appeared that the persons preparing the history had had l i t t l e or no direct contact with the patients. Those histories which included the interviewers' own observations of the patients as well as the statements made by parents and others, contained more distinct portrayals of the children as persons. Interests and forms of recreation are significant i n the study of maladjusted children. In the choice of recreation each individual seeks to satisfy some inner need. S.R. Slavson, a recognized authority on group therapy, describes play i n the following terms: "To the child, play i s of utmost importance, for i t i s through his play that he learns the world. Play i s the means whereby the child in fantasy, comes to know re a l i t y . The child scales down the world around him to simpler patterns that he can understand and master, gaining greater security and acquiring power as he does i t . The adult world i s to the small child threatening and for-bidding, and i n play he reduces i t s complexity to the level of his powers and understanding. As he grows and i s able to deal with this world, his play a c t i v i t i e s gradually fuse with reality, u n t i l the latter becomes predominant. Through play, also, the child diverts his aggressions, which are part and parcel of his biological heritage. Instead of attacking someone, he bangs an object or throws a b a l l . This draining (sublimation) of basic aggressiveness i s of extreme importance i n socializing him. Where there are no sublimations or substitutions, the child antagonizes other children and adults; and as a result of their rejection and punishment, he grows resentful and maladjusted. 5(1) (l)Slavson, S.R., Recreation and the Total Personality Associated Press, New York, 19-46. p. 2-3. 65. In less than two-thirds (63.46 per cent) of the social histories mention was made of the patients' interests and recreation. Very few of the histories outlined the opportunities for the pursuit of interests or for play, provided i n the patient's environment. On the subject of group adjustment, (socialization i n situations involving other children) there was more adequate coverage by the social histories. In 9.6 per cent of the cases, however, no reference was made to this important aspect of development. The summary of the reports on this topic indicates that group adjustment was "poor" i n 63.8 per cent of the cases, " f a i r " i n 27.7 per cent and "good" in 8.5 per cent. In other words, i n the cases i n which group adjustment was described, at least 9 out of every 10 children had some d i f f i c u l t y i n this area, and that for more than 6 out of 10 the d i f f i c u l t y was marked. The conclusion reached, through this study of social histories i s that i n many instances there was inadequate information about both the past and present aspects of the patient's development. More information about the child himself should be available, and i n order that the social and cultural atmosphere i n which he i s being reared may be considered i n a. relation to his problem, social histories should contain information about the parents' nationality, isligion, age, education, intelligence, occupation and earning capacity, habits, attitudes toward family and patient. Past and present physical and mental health of parents may also have an important bearing on the patient's development and should be assessed i f possible. The patient's brothers and sisters should also be described, particularly with regard to their attitudes toward him. 66. CHAPTER 5. SOCIALLY UNACCEPTABLE BEHAVIOUR One hundred of the 257 children given psychiatric examinations were referred because of socially unacceptable behaviour. This number represents almost 39 per cent of the total number of cases. The highest incidence, (22 per cent), of this type of problem occurred i n the 7 to 8 year old group. The second highest number of cases, (20 per cent), occurred in the 11 to 12 year old group. The other age groups are represented i n decreasing order as follows: 9 to 10 years - 18 per cent; 8 to 9 years - 17 per centj 10 to 11 years - 13 per centj and 6 to 7 years - 10 per cent. The 7 to 8 year old boys and g i r l s whose behaviour was socially unacceptable represented 46.8 per cent of a l l the children of this age examined. The 11 to 12 year old children i n this group comprised 51.28 per cent of a l l patients of this age. "Only" children represented 24- per cent of the c l i n i c patients showing socially unacceptable behaviour. Patients from families of 2 children comprised 21 per cent of the cases i n this classification of symptoms, while those from families of 3 children represented 28 per cent. In summary, more than seven out of every 10 boys and g i r l s who were referred to c l i n i c because their behaviour was socially unacceptable came from families i n which there were not more than 3 children. Larger families were represented i n this group of patients as follows: 4 children - 15 per cent, 5 children - 1 per cent, 6 children - 5 per cent, 67 7 - 2 per cent, 8 - 1 per cent, 1 0 - 3 per cent. In the matter of patients 1 ordinal positions i n families, "oldest" children comprised the largest group (34 per cent) "middle" children comprised the second largest (27 per cent), "only" children the third largest, (24 per cent) and "youngest" children the smallest group (12 per cent). In 40 per cent of the cases i n this group there was evidence of family disorganization.^ The single factor most prevalent, divorce, was present i n U per cent of the cases. Marked discord between parents was noted i n 7 per cent, father deceased i n 6 per cent, and desertion by one parent i n 6 per cent of the cases. Other circumstances, such as separation and parents i n mental hospital were less frequent. In 45 per cent of the cases in this group there were factors contributing to maladjustment of children, (2) other than those which constitute "broken families". These unfavourable circumstances, i n de-creasing order of incidence were: interference by grandparents and other relatives l i v i n g i n the home (18 per cent), poor or very crowded housing (16 per cent) and fathers' absence while serving i n the Armed Forces (11 per cent). Findings based on the 20 per cent sample of cases. Judging from the sample of cases showing symptoms i n the form of socially unacceptable behaviour, 6 out of every 10 children had d i f f -culty i n their group adjustment.^) Some of these children refused to (^Table 6, p. 40. ' (2) Table 7, p. 4 1 . (3) The information i n the remainder of this chapter, and corresponding sections i n subsequent chapters i s based on the total c l i n i c study of each case, and not as i n Chapter 4 , solely on the social history. 68 participate i n group a c t i v i t i e s i f they were not "captains" or "leaders". Others had few friends because of their aggressive behaviour. Ralph, (aged 8 years 11 months) was completely ostra-cized by children i n the neighbourhood because his violent temper tantrums at home and on the street (he struck and b i t his parents, broke windows, swore profusely, etc.,) had gained for him the re-putation of being "a holy terror". Some of these patients preferred playing with children much older or much younger than themselves. A brief sketch of one boy's at-tempts to find satisfactions i n his relationships with others follows. George, who was examined when 11 years 11 months of age was referred to the c l i n i c by the Juvenile Court. The boy had been involved i n theft several times. At school he was unpopular with children of his own age. Classmates considered him "a cheat and a tattle - t a l e " . For some time George had relied on younger child-ren for companionship, but this brought more ridicule from his own age group. He turned later to teen-aged boys but was rebuffed by them. In his search for recreation and friendship George found transitory satisfaction i n his association with a vaudeville . group. He was used as an hypnotic subject (faked) by M , the Magician. A g i r l whose chief symptom of emotional disturbance was stealing, had increasing d i f f i c u l t y i n her group adjustment while the underlying causes of her maladjustment remained untouched. Her efforts toward group adjustment are outlined below. Dorothy, an 11 year old g i r l , referred for examination because of repeated thefts over a period of more than 3 years, was called "robber" by her classmates. She was "polite and well liked by adults", but had no friends of her own age. Frequently, with stolen money, she bought things to share with other child-ren, and so the vicious circle continued. She liked to play "cops and robbers", and football with the boys i n the neighbour-hood. On rare occasions when the boys accepted her i n their games, Dorothy was subjected to further rejection by g i r l s of her own age, who called her "tomboy". (DAII names, of course, are f i c t i t i o u s . 69. In the case of Dick, described below, the boy's poor group ad-justment was obviously a reflection of the treatment he himself had re-ceived i n his home. Dick was nine and a half years of age when he was referred for c l i n i c a l examination. His symptoms were "bullying, lying, firesetting, stealing and negativism". In school, Dick's a t t i -tude to authority was unsatisfactory. He was described as "only reacting to force". Sick was the seventh child i n a family of 10 children. He had 5 older brothers. Dick's father was "arbit-rary and r i g i d " i n his attitude toward his wife and children. The" older boys, four of whom had had "some contact with an underworld crowd", imitated their father. They dominated younger members of the family, particularly Dick. Dick played only with children young enough or small enough for him to bully. He said that he had "a devil inside", which made him cruel and disobedient. In 34- per cent of'the sample cases of children whose behaviour was socially unacceptable^ patients' school reports indicated that they were not making satisfactory progress i n their academic work. Compared with the three other classifications of symptoms, children i n this group had the least d i f f i c u l t y i n meeting with the school's standards. Ralph, was repeating Grade 3 when he was examined by the school c l i n i c . His symptoms at that time were "swearing, poor application at school, poor group adjustment and poor control of temper". Frequently he refused to attend school. In the group test given by the Bureau of Measurements, Ralph's i n t e l -ligence quotient was 109. Five months later Ralph became so unmanageable at home that the parents sought help from the Child Guidance C l i n i c . On an individual test at this c l i n i c , Ralph's intelligence quotient was rated as 121. However, i n a l l of the other cases i n which school progress was unsatisfactory, the children i n question had "low average" or "average" intelligence. Sibling r i v a l r y was apparent i n 70 per cent of the sample cases. In some instances this seemed to be closely related to the mother's 70. rejection of children of an earlier marriage. An i l l u s t r a t i o n w i l l be given. Marlene was referred to Child Guidance Clinic at the age of 6 years by her mother on the advice of the family doctor. The l i t t l e g i r l was "disobedient, slapped back threatened to run away, and cruel to her half-brother". To the mother the child was a reminder of her f i r s t husband whom she had divorced. (This had been the father's fourth marriage). Each unfavourable t r a i t of the child's personality was said by the mother to be "just l i k e her father". The mother's second marriage was a satisfying relation-ship for her. The child of this marriage, 3 years younger than the patient, was preferred by the mother. She realized that Marlene's behaviour antagonized the step-father and feared that her marriage was being jeopardized by the presence of the l i t t l e g i r l i n the home. Marlene f e l t insecure i n this situation, and openly showed her resentment of the step-brother who received so much of her mother's affection. In several other cases, parents openly promoted sibling r i v a l r y by such remarks as: "Wait t i l l your brother starts to school. He'll get out of Grade 3 before you do." (to a g i r l who had just f a i l e d i n Grade 3)• "Girls are so much easier to bring up. I was very disappointed when Jack was born. I had hoped for a g i r l . It was a happy day when Angela came" (said i n the presence of Jack, whose resentment of his younger sister was marked.) In one half of the sample cases, one or more siblings of patients showed some form of maladjustment. ^h±3 i s more marked than in-any of the three other classifications of symptoms. One mother, a widow with 4 sons, requested c l i n i c a l examination for Mike, her third child, who was truanting from school and stealing. She had found the c l i n i c helpful when her oldest son had been examined 4- years before. The syjnptoms. shown by the f i r s t boy had been "nightmares, f a c i a l t i c s , i n a b i l i t y to make friends". 71 Norman (aged 10 years) was referred for examination by the Juvenile Court because of "breaking and entering and petty thievery" had one sister who was an unmarried mother, and another sister who had been a "pickpocket" and a truant. Dick (previously mentioned with regard to group adjust-ment) had A older brothers who were not able to make satisfactory work adjustment, -^hey tried to "make an easy l i v i n g " by con-tact with "an underworld crowd". Arthur, an 11 year old boy examined at the request of the Juvenile Court, because of his stealing had a sister who had spent a year i n a Girl's Industrial School on a charge of sexual immorality. Leslie, a boy (aged 10 years and 8 months), was said by his mother to be incorrigible. His symptoms were stealing and truancy. This boy's sister (10 years older) became an unmarried mother at the age of 16, became involved with youthful criminals of both sexes, and later was imprisoned because of drug addiction. In 80 per cent of the sample cases in this classification of symptoms, patients had experienced unfavourable circumstances i n the per-iod between birth and the end of their second year. This i s a higher per-centage than was found i n any of the other three classifications of symptoms. The cases of Ralph and B i l l w i l l i l l u s t r a t e some of the kinds of unsatisfactory circumstances described i n the c l i n i c records. Ralph, (previously mentioned) was cared for part of the time during infancy by his elderly paternal grandmother who had lived with his parents from the time of their marriage. There was considerable tension i n the home. The child's father was not a well adjusted person. He said that he had had several "nervous breakdowns". He had always been dominated by his mother who was showing signs of senility before Ralph was born. The father was not able to help his wife withstand the domination of her mother-in-law. The baby had "cradle cap" during the f i r s t 6 months of his l i f e . His hands were frequently tied to keep them away from his head. When Ralph was 5 months old, the mother became pregnant, and was at times very i l l during the pregnancy. The second child died shortly sifter birth. Soon after this the mother worked in an office half-days, leaving Ralph with his grandmother. 72. B i l l , the product of a forced marriage, was deserted by his father shortly after birth. The mother left the baby with relatives during the day while she worked. The baby's legs were "weak and crooked". He had difficulty in learning to walk, and was under a doctor's care for several months. Meanwhile, the father's infrequent visits were occasions of bitter quarrels between the child's parents. They obtained a divorde before the l i t t l e boy was 3 years old. In other cases one or both parents were disappointed because the child was not of the sex they had hoped for. In some instances par-ents said that children were not wanted because of poor financial circum-stances, poor health of parents, crowded housing and other similar reasons. Sudden weaning, nutritional deficiencies, early and rigid toilet training, over-concern about thumb-sucking and masturbation, and illnesses such as bronchitis, whooping cough and eczema during the first 3 years were noted in other cases. Negative factors such as some of those described above were present in 85 per cent of the sample cases in the period of patients' lives from 3 to 6 years. Severe illnesses, falls resulting in fractures or concussion, tonsil, adenoid and mastoid operations, or frights, were also experienced by some of the children during this period. For some children the birth of a sibling at this time appeared to be a threat to their security. In 35 per cent of the sample cases of children whose behaviour was socially unacceptable, there was evidence of harsh or rigid parental discipline. For example, the case of Margaret, (aged 8£) wi l l be described. 73 This child lived i n a good residential d i s t r i c t . She was the eldest child i n a family of 3 children. A children's agency received several complaints from neighbours that the mother Was whipping the child severely.- The mother frankly admitted that the reports were true. She told of Margaret's temper tantrums and fluctuating behaviour and readily accepted the agency's offer of c l i n i c a l examination for the child. In the course of the study of this child i t was learned that the mother had used this method of punishment for several years. Another mother, said that her daughter, (aged 11 years 10 months) was incorrigible. A study of the case (also referred by a children's agency) revealed that the mother, a hard-working embittered woman was i n need of psychiatric help for herself and that the g i r l ' s adjustment was f a i r l y good. The mother had a deep-seated hatred of the g i r l (her f i r s t child); she tried to keep her daughter busy with household duties and homework, refusing to l e t the g i r l go to friends' homes or have friends v i s i t her. When the g i r l rebelled at this injustice she was beaten, verbally reprimanded i n a de-structive manner, and threatened with police, industrial school, etc. Earlier i n this chapter i t was pointed out that the highest incidence of patients showing socially unacceptable behaviour occurred i n the 7 to 8 year old group. The case of Peter G. aged 7 years 9 months i s one i n which the diagnostic and consultative services of the Child Guidance Clin i c were used by a social worker in a family agency. Peter was brought to Child Guidance Clinic when his mother expressed concern to a social worker i n a family agency about his defiance, disobedience and "whining". The social worker i n this agency, to which the mother had gone for help with a marital problem, prepared the social history. Peter's home was a small, crowded, dirty apartment, but i n a good neighbourhood. His father, aged 35 years, had had Normal School training, but at the time Peter was examined, aspired to a position of public accountant in the U.S.A. and was trying to get American citizenship papers. The mother, on 74. the other hand, had refused to sign the necessary form for citizenship papers. The father seldom lived with his family but when he did come home, Peter was witness to bitter quarrels between his parents. The father wanted a divorce, but the mother f l a t l y opposed,it. Peter remembered clearly that his father had gone away for quite a while before his baby brother was born. Perhaps Peter remembered too that his father had l e f t the family for a long time before the birth of his sister when the l i t t l e boy was only 4- years old. Peter's mother was 2 years older than his father. She had finished Grade 8, and had later become a clerk i n a small store. Peter was Mrs. G.'s f i r s t child, and she said that she had wanted a baby very much. She told of her i l l n e s s during pregnancy, of the severe nausea which was followed by extreme hunger. Her husband was described as "unsympathetic" during this period. Family finances had never been very good, but they were partic-ularly bad at that time, and often there was no food i n the house when the mother f e l t l i k e eating. Mrs. G. had breast-fed Peter for only 2 weeks. She changed to bottle-feedings when the baby seemed to be "always hungry". The story of when and how he was weaned from the bottle wasn't told but the mother did say that Peter had been a "problem" ever since he was 3 years old. He was "slow" i n learning t o i l e t training, and mother was not very successful with this u n t i l Peter was over 3ji years old • A few months before the l i t t l e boy was examined at Child Guidance Clinic, he had begun soiling under the bed. Mother thought that this was sheer "spitefulness". The soiling continued. Besides Mother, sister, brother, and Father, who came and l e f t again, there was also a maternal grandmother l i v i n g i n the small, crowded dirty apartment with Peter. Grandmother said that her husband, l i v i n g i n Manitoba, was a successful business man. She did not say why she was not l i v i n g with him. In grandmother's eyes Peter was a bad l i t t l e boy. Everything he did was "wrong". Her chief complaint was "He has no more manners than an animal". He threw things at her, and once had threatened her with a knife. The social worker i n the family agency was not the f i r s t person who had tried to help Peter. When the l i t t l e boy had failed i n Grade 1 his teacher and the school principal had conferred about him and decided that "special class" might offer this pupil better opportunities. They had reached this decision after taking into consideration the boy's score 75 on a group intelligence test. The special class teacher reported that Peter was not a "problem" in school* and that he seemed happier than when he was in the regular Grade 1. Mrs. G. said that she had to "force him to go to school every day" though. Although Peter was defiant and at times sullen with his mother, he always "sided fiercely" with her against his father during the parents' frequent quarrels. The father thought that there was "nothing wrong with the boy except his mother's spoiling". The boy had had severe bronchitis 4 months before he came to Child Guidance Cl i n i c . This had recurred frequently; i n fact, i t had not really "cleared up" during the 4 months. The physical, psychiatric, and psychological examinations as well as the nurse's observations of Peter i n playroom with his mother a l l revealed that the boy was immature and anxious. He was f r a i l and looked undernourished. Peter tested i n the low average group of general intelligence. His I.Q. was 87. The mother was emotional and inconsistent i n her handling of him. At the conference which followed Peter's examination at Child Guidance Cl i n i c , case work with mother was recommended. Peter needed more security and more consistent handling. Even-tual foster home placement seemed indicated, and i t was recom-mended that another conference should be held i n 2 months, with a representative of a children's agency present unless there was an improvement i n the family situation. The second conference (consultative), was held and a social worker from a children's agency was present. The family agency's supple-mentary history covered the 2 month interval, between the conferences and was as follows: Peter had been i n hospital twice during the 2 months. Each time he had had severe bronchitis. He seemed to enjoy being i n hospital. His grandmother had said that the l i t t l e boy "did not get proper rest". He was frequently up u n t i l 11 p.m. There had been constant quarrelling whenever father returned to the home. Peter's mother became "upset and hysterical" after each of father's v i s i t s . Grandmother com-plained that she was i l l and wanted to leave British Columbia. 76. The family agency worker reported that she had been unable to help the family to any extent. Both Mr. and Mrs. G. had en-gaged lawyers. Besides, Mrs. G, who was an ardent member of a religious sect was getting additional advice from the church president. Child Guidance Clinic recommendations at the second con-ference were "(1) Try admission to Solarium (2) If this cannot be arranged, the possibility of Peter going to live with his aunt in Saskatchewan should be explored (3) Foster home place-ment of 1 year or longer, since the mother seems unlikely to respond to case work." That this l i t t l e boy, caught in the maelstrom of parental immat-urity and discord, should become maladjusted is not surprising. The social work implications in this case are numerous. Perhaps the out-standing one is the limitations of a social agency when the problem has  existed for many years before i t is referred. Had the family agency been  brought into the picture at an earlier phase of the marital difficulty the outcome for parents might have been more favourable. Peter and his sib-lings might have had a richer soil of healthy family l i f e in which to take roots and grow. If the problem had been detected and referred to the fam-i l y agency during Mrs. G.'s pregnancy or confinement i t is highly probable that the personality strengths of each parent might have been released and utilized. Another time at which the problem might well have been detected was during attendance at Well Baby Clinics. Later, but s t i l l before the difficulty had reached the serious proportions described, a teacher in a nursery school or kindergarten might have noticed that Peter was unhappy. Through discussion with the mother, the teacher could have directed her to a source of help. In Grade 1, a public health nurse, or school social worker, making a thorough investigation of the reason for the boy's lack 77. of progress, might have considered placement in a special class a neces-sary, but only partial, solution of his problem. When the family agency arranged to have Peter re-examined at Child Guidance Clin i c 1 year and 4- months after the conference, the value of continued case work with the G. family was apparent. Following the second conference at Child Guidance Clinic, the social worker had suggested that Mrs. G. should discuss with the family doctor the possibility of Peter's admission to the Solarium. Mrs. G. readily accepted this suggestion. The doctor examined Peter again and made a diagnosis of bronchial asthma, but did not consider the l i t t l e boy eligible for care i n the Solarium. The mother carefully administered the medication which the doctor prescribed, and the improvement i n Peter's physical health was encouraging to her. Mrs. G. told the social worker about Peter's increasing appetite. Later she told that he was sleeping well. There were discussions between the mother and the social worker about consistency i n dealing with Peter and his siblings. The grandmother l e f t the G. home, ^he mother gradually faced the reality of her husband's loss of interest in her and i n the children. She obtained a j u d i c i a l separation from Mr. G. and he was required to pay a substantial sum of money each month for the support of his wife and family. With less anxiety about family finances (Mrs. G. had been t o t a l l y dependent on her parents for support for 2 years before) the mother's own health improved and her a b i l i t y to care for her children increased. Mrs. G. no longer became upset when her husband urged her to consent to a divorce. She was even able to face the same suggestion frequently from the young woman Mr. G. wished to marry. Mrs. G. discussed her children's problems with the social worker as they became apparent to her. She was able to accept the case worker's explanation that her small daughter's mastur-bation indicated a need for greater security rather than punish-ment. When the family doctor told her that her youngest child needed a serious operation urgently, Mrs. G. discussed with the social worker her unwillingness to increase her- already large debt to the doctor. The social worker, u t i l i z i n g her knowledge of community resources, told the mother about the out-patients' department of the Vancouver General Hospital. As a result of this, arrangements were made for the nedessary operation, the postponement of which might have had serious effects on the l i t t l e boy's health. 78 Peter's second examination at Child Guidance Clinic re-vealed that his physical health had improved a great deal. His emotional adjustment showed even greater improvement. The ex-amining psychiatrist noted that Mrs. G. was less anxious and less worried about the future than at the time of her f i r s t inter-view at Child Guidance C l i n i c . She showed improved health and her whole attitude toward her family was better. The psychiatrist ad-vised that although marked progress had been made, the mother needed continued contact with the family agency. Much of the progress i n this case may be attributed to the fact that throughout a d i f f i c u l t 2 year period, Mrs. G. had a continued suppor-tive relationship with one well-trained and experienced social worker. This non-judgmental, helpful relationship was i n marked contrast to Mrs. G.'s relationship with her mother and her husband. It enabled her to u t i l i z e her own a b i l i t i e s with advantage to her children and herself. The case of Peter i s not an extreme example. As pointed out earlier i n this chapter, i n 4-0 of the 100 homes from which patients showing socially unacceptable behaviour, there were known factors of family disorganization such as desertion, separation, divorce, and marked discord. Eighteen of the 100 children were affected by the interference of grandparents, aunts, uncles or other relatives l i v i n g i n their homes. There were 16 instances of extremely poor or crowded housing. An example of a case in which none of the above mentioned fac-tors were apparent i s that of Tom Z., aged 7 years. Tom was examined at the Mental Hygiene Clini c because of marked disobedience at school. He also told many l i e s . He was referred for examination by a public health nurse. Tom's mother said that he was very jealous of his brother who was U years younger. There were no other children i n the family. Mr. and Mrs. Z. were born i n Central European countries. The social history did not state when either parent had emigrated to Canada. The father had attended university for 1 year and was 79 r e g u l a r l y employed a t s e m i - s k i l l e d l a b o u r . The mother had a G r a d e 9 e d u c a t i o n . She s a i d t h a t she l i k e d t o w r i t e s t o r i e s a n d t h o u g h t t h a t Tom's i m a g i n a t i o n was l i k e h e r own. The f a m i l y l i v e d in" a good h o u s e i n a m i d d l e c l a s s n e i g h b o u r h o o d . - T h e p u b l i c h e a l t h n u r s e t h o u g h t t h a t " f a m i l y r e l a t i o n s h i p s seemed good and s o c i a l s t a n d a r d s seemed n o r m a l " . The age o f n e i t h e r p a r e n t was s t a t e d . The m o t h e r ' s a t t i t u d e t o w a r d Tom was d e s c r i b e d a s one o f " s y m p a t h e t i c u n d e r s t a n d i n g " . The f a t h e r i g n o r e d t h e b o y . The i n f o r m a t i o n a b o u t T o m ' s e a r l y d e v e l o p m e n t was m e a g r e . The exam-i n i n g p s y c h i a t r i s t e l i c i t e d t h e i n f o r m a t i o n t h a t a s a b a b y Tom h a d been " h a r d t o wean". He had t o be f e d u n t i l 2 y e a r s o l d " . Tom had eczema, and a "wheezy c h e s t " . He was a l s o s u b j e c t t o h a y f e v e r . H i s mother s a i d t h a t he had "a lways" been r e s t l e s s . He seemed t o c a r e l i t t l e f o r h i s own s a f e t y o r t h a t o f o t h e r s . M r s . -Z . s a i d t h a t f o r t h e p a s t 4 y e a r s Tom h a d been i n d i f f e r e n t t o d i s c i p l i n e . She had f o u n d making torn " s i t s t i l l on a c h a i r " t h e b e s t f o r m o f p u n i s h m e n t b e c a u s e i t was "so: i r k s o m e t o h i s n a t u r e " . Some c o r p o r a l p u n i s h m e n t had b e e n u s e d a t t i m e s t o o . Tom's i n t e l l i g e n c e was r a t e d a s l o w a v e r a g e . He h a d a good s i n g i n g v o i c e and l i k e d t o s i n g . He p r e f e r r e d p l a y i n g w i t h o l d e r c h i l d r e n . He was q u i c k tempered and r a t h e r r o u g h i n h i s p l a y a t t i m e s . The e x a m i n i n g p s y c h i a t r i s t gave a d v i c e t o Tom's mother and h i s t e a c h e r . He recommended t h a t a n o u t l e t f o r T o m ' s m u s i c a l and i m a g i n a t i v e t a s t e s s h o u l d be p r o v i d e d . Tom's mother was a d v i s e d t o a v o i d a n y t h i n g w h i c h would promote s i b l i n g r i v a l r y . T h e r e i s no p r o g r e s s r e p o r t on t h i s b o y , d u r i n g t h e 2 and 1 h a l f y e a r s w h i c h hade e l a p s e d s i n c e h i s e x a m i n a t i o n a t t h e c l i n i c . I n • t h e b r i e f s o c i a l h i s t o r y t h e r e a r e i n d i c a t i o n s t h a t t h i s mother h a s n o t been v e r y w i s e i n h e r c a r e o f Tom i n t h e p a s t . One m i g h t q u e s t i o n h e r a b i l i t y t o c a r r y out t h e c l i n i c r e c o m m e n d a t i o n s , w i t h o u t h e l p f r o m a p u b l i c h e a l t h n u r s e , o r a s o c i a l w o r k e r . The case o f T i m M. i l l u s t r a t e s t h e i m p o r t a n c e o f l e a r n i n g a b o u t  t h e p a r e n t s a s w e l l a s t h e c h i l d . I t a l s o i l l u s t r a t e s t h e u s e o f a f a m i l y a g e n c y ' s h e l p b y t h e C h i l d G u i d a n c e C l i n i c i n t h e t r e a t m e n t o f a. p r i v a t e c a s e . • 80. Tim was 9 years old when he was referred to the clinic by his mother, on the advice of his teacher and a children's agency. Tim's symptoms were stealing and lying. The mother had learned that corporal punishment, (suggested by a clergyman) did not produce the desired results. Tim was born prematurely, and spent the f i r s t 2 months of his l i f e in a hospital incubator. He was at home only 1 month when feeding difficulties became so severe that he was hospitalized for 6 months. Again he returned home, but only for 1 months. This time, Tim was in hospital for 6 months, because of pneumonia and impetigo. After another brief period at home, Tim returned to hospital and remained there for 8 months being treated for rickets.- Again he was home for only a few months when he returned to hospital to have his tonsils and adenoids removed. The week after he went home, Tim drank half of a bottle of his mother's medicine, had a convulsion and was taken to hospital to have his stomach drained. After this episode, Tim had measles, numerous colds and impetigo, but did not return to hospital until he was four and a half years old, when he suffered a broken collar bone. When Tim was 5, he became very disturbed because his mother underwent an operation and he thought that she was going to die. Shortly after this Tim was found to be anaemic and was treated for this condition by the family doctor. When the clinic social worker in preparing the history con-ferred with the school principal, the latter reported,that Tim liked to be the centre of attention and boasted a great deal about his illnesses. In view of Tim's medical history this was quite understandable. Three days before the date set for clinical examination, Tim had an appendectomy operation, necessitating postponement of the clinic appointment. A casual observer of this history might consider that there was a large element of neglect on the part of Mrs. M., and might call her "a careless mother". What did the clinic social worker learn about the mother which would throw a light on the reasons for her being the kind of person she was? What did the worker learn which would help her to understand the mother's unmet emotional needs? 81 Mrs. M. was one of the younger members i n a family of 13 children. There was a great deal of marital discord between her parents. Her father, who was described as "very s t r i c t " , seemed to r e j e c t h i s daughters. When Mrs. M. was 14, she developed tuberculosis. In t a l k i n g with the soci a l worker t h i s mother appeared to r e a l i z e that she was extremely anxious about health matters, and thought that t h i s anxiety dated from her i l l n e s s during adolescence. Mrs. M. married before the age of 19, pa r t l y to escape the domination of her father. However, she soon found herself i n -volved i n d i f f i c u l t i e s with a dominating mother-in-law. Mr. M. was 21 years old when he married. He had a Grade 7 education, and was frequently unemployed. During the f i r s t 3 years of marriage Mr. and Mrs. M. l i v e d with or near t h i s mother-in-law. There was constant bickering between Mrs. M. and her mother-in-law i n t h i s period. Mrs. M. thought that the basis for t h i s was r a c i a l prejudice (she was French-Canadian, and the mother-in-law was I r i s h ) . When Tim started t o school, at the age of 6, h i s mother was working, so he was sent to a boarding school f o r a year and a h a l f . When he returned home, there was discord between the parents and separation was threatened. The soc i a l h i s t o r y contained l e s s information about Mr. M.'s early l i f e , but he too, had many i l l n e s s e s . At one time of Tim's r e f e r r a l to the c l i n i c , Mr. M. was i n a m i l i t a r y hospital suffering from what h i s wife vaguely des-cribed as "war trouble". For years he had been on a d i e t (to which he rarely adhered), because of duodenal ulcers. He had had pneumonia several times, and he had been very i l l following an appendectomy. Obviously, i n much of h i s i l l n e s s , Tim had followed the pattern of the 2 adults nearest to him. There was undoubtedly an i n t e r - r e l a t i o n -ship between the l i t t l e boy's physical neglect by his sick parents and his i d e n t i f i c a t i o n with these parents i n t h e i r retreat i n t o i l l n e s s . Apparently both parents were over-dependent persons, and t h i s was taken into consideration i n the casework services of the c l i n i c . 82. The mother, whose dependency needs had not been met i n her youth, responded well to the sympathetic understanding and emotional support given her by the caseworker. Mrs. M. was encouraged by the know-ledge that Tim was not mentally retarded. (His I.Q. was 129). She was able to gradually learn a new approach to the training of her son. She began to recognize the importance of consistency i n handling Tim. Tim's stealing and lying which had caused the mother so much concern, ceased as his environment became more stabilized. These symptoms recurred however when the mother became pregnant and again grew concerned about her health. During the third month of the pregnancy, the mother f e l l while leaving a street car. At this point, the c l i n i c sought the help of another agency for Tim and his parents. A family agency provided the services of a v i s i t i n g homemaker, a kind and*motherly person who remained with the M.'s u n t i l after the birth of the second child. Again the dependency needs of this family were met. Mrs. M., with this help was able to give Tim a greater sense of security and his former symptoms disappeared. Mr. M., relieved of some of his responsibilities at home, found steady employment. He was able to pay partially for the v i s i t i n g homemaker's services. Shortly after the birth of the baby, the family moved to another province (not the one i n which the mother-in-law lived) to take advantage of a better work position offered to the father there. It would be presumptuous to predict that there would be no more d i f f i c u l t i e s i n this family which would require help from social agencies. It can be said however that casework services while the family were i n 83 this city were a step i n the right direction because the unmet needs of this family were recognized. Based on the cases i n which the information was available, the average period of time between the appearance of f i r s t symptoms of mal-adjustment and referral to c l i n i c was 3 years. This does not include cases i n which there were indefinite statements such as "early",•"a long time" and "always". The importance of early recognition of symptoms and prompt action in seeking to eliminate, or alleviate the underlying causes of these symptoms cannot be overstressed. The undesirable methods' of dealing with these "problem" children had, i n many cases, aggravated the situation which las already intolerable for them. 84 CHAPTER 6. UNFAVOURABLE PERSONALITY REACTIONS Eighty of the 257 children given c l i n i c a l examinations were • referred because of personality reactions which were indications of mal-adjustment. This number represents 31 per cent of the total number of cases. The highest percentage of children showing symptoms of this kind were between the ages of 6 and 7 years and between 8 and 9 years. Each of these age groups comprised 21.25 per cent of the 80 children examined. In the order of decreasing percentages the other age groups were repre-sented as follows: 9 to 10 years - 17.5 per cent, 10 to 11 years - 16.25 per cent, 11 to 12 years - 12.5 per cent, and 7 to 8 years - 11.25 per cent. The 6 to 7 year old children whose symptoms were personality reactions comprised 42.25 per cent of a l l the patients of this age group. The 8 to 9 year old children showing these symptoms formed 35.41 per cent of a l l the patients between these ages. An equal percentage ofithe child-ren between 8 and 9 years showed symptoms i n the form of socially unac-ceptable behaviour. Almost one quarter (23.75 per cent) of the children examined who were manifesting unfavourable personality reactions, were "only" children i n their families. Patients from families of 2 children com-prised 46.25 per cent. In other words 7 out of every 10 children exam-ined came from families i n which there were only 1 or 2 children. Larger families were represented i n this group of patients as follows: 3 child-ren - 11.25 per cent, 4 children - 8.75 per cent, 5 children - 2.50 per 85. cent, 6 children - 5 per cent, 7 children - 1.25 per cent, and 8 children -1.25 per cent. With regard to ordinal positions i n families, "oldest" children comprised the largest group (35 per cent) "youngest" the second largest (26.25 per cent) "only" children the third largest (23.75 per cent) and "middle" children the smallest group (15 per cent). Turning now to findings based on the 20 per cent sample, i n 96.75 per cent of the cases children had d i f f i c u l t y i n their group adjust-ment. There were varying degrees of maladjustment i n this area. Several of the patients, though of high average average intelligence, did not play with children of their own age. Some who associated with younger children only, were aggressive and at times cruel i n their play, while others had no friends near their own age and r e l i e d on adults for companionship. A specific example of another form of unsatisfactory group ad-justment i s that of B i l l , aged 8 years 11 months. B i l l had suffered from severe headaches and nausea inter-mittently for a period of 6 years. His I.Q. was 116. This boy had no friends, and used to s i t outside alone for hours. He liked knitting, sewing, and cooking. B i l l ' s mother commented "He should have been a g i r l . " B i l l had no interest i n outdoor sports. Denise, aged 10, with average intelligence, referred to c l i n i c because of her daydreaming, "ugly moods" and awkward gait, told the social worker this story: "George i s my only friend. I wish he could be i n my grade at school. (George was a 7 year old mentally retarded Hindu-; child). I hate a l l the kids i n school. I don't l i k e chocolate milk very much either, but I get some every day ar recess time. I drink i t real slow so I won't have to go into any games. None 86. of the kids l i k e me. They c a l l me "stupid" and "slow poke"." when the worker made inquiries about what Denise liked to do most her reply was immediate and vehement. "I l i k e to "crab" at my mother. She "crabs" back and we get madder and madder. That's the most fun. Kids don't l i k e me when I "crab" at them, but I don't care. I hate them a l l 'cept George. Nobody else likes him. Sometimes I fight with him, too, but he comes back again i n a few days." In 37.5 per cent of the sample cases of children showing un-favourable personality reactions, patients had d i f f i c u l t y i n keeping up with the school standards of academic work. In most cases this could not be attributed to lack of intelligence, as the 2 illustrations of Patricia and Sam show: Patricia, aged 8 years 10 months, was referred to c l i n i c by her parents, because of her lack of self-confidence and con-stant quarrelling with her twin brother. Patricia showed l i t t l e -interest i n her work at school, and her progress was slow. She complained about being t a l l e r than the g i r l s i n her class, (she was not as old as many of her classmates but was very large for her age). She said that she could not do better work because she was "too dumb". Her I.Q. was 129. Sam, aged 10 years 7 months, was referred to c l i n i c by his mother because he had "no sense of responsibility" and was " f u l l of fears". Sam's school report indicated that he had a negative attitude toward learning. He seldom completed his work and showed no interest i n new lessons. Sam's I.Q. was 150, In half of the cases in this sample, marked sibling r i v a l r y was apparent. Examples of some of the forms of this are illustrated i n the two following cases. Roger, aged 8 years, the eldest of 3 children, was re-ferred to c l i n i c by his mother on the advice of the family doctor. Of Soger's numerous physical complaints of several year's standing, bilious attacks were the most severe. He occasionally had violent temper tantrums. Usually he showed 87 l i t t l e animation. Roger's father, whose employment had kept him away from home for months at a time spoke harshly to the boy during his short periods with the family. Often the father added to his reprimand the statement: "You're the oldest. You should have better sense." The mother, i n the absence of her husband, expected Roger to assume many chores around the home, particularly the responsibility of "keeping an eye" on his brother and sister. Roger had no time to make friends or pursue any of the usual boyish interests. Most of his small allowance was saved to buy g i f t s for his 2 siblings. It appears that by this gesture Roger was trying to gain the approval of his parents. Their single favourable comment about him was: "One good thing about Roger i s that he's very unselfish. He's always buying g i f t s . " This "unselfishness" may have been Roger's outward denial of his resentful feelings toward his siblings, which were only rarely exhibited by aggressiveness toward them. Sam, the boy previously referred to i n the discussion of poor school achievement, showed his feelings of riva l r y toward his brother more openly. Sam's mother said that she had tried to "bring him up s c i e n t i f i c a l l y " which to her meant "no cuddling or picking up". When the second child, John, was born 3 years after. Sam's birth, the attending doctor told the mother that she would not be able to have any more children. The mother said that this had caused her to "lavish attention" on the younger boy. Both parents had found, John "more lovable". Sam showed his resentment of his brother with increasing vehemence. Before John was 5, one of his ear drums was punctured when Sam struck his head several times with part of a mechano set. In one quarter of the sample cases, the siblings of patients showed varying degrees of maladjustment. Patricia's twin brother, Jack, was examined at c l i n i c too. Like his sister this boy had very superior intelligence (I.Q. 127). The symptoms which led to the examination at c l i n i c were defiance, cynicism, and marked aggressiveness. In 68.7 per cent of the sample cases i n this group, patients had experienced unfavourable circumstances i n the period between birth and the end of their second year. Three examples w i l l show the serious-88. ness of some of these experiences. Albert, breastfed from birth, was suddenly changed to bottle feedings at the age of 1 month when his mother was hospitalized for several weeks. Feeding d i f f i c u l t i e s arose and he became very f r a i l . At the age of 2 years, this boy barely survived when pneumonia developed. Denise (whose poor group adjustment was previously described) was rejected before birth by both of her parents. The mother aged 45, "wished for death" during the pregnancy. The father consumed alcohol excessively during the pregnancy, and for several months afterwards causing many hardships for the family whose income at best was only marginal. The mother said that she was so busy with her other 6 children that she ignored the baby. Besides parental rejection, Denise had the frightening experience of being badly bitten by a dog before the age of 3 years. Harold, as an infant, was "held by the neck and beaten" by his father. The mother stated that the father would "throw him into the crib" and refuse to l e t her go to comfort the baby. Negative factors i n the period from the 3 to 6 years were pre-sent i n every case i n this sample. In none of the other three c l a s s i f i -cations of symptoms were such factors apparent to this degree. As was pointed out i n the previous chapter 85 per cent of the children whose behaviour was socially unacceptable had met with d i f f i c u l t i e s or unfav-ourable circumstances during this period. Jimmy, at the age of U, suffered concussion as a result of a f a l l . The year before this child was old enough to attend school, the father, discontented with his work was unusually i r r i t a b l e . Part of the home in which the boy lived was sub-let to tenants who were noisy. The mother had many disputes with the tenants and the boy was constantly reminded to "be careful about noise". Several children had tonsils and adenoids removed before they began attendance a t school. Some were inadequately prepared for this operation, being told " i t won't hurt a b i t " . 8 9 . Mary, aged Ak years, was suddenly separated from her mother who was sent to a sanatorium. She was not told why her mother had l e f t and was not given an opportunity to say good-bye to her. For over a year before the mother had l e f t , she was run-down and apprehensive, and was afraid at night when l e f t alone with the child while the father worked. The child imagined that she heard footsteps and could not sleep. Not only did the l i t t l e g i r l lose her mother, but she was also separated from a l l of her maternal relatives because her father feared that they, too, might have tuberculosis. She was passed from one to another of the father's relatives and friends. Another factor which was more prevalent i n the sample cases of this group, than i n the other three classifications of symptoms i s that of r i g i d or harsh discipline of children by their parents, older siblings o r B l a t i v e s . In 81.25 per cent of the cases, this factor was evident. One boy's mother said that the only lemedy for his "sauciness" was a "good slap i n the face". The father's method of discipline was that of "commanding" the boy i n a loud tone of voice. The mother's com-ment was "He just wilts when his father scolds him." Another boy's father, a periodic deserter of the family, en-couraged the child to disobey his mother. Frequently this father had temper tantrums during which the boy was severely beaten. Discipline came from several sources for the 8 year old Jack who was "taciturn at school and aggressive i n an impulsive way". Jack lived in a home in which there was considerable f r i c t i o n among the adults i n the family. During the brief periods when the father was at home (the parents separated frequently) he ignored the boy. -*he maternal grandmother, an invalid, lived i n the home, and frequently c r i t i c i z e d the boy and his mother's training of him. A maternal aunt who also lived with the family, worked i n an office. She was tense and i r r i t a b l e after work, and constantly "nagged and scolded" the boy and his 3 siblings. Besides using corporal punishment to discipline the boy, the mother frequently 90 threatened him with "a v i s i t from the d e v i l who might take him away at night". I t has been stated previously that the highest percentages of patients showing unfavourable personality reactions were found i n the age groups from 6 to 7 years, and from 8 to 9 years - (21.25 per cent each). The case of David S., aged 6 years 2 months i s an i l l u s t r a t i o n of early detection by the school of a child's maladjustment. This case also i l l u s t r a t e s i n a pa r t i c u l a r way, the mental hygienist's v i g i l a n c e i n d i s -covering opportunities t o stress the aim of the c l i n i c ' s program, the pro-motion of mental health. I t demonstrates too, the value of careful 'follow-up" work by the public health nurse. During the f i r s t few days of David's attendance i n Grade 1, h i s teacher observed h i s extreme d i s t r a c t a b i l i t y , h i s fear of new experiences, and h i s use of tears i n meeting whatever constituted for him a d i f f i c u l t s i t u a t i o n . These symptoms were brought to the attention of the school nurse, and the boy was examined at the Mental Hygiene C l i n i c before the end of h i s f i r s t month i n school. In addition to the above-mentioned symptoms, the school hist o r y revealed that the patient was excitable, wanted to run home from school at times, was "bossy" with other children, and almost constantly rubbed h i s fingers against h i s sweater sleeve. The s o c i a l and family history revealed that the patient l i v e d i n an excellent home i n a good neighbourhood. David's parents were well educated, economically secure, and seemed w e l l adjusted. David was the f i r s t c h i l d i n the family, '^he only s i b l i n g , a s i s t e r , 3 years younger, appeared to be a healthy, normal c h i l d . The parents had noticed that David was a f r a i d of new experiences, excitable and sensitive. They said that for several years he had l i k e d to rub fuzzy objects between h i s fingers. This habit was f i r s t noticed when he rubbed the c r i b blanket before f a l l i n g off t o sleep. The parents also commented on David's dawdling over h i s food, and h i s disobedience at home. Bladder and bowel control had not been established u n t i l David was 3 years old. At the age of 2 years, the boy had been severely burned with b o i l i n g water. This had necessitated medical attention for several months. 91 David had not been in school long enough to have been tested by the Bureau of Measurements. He had not yet been examined by the school doctor. The examining psychiatrist diagnosed David's case as "immaturity" and described the rubbing of fuzzy objects as a fetishism which was a regressive attempt to escape from conflict. The psychiatrist considered David's intelligence to be normal, but at the conference recommended having an individual test done by the Bureau of Measurements. Further recommendations arrived at during the confer-ence were: 1. Discussion with the mother regarding encouraging maturation. The mother should show less anxiety, ignore the fetishism, and prevent the child's use of behaviour to get out of d i f f i c u l t situations. 2. Encouragement of more companionship with the father. Four months after this conference, the school nurse reported that the case had been closed because of the attitude of the parents and teacher. A summary of this report follows: A l l recommendations except that of having a psychometric test, had been carried out. An individual intelligence test had not been done because the teacher did not consider this to be necessary. The parents and teacher f e l t that the boy should not have been referred to the mental hygienist before more serious symptoms had developed. David's progress i n school was slow, He did f a i r l y good work while closely watched. He no longer cried i n school and did not want to run home. Following this report, a letter from the mental hygienist to the director of the health unit was instrumental i n clarifying the func-tion of the c l i n i c , and subsequently in the reopening of the case. In this letter the c l i n i c director suggested that "in the interests of good education and public relations" an attempt should be made "to get an understanding of the discrepancy between the original attitude of the parents and teacher and the present one". The mental hygienist further 92 emphasized the importance of a l l public health workers stressing the aim of the c l i n i c program which i s "to promote mental health", and not to wait u n t i l the development of serious symptoms. In less than a month there was a second progress report from the school nurse i n which i t was revealed that the teacher had not seen the mental hygienist's report containing the con-ference recommendations, at the time she had said that a psy-chometric test was unnecessary. Arrangements were now being made to have t h i s recommendation carried out. The teacher said that David's parents had been most cooperative with the school i n i t s attempts to help the boy. The school nurse reported that she would again have interviews with the mother. Later, another progress report was made. This summary of the report i s as follows: The r e s u l t s of the individual t e s t given by the Bureau of Measurements showed David's i n t e l l i g e n c e to be "average". (This t e s t was given 8 months after the above-quoted l e t t e r from the mental hygienist). At school David had been placed i n the "A" class. He was repeating Grade 1. He was s t i l l somewhat immature and excitable, but there had been considerable improvement i n t h i s area. The parents and teacher were well s a t i s f i e d with the progress made by David. The f i n a l progress report was sent to the mental hygienist, 6 months afterwards. * t was a much more favourable report than the previous ones. David was progressing w e l l . He was i n the "A" class i n Grade 2 and able to keep up with h i s school work e a s i l y . At home, the parents had been able to help the c h i l d assume and enjoy more r e s p o n s i b i l i t y . His former symptoms had disappeared. The case was closed. Evidently, the teacher though instrumental i n having t h i s boy examined at the c l i n i c , was unable to attend the conference which followed the examination. Although a l e t t e r containing the recommendations was sent to the p r i n c i p a l , apparently the teacher had not seen i t . Presum-93. ably i n the "follow-up" of the case of a pupil, the teacher and nurse confer from time to time. The duties of principals are manifold, as l i k e -wise, are those of public health n u r s e s . T h e addition of psychiatric social workers to the Mental Hygiene Cl i n i c staff, and social workers in the schools should lighten the responsibilities of nurses, and principals and make for closer cooperation among the various persons concerned with the welfare of the pupils. This closer cooperation and consequent better understanding, together with the special s k i l l s of social work would un-doubtedly result i n more adequate services to emotionally disturbed children. The case of Sam G., aged 10 years 7 months, il l u s t r a t e s the need for close contact between the parents and the c l i n i c i f the recom-mendations made after examination are to be of value. Sam was isf erred to the Child Guidance Clinic by his mother because he had "no sense of responsibility" and was " f u l l of fears". This boy's poor school achievement, although he had high intelligence, as well as his aggressive behaviour toward his brother have been referred to previously i n this chapter. Both parents had high school education. Mrs. G. was 6 years older than her husband. The parents had several mutual interests such as athletic sports, reading, entertaining, and community a c t i v i t i e s . The father was not seen by the social worker who prepared the history, nor did he come to the c l i n i c when Sam was examined. However, the mother gave the impression that the marriage was a happy one. The family lived i n a com-fortable home in a good neighbourhood. The father was a success-f u l business executive. Besides her work in the school, each public health nurse spends some time i n Child Health Centres (Well-Baby Clinics), v i s i t s tuberculosis cases in her d i s t r i c t , and assists with the program for the control of communicable diseases. 94. Sam was breast-fed for 2 months, and weaned from bottle feedings at 9 months. As an Infant he had severe eczema and a "nervous stomach". He was not handled unnecessarily by the parents as the mother wished to "bring him up s c i e n t i f i c a l l y " . According to the mother t o i l e t training presented no d i f f i c u l t y and was completed before Sam was ife years old. At an early age (about 2 years) Sam plucked at his clothing, pulling out the threads. Shortly after this thumb sucking, head scratching, and picking at his ears, nose and fingernails were "annoying habits" developed by Sam. These habits persisted up to the time of the c l i n i c a l examination with the exception of thumb sucking which had ceased when Sam began biting his fingernails. When Sam was 3, a baby brother was born. Because the parents had been told that this would be their last child, they "lavished attention" on the baby. From the beginning Sam seemed to resent th i s . The mother said that she f e l t that Sam had "suffered through lack of affection and attention". The brother John was described by the mother as "a perfect boy". At the age of-8 years, Sam had missed 4 months of school, when he had impetigo. Soon after he returned to school, he became i l l and was hospitalized for a month because of nephritis. The mother said that Sam had not entered into active sports. "He always seemed to be afraid of hurting himself. He's too cowardly to catch a baseball. His father and I are so disappointed. We were both athletic." Mrs. G. said that Sam had wanted his own way since infancy, had always been "fussy", and a "lone wolf". Mrs. G. also commented on Sam's fear of water, both at the beach and i n the bath tub. He did not even l i k e to wash, and insisted on being bathed by his mother. The mother considered these "problems" more acute since Sam had had nephritis. Sam's interests were "mechanics, riding his bicycle, making model aeroplanes, and boats." He was very interested in science, especially e l e c t r i c i t y . He played the piano and v i o l i n well. He seemed to prefer being alone while he pursued these interests. He did not have any friends of his own age. The mother attributed this to his "bossiness". The parents had considered sending Sam to a private school for boys. It was chiefly for advice about this that the mother sought the help of the c l i n i c . They thought that this might be of help i n solving many problems, particularly the constant quarrelling between Sam and his brother. Sam was examined shortly before the end of the school term. At the c l i n i c , Sam was uncommunicative concerning his feelings 95. about his home and family, and about school. His I.Q. was 150. The recommendations of the c l i n i c were given directly to the mother by the examining psychiatrist. It was noted by the psychiatrist that the mother appeared to be very intelligent. She was somewhat tense, and had prepared a l i s t of questions to ask the psychiatrist. She care-f u l l y wrote down a l l of his recommendations. These were as follows: 1. Attendance at Y. Camp for a period during the summer holidays. 2. Private boarding school for at least a year. 3. The boy should be given e l e c t r i c a l apparatus to work with. 4. Parents should not expect Sam to play with boys of his own age. They should not expect the younger brother to keep up with Sam. This boy was referred to the c l i n i c in 1945, when staff short-ages were acute. No follow-up work was done by the social worker. In 1948, after there had been some enlargement of the c l i n i c staff, inquiries were made about the adjustment of some of the patients who had been exam-ined during the war years while the c l i n i c services were curtailed. Sam was one of these patients. The mother's reply to the i n i t i a l inquiry was as follows: Following the c l i n i c examination of Sam, both boys had been sent to a private boarding school in the interior of British Columbia. They had remained there for 2 years. They were now at home and attending the public school i n the neigh-bourhood. Rather b i t t e r l y the mother said "Sara i s worse than ever, and John i s just about as bad. They fight more than ever, and neither of them have any sense of responsibility". Mrs. G. said that Sam was now i n Grade 8 but was doing very poor work. He s t i l l was without friends and did not enter into active sports. His interests were said to have dwindled to "only e l e c t r i c i t y and radios". The mother commented on how much money had been spent i n sending 96 the boys to private school and how discouraged she and her husband were with the results. Mrs. G. said that she would discuss with her husband the c l i n i c ' s offer of further service. The following day she phoned stating that the parents would like to have the help of the c l i n i c . This case was assigned to a male social worker and a summary of his contact with the mother and patient follows. Mrs. G. was interviewed at home. She described the s t r i c t routines within the home to which the boys were expected to adhere. She did not seem to understand how Sam could learn to evade this routine or be unhappy i n accepting the "more normal interests" which the parents tried to impose upon him. . She refused to see that environment had anything to do with the problem. Three weeks later, Sam was interviewed by the social worker. The boy was described as "small for his age". Sam remarked that his father had told him that he would probably "turn out to be a tramp radio man". The boy would not bring up any negative feeling i n r egard to the limitations set by his parents. The worker went over the reasons why he was wondering i f Sam had sometimes been rather unhappy at home, and whether perhaps the members of the family did not under-stand one another. Sam showed very l i t t l e response to this except i n terms of everything teing " a l l right". It was noted that the boy was extremely polite. A month later the worker visited the home again. Mrs. G. said that her husband was "much too busy" to see the worker. She wanted to know whether worker had "anything definite" to t e l l the parents. Mrs. G. quoted Sam's remarks after his i n -terview with the social worker: "What i s that Child Guidance Clinic? A recruiting centre for Essondale?" During this interview with the mother the worker pointed out that the parents methods of training and their reactions to their child-ren were natural ones arising from the parents own experiences. He tried to give the mother reassurance that the parents had done everything, as they aaw i t , to give the boys what they needed i n home l i f e and training. 97. The mother suggested that perhaps she and her husband had expected too much of the boys and had placed too many responsibilities upon them. Mrs. G. accused Sam of being self-centred and "working i n reverse". At this point the worker pointed out what Sam by his negativism and by passively working against the parents was showing strong resentment inside himself and real feeling that he could not compete equally with other children. He said that the c l i n i c might help the parents find out how Sam's resentment and pent-up feelings could be changed and particularly how the parents' handling might change to meet this special situation. The mother then said that perhaps her.husband would have time in the next month to see the worker. She said that she would phone later and l e t the worker know about this. The social worker during his v i s i t s to the home.had ob-served the mother's negative methods i n handling the one and a half year old boy (a third child had been bom while the 2 boys were attending the private boarding school). Mrs. G. shouted at this child, and constantly followed him saying "No, no", "Don't touch", etc. She said that she was deter-mined that this child would learn the meaning of "no". When Sam came home from school, he showed the worker his room and "radio lab". Again the boy was exceptionally courteous but completely uncommunicative on the subject of his feelings about the home situation. One month elapsed, and there was s t i l l no phone c a l l from Sam's mother. The worker recognizing the seriousness of Sam's problem decided that another attempt should be made to offer the c l i n i c ' s help. He phoned the mother and suggested that a plan to alleviate the situation might be discussed. The mother said that at the moment she was busy with the baby but she would phone back i n a few minutes. The mother did not phone. Two months later this case was closed. The closing summary ended with the following comment by the worker. "It appears that Sam's parents are not really willing to look at the problem or at their own approach to i t , and i t seems to be a situation where their negative and rather destructive methods cannot be changed at this time." The extent to which these parents would have been willing to look at the problem i n 194-5 cannot be estimated. However, i t seems safe 98. to say that had i t been possible for a social worker to maintain contact with the family immediately after Sam's examination, the c l i n i c recommen-dations might have been carried out i n a more satisfactory manner. The parents might have been helped to recognize the advantages of their o r i -ginal plan of sending only Sam to the private boarding school, They might have decided, too, that a school near enough to permit more contact with his home would have been more in keeping with Sam's needs. Casework services with the parents might have been beneficial to the other children i n the family as well as to Sam. At best Mrs. G. might have been a somewhat r i g i d and unrelenting person. However, during her early contact with the c l i n i c she was not given an opportunity to demonstrate whether or not she would be amenable to casework services. Obviously the mother's resentment of what she con-sidered the c l i n i c ' s failure i n the past was a large obstacle to her a b i l i t y to use casework services when they were offered. There was a-higher percentage of g i r l s i n this group than i n other classifications of symptoms. The case of Denise describes a g i r l whose problems were of long standing. Denise was aged 7 years 2 months at the time of her referral by the teacher to the Mental Hygiene Clini c and aged 9 years when referred by her sister to the Child Guidance C l i n i c . The symptoms described i n the social histories of each c l i n i c are similar, namely, lack of concentration, day dreaming, awkward, gait, poor group adjustment. Before Denise was studied by the school c l i n i c she had been examined by a private psychiatrist. This had been done because her older sisters urged the parents to do something about the child's maladjustment. The family finances, however, did not make i t possible for more than 2 interviews with the psychiatrist. The school teacher's report prepared for the c l i n i c revealed that she had observed the child closely and was 99. interested in understanding the meaning of her behaviour. She was particularly interested i n knowing how she could help Denise i n the class room. The teacher described the child as "always seeming exhausted". Her speech was slow and forced, her gait was awkward. The child dawdled i n getting ready to go home from school. On the few occasions when the teacher had seen the mother and child together i t appeared that the patient tried to "bully" her mother. Denise showed l i t t l e or none of this a t t i -tude toward the teacher. Denise had started school when she was 5g years old. She was l e f t handed and had done mirror writing during the f i r s t year. At the time of the examination Denise was i n special class. In neither her f i r s t nor second year at school had she shown very much progress. The social history revealed Denise was the l a s t child i n a family of 7 g i r l s . Her mother had said that she was busy with older members of the family and had not spent very much time on the child during infancy. At the age of 3, Denise began pulling out her hair. Facial twitching began about this time too. She was described as a "very restless" child, with a marked tendency to become "so sti£f and clumsy when excited" that she was hardly able to walk. The mother said that Denise was "slow, forgetful and usually'disobedient" and that she only obeyed "when afraid of punishment". The iecommendations made at the conference were as follows: 1. In the training and management of this child the parents should be guided by the general principles of habit training and the establishment of good emotional attitudes. 2 . The child should be enoouraged to do things for herself at home. 3. T'he mother should avoid nagging. (The above recommendations were discussed with the mother by the mental hygienist). 4. The child has normal intelligence and should be restored to regular class soon. The psychiatrist pointed out the possibility of slight brain damage at the patient's birth. The progress report 6 months after this conference de-scribed improvement i n Denise's adjustment. She appeared to be more self-reliant. Her gait was less awkward and better group adjustment was noted. Her speech had improved and she was making f a i r l y good progress i n school. 100 The increased understanding of the child on the part of the teacher undoubtedly contributed much to this improvement. The mother's interview with the mental hygienist and home vi s i t i n g by the nurse may also have helped. There was only one progress report, however. Apparently there was enough improvement i n the school situation that this case was closed. About 2 years after this progress report the case was referred to the Child Guidance Cl i n i c by one of the patient's older sisters who said that her mother wanted the c l i n i c ' s help. Not only were the symptoms s t i l l present but in many respects they were intensified. The mother's anxiety about the child was increasing. In giving the information for the social history there were many things about the child's earlier development which she could not remember. She mentioned her own tendency to cry at the least thing and dried her eyes almost continuously during the interview. Mrs. C. said that Denise was "just an entirely different child" from her other daughters and that she worried about her future. In her interview with the psychiatrist the mother questioned whether Denise would ever be self-supporting. She complained that the father had not given this child any attention. Psychological tests revealed that Denise had average intelligence. She appeared to be very withdrawn throughout the test. In the play room she seemed shy and immature. She spoke baby talk to her mother but dropped i t when speaking to others. She was rather childish and awkward with play things dropping toys and f a l l i n g on the floor. At the conference i t was f e l t that there was a definite element of rejection of this child and an accompanying over-solicitousness. Home relationships were considered poor and the family in need of a good deal of help i n order to under-stand this child. The mother herself appeared quite disturbed and possibly tended to be rather hypocondriacal. It was the opinion of the c l i n i c team that the child had assets within herself i f she could be better understood and her self-confidence and recognition of herself as an integral part of the family could be built up. It was recommended that continued casework 101 should be given to the chi l d and the parents. This case was transferred to another s o c i a l worker after the c l i n i c a l examination. Rather early i n her contact with the second worker the mother revealed that she had only agreed to come to the c l i n i c for help because there had been so much pressure from her older daughters to do t h i s . One daughter i n part i c u l a r (the one who had made the i n i t i a l contact with the c l i n i c ) was very interested i n what the mother termed "th i s new psychology s t u f f " . In the weekly interviews which followed Mrs. C. poured out her feelings about the daughters who had been very c r i t i c a l of her and who s t i l l demanded so much attention from her. At f i r s t she seemed to t r y to test the worker to determine whether she would be l i k e her c r i t i c a l daughters. "What would new psychology say about that?" she would ask rather tauntingly at times, The worker t r i e d to interpret simply and gradually what "new psychology" would say, and the mother began to recognize that i n t e l l e c t u a l l y at least t h i s was not so "new" to her. "Do you think i t ' s a l l r i g h t for me to go to meetings?" (rel i g i o u s sect not approved of by the husband and daughters) l e d to a b r i e f discussion which apparently resulted i n the mother's fee l i n g that she was accepted by the worker. The following week Mrs. C. remarked "I've been thinking that t h i s psychology and my r e l i g i o n have a l o t i n common. They both t r y to give a" person the chance to buil d up the good things i n them-selves and they both say that people can help one another." Having released some of her resentment and fears, Mrs. C. slowly began to look f o r the positive things which she might do to help Denise. She was ea s i l y discouraged, however, and needed help i n understanding that evidences of improvement might be gradual. No longer did she make such remarks as "She's a queer one. None of the psych i a t r i s t s can figure her out." This mother f i n a l l y developed the courage required to face a serious surgical operation which she had postponed for a long time. For 13 years she had suffered from a physical condition which caused almost complete lack of bladder control. There was an equal number of interviews with Denise during t h i s time. Through play at f i r s t (she was too withdrawn to talk) t h i s c h i l d showed indications of her feelings of rejection. A l l of the toy furniture associated with babies (high chairs, play pens, cradles, etc.) were thrown into a room i n the doll house which Denise called the a t t i c . "These people don't want any more kids. The mother says she's had enough babies" was her f i r s t remark while playing. Another day, re-peating this game, Denise said "That woman i s going to have another baby. She doesn't know i t , but the doctor does." Later, "She's going to have twins." The child f i n a l l y placed 7 baby dolls on the window s i l l saying "Boy, she's going to have 7 kids. Let's clean up that baby furniture and get the bedroom ready for a l l these babies." Another time she arranged the farm animal toys on the desk, and taking a gun said "Let's k i l l this old grandfather horse" (she frequently called her mother "Grandma"). The next week Denise asked "Did the grandfather horse die?" and taking the toy from the box said "If I had a band-aid and stuff I could f i x him up so he'd l i v e . " She was given a toy nurse's set and while she administered f i r s t a i d talked about what a good old horse i t was and how hard he had worked. She said that she had shot him because "just sometimes he's so mean". At f i r s t Denise used the term "one of my mother's daughters" rather than "my sister". (The mother referred to her children as "my oldest daughter", "my second daughter", etc.) The child's nieces and nephews, several of whom were older than herself, were spoken of as "one of my mother s daughter's children". This gave the worker an opening for discussion of Denise's place in the family group. The child appeared not too sure of her position. There were indications that she f e l t on the fringe of the family constellation rather than a part of i t . She learned to say "sister", "niece", "nephew", "cousin", etc., and seemed both surprised and pleased when the worker referred to her as "mother's youngest daughter". This child's gait became less tense when she vi s i t e d the c l i n i c . At f i r s t she scowled or gave what she called "dirty looks" at others she met i n the c l i n i c corridors. Occasionally now she smiles at them. There i s less faltering in her speech at times. She i s t i l l finding i t d i f f i c u l t to make friends and she daydreams a great deal. The mother sees a slight improve-ment in Denise's attitude toward small responsibilities at home and i n her a b i l i t y to get along with her nieces and nephews. There s t i l l remains much to be done in helping this child and 103. her family. The father and 3 of the older s i s t e r s were each interviewed once. Possibly more interviews w i l l be held with them. Neurological tests may be recommended l a t e r . The examining ps y c h i a t r i s t with whom the worker consults frequently about t h i s case doubts whether a s a t i s -factory adjustment can be made by the c h i l d i n t h i s home, ^he father's continued lack of i n t e r e s t and the mother's poor health and emotional disturbance are viewed as serious obstacles. In the process of helping Denise f i n d the satisfactions which she has missed i n e a r l i e r years, and the consequent f a c i l i t a t i o n of her movement i n t o a stage of development more i n keeping with her age, a treatment and observation centre might be of great benefit. Lacking t h i s , a boarding school or foster home may be the means used. In the case of Denise, the school recognized the maladjustment early, but the study made by the Mental Hygiene C l i n i c did not take i n t o f u l l consideration the i n t r a f a m i l i a l relationships which had such an im-portant bearing on the child's maladjustment. Closer follow-up or refer-r a l of t h i s case by the c l i n i c to an agency which might have given case work services would undoubtedly have led to better r e s u l t s than were obtained. For children showing unfavourable personality reactions the average period of time between the appearance of the f i r s t symptoms of maladjustment and r e f e r r a l to c l i n i c was the same as f o r the children showing s o c i a l l y unacceptable behaviour, namely, 3 years. There were fewer omissions i n the s o c i a l h i s t o r i e s regarding t h i s subject and no i n d e f i n i t e statements such as "always" and "a long time". iherefore, 104. the average period of 3 years may be considered a more accurate indication of the duration of symptoms previous to c l i n i c a l examination than i t was in the case of patients showing socially unacceptable behaviour. The lack of awareness on the part of parents of the avai l a b i l i t y of c l i n i c a l services was in many instances one reason for the delay i n seeking help. 105. CHAPTER 7. CHILDREN PRESENTING HABIT DISORDERS Thirty-nine of the 257 children given c l i n i c a l examinations were referred because of habit disorders. This group of patients represented 15.17 per cent of the total number of cases. The highest incidence of this type of problem occurred i n children from 7 to 8 years and from 9 to 10 years, each of these age groups comprising 23.08 per cent of the number of children whose chief symptoms were habit disorders. The other age groups are represented i n decreasing order as follows: 8 to 9 years -17.95 per cent, 10 to 11 years - 12.82 per cent, 11 to 12 years - 12.82 per cent, 6 to 7 years - 10.25 per cent. Not only within this classification of symptoms were the 7 to 8 year old children and those from 9 to 10 years represented i n the same proportion, (23.08 per cent) but also i n relation to the total number of patients In each age group the proportion was identical (19.14 per cent). In other words, almost 1 out of every 5 patients between the ages of 7 and 8 years, was referred to c l i n i c because of disorders i n habit forma-tion. Likewise, i n the 9 to 10 year old group, about 1 out of every 5 patients were referred for this reason. Patients from families of 2 children represented the highest percentage of patients with habit disorders (25 . 6 4 per cent). The second highest incidence was found i n families with one child (20.51 per cent). Patients from families of 3 children comprised 17.95 per cent. Larger families were represented i n this classification of symptoms as follows: 106. 4 children - 12.85 per cent, 5 children - 7.69 per cent, 6 children -12.82 per cent, 7 children - 2.57 per cent. Comparing these percentages with those found in the other classifications of symptoms, this group wil l be seen to have a greater proportion of patients from larger families than did the other groups. Whereas 35.9 per cent of the children with habit disorders came from families of 4 or more children, 27 per cent of the patients showing socially unacceptable behaviour, and only 18.75 per cent of those with unfavourable personality reactions were from families of this size. In Chapter 10 i t wil l be seen that only 7.9 per cent of the patients with special school disabilities came from families of 4 children, and non« of the patients in that classification were from families of more than 4. "Middle" children comprised 30.77 per cent, "youngest" 28.21 per cent, "oldest" 20.51 per cent and "only" children 20.51 per cent of the patients showing disorders in habit formation. Marked discord between parents was evident as a factor contri-buting to maladjustment in a larger proportion of cases in this group than in the other three classifications of symptoms. This was noted in 17.95 per cent of the cases, while divorce was a factor in 10.26 per cent. In almost one quarter of the cases (23.08 per cent) the father had been away from the family while serving in the armed forces. In over an eighth of the cases (12.82 per cent) housing was poor or very crowded. In the same percentage of cases there had been interference in training and care of the patients by grandparents or other relatives living in the home. 107 Turning now to the 20 per cent- sample of patients showing dis-orders i n habit formation, the c l i n i c studies indicated that i n only one out of every 4- cases of this kind children had d i f f i c u l t y i n group adjust-ment. In this respect children i n this group showed less maladjustment than those i n the other classifications of symptoms. One example of poor group adjustment i s described below. Walter, aged 8 years 7 months was referred to the school c l i n i c because of "soiling, enuresis, timidity and quarrel-someness". He complained that the boys of his own age teased him and were "too rough". He cried easily and usually sought the companionship of younger children. He insisted on being . the "leader" with these children and was inclined to be cruel, when his playmates opposed his leadership. Poor progress i n school was more apparent i n this group of patients than i n the two classifications previously described. In 75 per cent of the sample cases, reports indicated that the patients were not keeping up with the school's standards of work. The boy whose poor group adjustment was described above, had repeated Grade 1, and was sullen and uncooperative i n school. His progress in Grade 2 was slow. His intelligence was "average". Another boy who was referred to the school c l i n i c by a family agency because of enuresis and soiling was doing Grade 1 work for the third year. His intelligence . was "low average". Sibling ri v a l r y was apparent i n 37.5 per cent of the sample cases. In comparison with the other classifications of symptoms, the proportion of children with disorders i n habit formation showing sibling rivalry was lowest. Evidence of maladjustments i n patients' siblings was 108. found i n 25 per cent of the sample cases. Seventy-five per cent of the patients i n this group had met with unfavourable circumstances i n the period between birth and the end of their second year. Harry, aged 6 years 9 months was referred to the Child Guidance Clin i c by a children's agency because of "soiling, enuresis, masturbation and destructiveness". This boy was the third offspring of a common-law marriage i n which there were many quarrels and periodic desertions by the father. The mother was described as having "an uncontrollable temper", Harry was abruptly weaned from bottle feedings before the age of 10 months. The mother complained that although she had attempted to t o i l e t train Harry "early" (7 months) and had used every method of which she had ever heard, she had not succeeded. Negative factors during the period from 3 to 6 years were also found i n 75 per cent of the sample cases. Jane, aged 9 years 3 months (a ward of a children's agency since the age. of 5J - years) was referred to the Child Guidance Clinic because of enuresis and excessive masturbation, Jane, the second child i n a family of U» had lived during her f i r s t 5 years i n poor, crowded quarters i n a low-standard d i s t r i c t known to the police as "a hotbed of vice". The father had spent some time i n prison for vagrancy and drunkenness. The mother, a promiscuous woman of borderline intelligence had deserted her children for several months when Jane was A« Before Jane was 5 years old, an elderly man had attempted to rape her. Jane became a ward at the age of 5§- years, when the mother was sentenced to prison on a charge of "contributing to juvenile delinquency" because of drunkenness and promiscuity i n the presence of her children. In 75 per cent of the sample cases, there was evidence of par-ental discipline which was harsh, r i g i d or inconsistent. Herman, a 7 year old boy whose chief symptom of maladjustment was soiling lived with a mother who entered into a common-law relationship when her husband deserted her. This boy who had received much blame and punishment from his own father met with harsh criticisms from his step-father and frequent deprivations 109. as well as "beatings" from'his mother. The case of Hubert S. ill u s t r a t e s the importance of a careful physical examination. Hubert was 11 years 11 months of age when he was referred to the school c l i n i c by the nurse. His symptoms were enuresis and choreaform movements. Hubert was the second child i n a family of 5 children. His mother, 43 years of age, was 8 years older than his father. The family's economic situation had fluctuated a great deal, and there were many debts. The family had lived i n several parts of Canada, and i n Alaska. Hubert had been i n Vancouver for only 1 year. The home was a f a i r l y large house in the city suburbs. The furnish-ings were scant. There were no boys' clubs or community centres i n the neighbourhood. This boy had suffered a stomach injury as a result of a car accident when he was only 18 months old. He had severe diarrhea for a short time after this. The food fussiness which had de-veloped around this time had persisted. When he was about 3fe years old Hubert had fallen off a dredge injuring his head and remaining unconscious for several hours. The enuresis had be-gun shortly before the boy was 9 years old. His father was i n the Navy and away from the family when this symptom developed. During the year previous to Hubert's examination at the c l i n i c , the father's employment had kept him away from the family for months at a time. The mother, a cook, worked at night and Hubert's brother aged 14 was i n charge of the family during the mother's absence from the home. Hubert strongly re-sented the authority given to this older brother. In school Hubert's work (grade 6) was average. His poor speech was observed by the teacher. The boy 's group adjust-ment at school appeared to be f a i r l y good, but he had no friends outside of school. Notations from the school medical card con-tained i n the social history were as follows: "complains of deafness", "choreaform movements" and "enuresis-sores on buttocks". The social history made i t obvious that Hubert's environment was such that emotional disturbances might be expected. One of the most f a -vourable aspects i n the family situation was that the father had recently 110, returned to Vancouver and was seeking employment i n the city which would make i t possible for him to li v e at home. The mental hygienist«s interview with the mother revealed that she was "an excitable, dependent person". The recomraendations arising out of the conference were? 1. The nurse should see the boy's father and form an opinion about his responsiveness to advice. The father should be en-couraged to offer the boy more companionship and encouragement. 2. An ear, nose and throat investigation should be made i n order to discover the cause of Hubert's deafness. 3. The boy should be given an opportunity to join the Y.M.C.A. or the Boy Scouts. A. Although the enuresis might be based on anxiety, a u r i n -alysis should be made. The progress report 6 months after the c l i n i c a l examination was brief and did not indicate the extent to which the above recommendations were carried out. It did reveal- however the validity of the recommend-ation for urinalysis. Information contained i n the report was as follows? Hubert had been severely i l l about 1 month after his examination at the c l i n i c . He was taken to a hospital where a diagnosis of diabetes mellitus was made. Diet and insulin were prescribed. Some improvement was noted i n Hubert. -He was now lese excitable. Mrs. S., "an excitable, dependent person", evidently had needed more help than the nurse had had time to give. The urinalysis had not been done u n t i l Hubert was hospitalized. It appears probable that the recommendation regarding ears, nose and throat investigation was not promptly carried out, either. Judging from the 20 per cent sample, i t appears that children showing disorders i n habit formation are referred for c l i n i c a l examin-ations earlier than those having other symptoms of maladjustment. How-ever, the average period of time between the f i r s t occurrence of symptoms I l l and examination was 2 years and 5 months, and there are indications that most of the patients were exposed to faulty methods of "curing" the di s -orders. In most instances, during this period no attempt was made to seek for underlying causes. These patients would undoubtedly have been spared much discomfort, had they been referred for c l i n i c a l examinations earlier. 112. CHAPTER 8. CHILDREN SHOWING DISABILITIES IN SCHOOL SUBJECTS Of the 257 children given c l i n i c a l examinations, 38 were re-ferred because they appeared to have d i s a b i l i t i e s i n specific school sub-jects. This number represents less than 15 per cent of the total number of cases. The highest incidence (23.67 per cent) of this problem was found i n the 6 to 7 year old group, ifiji equal percentage of cases (18.41 per cent) were found i n the 7 to 8 and 8 to 9 year old groups. As might be expected the occurrence of this type of problem diminished i n the higher age groups. The other age groups are represented as follows. 9 to 10 years - 15.78 per cent, 10 to 11 years - 13.13 per cent and 11 to 12 years - 10.52 per cent. The 6 to 7 year old children who were referred because of dis-a b i l i t i e s i n special school subjects comprised 22.5 per cent of a l l the patients i n this age group. Reading was the school subject with which the majority of these patients as well as those i n other age groups had d i f f i c u l t y . Arithmetic was second on the l i s t , while mirror writing was the reason for examination i n only one of the cases. One half of the patients with specific school d i s a b i l i t i e s were members of families i n which there were only 2 children. "Only" children represented 23.68 per cent of the patients i n this classification. Pat-ients from families of 3 children comprised 18.42 per cent, and those from families of 4. - 7.9 per cent of the cases i n this group. None of the patients came from families of more than 4-. 113. A markedly high percentage (44.71) of these patients were the "youngest" member of families. In no other classification of symptoms as well as i n no other category of the ordinal positions i n the family was such a high percentage found. The nearest percentage to this was i n the "socially unacceptable behaviour" classification i n which 37 per cent of the patients were the "oldest" i n their families. "Oldest" children i n the school d i s a b i l i t i e s group formed 21.04 per cent of the cases, while only half as many (10.52 per cent) were "middle" children. Although i n 1 out of every 3 of the 257 children examined there were factors of family disorganization which appeared to contribute to the patients' maladjustment i n this particular group such factors were evident i n less than 1 out of 6 cases. Marked discord between the parents was the most frequently found factor of family disorganization, this being apparent i n half of the cases i n which such influences were found. Similarly, the three other factors contributing to maladjustment, namely, absence of the father while serving i n the armed forces, inadequate housing, and interference of relatives l i v i n g i n the home, were less f r e -quently found i n this group than i n other classifications of symptoms. A comparison between the intelligence levels of the children who had di s a b i l i t i e s i n specific school subjects and those of children who were referred because of other symptoms reveals that i n the first-named group the intelligence quotients were "average" and "low average". In only one case (2.63 per cent) i n this group was the intelligence "superior", and i n no cases were the test results indicative of "very superior" or "near genius" intelligence, although such results were found i n each of 1U. the other classifications of symptoms. Turning now to the 20 per cent sample of cases in which patients had specific school disabilities, slightly more than 6 out of 10 children (62.5 per cent) had not made satisfactory group adjustments. Floyd, aged 6 years 6 months showing no ability to learn to read, ate crayons and paste in the classroom, and used scissors to cut books. He preferred girls' toys and tried to get into the girls' games when the other boys shunned him. Edna, aged 11 years 10 months who was unable to grasp number concepts, was usually quiet and listless and had no companions of her own age outside of school. When she en-tered into games with her classmates she was "rough and awkward". Arising out of nature of the symptoms presented by this group of children, there were reports of unsatisfactory school progress in a l l cases. Of course, as previously pointed out, there was a high incidence of poor school progress in the cases of habit disorder where 75 per cent of the patients were not keeping up with the school standards of achieve-ment. In cases of children showing socially unacceptable behaviour poor school adjustment was found in 35 per cent, while in those in which thero were unfavourable personality reactions lack of progress in school was evident in 37.5 per cent. Sibling rivalry was apparent in half of the sample cases in this group. This is the same proportion as was found in cases where the symptoms were unfavourable personality reactions. As in the children in other classifications sibling rivalry in patients having school disabil-ities appeared to be attributable to a multiplicity of factors. In this group however, parents in their efforts to urge the children to do better 115. school work, frequently promoted sibling rivalry by attempting to arouse competition between patients and their siblings. An i l l u s t r a t i o n of this follows. One boy who had fai l e d i n 2 grades chiefly because of poor reading was told "Wait t i l l Jeannie starts to school. She'll learn quickly and w i l l soon be able to read the comics to you." In 37.5 per cent of the sample cases, siblings of patients showed maladjustments. In the case of an 11 year old boy, his 13 year old sister had also been examined at the school c l i n i c . The diagnosis was "adolescent personality d i f f i c u l t y " . In another case, an 8 year old boy had a sister, aged 6, who was described as "destructive, and high strung". (Clinical services were later requested by the parents for the younger child). In 75 per cent of the sample cases, patients had experienced unfavourable circumstances i n the period between birth and the end of their second year. Gerald, a 7 year old boy, who was examined because of a reading disability, was born into a family where neither parent wanted a second child. The mother was quite i l l during most of the pregnancy and remained i n bed for 6 months after his birth. The infant was cared for by relatives, friends and the father during this time. Feeding d i f f i c u l t i e s arose. Toilet training was begun early, and the mother was quite r i g i d and demanding i n the methods she used to establish bladder and bowel control. This child was severely i l l with whooping cough i n his second year. Eileen (aged ll£ years) was referred to the c l i n i c because of reading dis a b i l i t y , had been suffocated at birth. The mother had not had medical assistance during confinement. When 10 months old this child had an abscessed jaw. During her second year she had pneumonia. In her f i r s t 3 years, as well as later, this child had lived i n a family where there were many stresses such as discord between the parents, unemployment, and frequent changes in residence. 116. Negative factors i n the period from the third to the sixth year were found i n 37.5 per cent of the cases. This showing bears a marked contrast to the findings i n the other classifications, as described i n previous chapters. One hundred per cent of the children showing unfav-ourable personality reactions had experienced d i f f i c u l t i e s during this period. In 85 per cent of the cases i n which patients showed socially unacceptable behaviour, and i n 75 per cent of the cases i n which there were disorders i n habit formation, such factors were present during the third to sixth year period. Roy (aged 8 years) referred to Child Guidance Clin i c because of i n a b i l i t y to learn to read, had met with unfav-ourable experiences during his f i r s t 3 years (strong resent-ment at the birth of a sibling, asphyxiation, and injury i n a car accident). It was i n the period between his third and sixth years however, that he encountered other experiences some of which he remembered and feared. The family moved from place to place i n his third and fourth year. Each time he was "train-sick". He had tonsils and adenoids removed when he was about 4- years old. Soon afterwards the family went to l i v e in the maternal grandfather's home. The grandfather i n -sisted on quietness i n the house, and refused to permit other children in the house or the yard. He was c r i t i c a l of the boy and compared him unfavourably with the younger sister. Shortly after the boy was 5 years old he injured his head when he f e l l from a swing. He was hospitalized for a short time. A few months later he stood by and watched with terror, a r t i f i c i a l respiration applied to his younger'sister when she had almost drowned. At the age of 6 this boy started to school reluctantly, not wanting to leave his mother who had been i n bed for several weeks because of rheumatic fever. Harsh, r i g i d or inconsistent parental discipline was found less frequently i n the cases i n which children had school d i s a b i l i t i e s than i n any of the other classifications of symptoms. This was evident i n only 25 per cent of the cases i n this group, whereas in 81.25 per cent of the 117. cases of children showing unfavourable personality reactions, 75 per cent of the cases showing disorders i n habit formation and 35 per cent of the cases showing socially unacceptable behaviour such discipline was apparent. Roy, referred to above, met with harsh words from his grandfather. Some of his threats were: " I ' l l break your neck," " I ' l l knock the head off you", and " I ' l l turn you over to the police". Sometimes when the boy spoke at meal time the grandfather would say: "Shut up. When I was your age children were seen and not heard." The parents, although resenting the grandfather's attitude, f e l t obliged to remain i n this home because of the d i f f i c u l t i e s involved i n finding l i v i n g accommodation for a family with children. They tried to compensate for the grandfather's harsh-ness by being over-indulgent with the boy and his sister. Eleven year old Sylvia, who had d i f f i c u l t y i n reading, had been frequently given corporal punishment by her father who had temper tantrums and was abusive to his wife and child-ren. Occasionally bribes were used by the mother i n handling the child. In the c l i n i c a l study of almost a l l of the sample cases, disab-i l i t i e s i n special school subjects were attributed to social and emotional factors and the recommendations stressed the alleviation of the adverse influences i n the child's environment. Progress reports of such cases indicated that as the environment became more stabilized, the d i s a b i l i t i e s in special school subjects diminished or disappeared. In the case de-scribed below, however, the c l i n i c a l diagnosis was "severe reading dis-a b i l i t y " and the c l i n i c a l recommendations centred around obtaining for the child direct help i n reading. Stephen W. (aged 7 years 2 months) was referred to the Child Guidance Clin i c by his mother on the advice of the school principal. The symptoms presented v/ere "unable to read, and slow i n school". 118. Stephen's father was at f i r s t reluctant to have the boy-examined. He had thought that the c l i n i c was "only for feeble-minded children". The boy was the younger of two children. His sister aged 11 had great d i f f i c u l t y i n learning arithmetic. The family lived i n a comfortable home i n an average neigh-bourhood. This appeared to be a united family group and both parents seemed eager to give their children emotional security. They were concerned because Stephen had been teased by his class-mates when he had failed i n Grade 1, and had since that time fre-quently referred to himself as "stupid". Stephen was said to have "not much energy" i n play but he entered f a i r l y well into the games i n the school yard. He wore glasses. At the age of 3 months Stephen had had measles, followed by whooping cough. The mother seemed anxious about the child having had a serious f a l l when only a few months old. She wondered too about a head injury Stephen had received when he was 2 years of age. She mentioned that the child had always been "rather slow". He had had many colds and frequent nose bleeds. The phsyical examination at the c l i n i c revealed that Stephen had enlarged tonsils and adenoids. The tonsils were badly infected. Psychological tests indicated that the boy's I.Q. was 101, and that he had a reading d i s a b i l i t y . The psychiatrist's interviews with the mother and child did not reveal anything negative. The c l i n i c recommendations were: 1. The child should be examined by the family doctor as his tonsils and adenoids require attention. 2. Social worker should confer with the school principal re special tutoring daily for the boy. The mother had already made an appointment for Stephen with the family doctor before the social worker's f i r s t v i s i t following the c l i n i -cal examination. Both parents were encouraged by the knowledge that Stephen had normal intelligence. The parents expressed willingness to provide help for the boy i n the form of tutoring i n reading and asked for the social worker's assistance i n finding a suitable tutor. 119. When the social worker conferred with the school prin-cipal and teacher about this she learned that there were no remedial classes in the school. However, the teacher said that she would give Stephen special remedial reading every day i n individual work with him. Three months later, this case was closed. Stephen's tonsils and adenoids had been removed and already an improve-ment i n his health was noted. With the special help from his teacher, Stephen had made considerable progress i n reading. Both the teacher and the parents observed that Stephen was de-veloping normal aggressiveness. He said that he liked school better and this was quite apparent to his teacher and parents. Two years later an inquiry about Stephen's adjustment was made by the c l i n i c . The mother said that the boy had passed into a new grade each year and was making good progress. She further reported that the special tutoring which Stephen had received had been so valuable that the parents had obtained similar help i n arithmetic for his sister. The results of the special lessons for the g i r l had been good. She, too, had been promoted each year and was enjoying school. The successful outcome of this case may be attributed i n part to the school's recognition of the problem and to the c l i n i c ' s diagnostic services. However, neither of these would have been effective i f there had not been close cooperation between the school and the c l i n i c i n the follow-up work. Undoubtedly, the greatest asset i n the case was the 2 adequate parents who saw the problem also and cooperated with the school and the c l i n i c i n doing something about i t . The lack of early recognition of maladjustment was more appar-ent i n the sample cases i n this group than i n the other three c l a s s i f i c -ations of symptoms the average period of time between f i r s t appearance of symptoms and c l i n i c referral, being 3 years and U months. In these cases as well as i n those of children showing socially unacceptable behaviour, unfavourable personality reactions, or disorders i n habit formation, earlier recognition of the problem and thorough investigation of under-lying causes would have benefitted the patients. 121. CHAPTER 9. RECOMMENDATIONS AND RESULTS The major objective i n the c l i n i c a l study of each c h i l d i s the strengthening of the patient so that less handicapped by emotional d i s -turbance he w i l l be able to work out an adjustment, which w i l l ho longer necessitate his formation and use of unhealthy symptoms. In both of the Vancouver c l i n i c s the conference i s used f o r the formulation of plans which offer the c h i l d help. Frequently the forms of assistance which his home, school and community might give are delineated. Besides these i n d i r e c t methods of helping the c h i l d , the d i r e c t treatment of h i s psychic problems may be included i n the plans f o r his welfare. These plans for treatment, d i r e c t and i n d i r e c t , are based on what i s known of the c h i l d through the c l i n i c ' s study of him as an i n d i v i d u a l and as a member of his family group and society. His unmet needs i n the past and his methods of attempting to meet these needs are taken into consider-ation by the persons formulating the plan. The four general types of approach to treatment as already out-li n e d i n Chapter 1, bear r e p e t i t i o n here. These were (1) promoting changes i n the p a t i e n t 1 s environment (2) the finding of new outlets f o r the pat-ient's energies or capacities (3) remedying of the patient's s p e c i f i c physical and i n t e l l e c t u a l d i s a b i l i t i e s and (4) dealing d i r e c t l y with the patient's psychic problems. Such approaches to treatment were found i n the recommendations made by the Vancouver c l i n i c s . In the samples of case studies given i n the preceding chapters s p e c i f i c recommendations of the 122. examining c l i n i c were given i n detail. In the accompanying table based on the 20 per cent sample (52 cases), five classifications of treatment re-commendations are used, a separate category having been u t i l i z e d to clas-sify proposals for educational adjustment. Table 1-4 FREQUENCY OF TYPES OF RECOMMENDATIONS MADE AT CLINIC CONFERENCES (Total of 52 cases.) Rank Recommendation No. Rate Per Case 1 Adjustment of the home situation (a) Social or educational work i n the home (b) Advice regarding methods of training (c) Suggestions regarding sibling relationships (d) More companionship with father (e) Consideration of placement 98 40 22 13 12 11 1.88 2 Social Adjustment (a) Development of recreation and other specific interests (b) Opportunities for adequate social relationships (c) "Summer camp 44 16 15 13 .84 3 Educational Adjustment (a) Advice to teacher regarding handling of patient (b) Adjustment of grade placement (c) Change of school 27 12 11 4 .54 4 Improvement of physical health (a) Referred to physician for treatment (b) Supplementary examinations 22 12 10 .42 5 Direct treatment of the patient 15 .28 Total 206 3.96 Clearly, many aspects of children's needs are recognized i n the cl i n i c s ' efforts to f a c i l i t a t e the adjustment of patients. I t w i l l be noted that almost half of the recommendations involved work with the pat-ients' families. This indicates the c l i n i c s ' acceptance of the theory 123. that "the chief supports or hindrances for the individual i n his struggle to adjust himself are found i n the family. Whether he develops emotional maturity depends very largely upon his home and his parents. "(1) In the preceding chapters s t a t i s t i c a l data and case illustrations have demonstr-ated the multiplicity of socio-economic factors which impinge upon the personality development of children. But diagnosis alone i s of no avail i f definite co-ordinated efforts are not made to alleviate the stresses which have created unhealthy symptoms. Although recommendations concerning social adjustment ranked second i n frequency, progress r eports and case records did not indicate that careful attention had been given to this. For example in only 2 of the 13 cases i n which summer camp was recommended, the workers conferred with the <amp director before and after the patients attended camp. In a few instances, social histories made such statements as "This boy spends most of his free time at X — H0use (Community Centre)" or "June belongs to a g i r l s ' group at ". In only one of the sample cases had a v i s i t been made to the Centre named and inquiries made about the child's participation i n group ac t i v i t i e s , and his adjustment as ob-served by the group workers i n the agency. In none of these cases was there any evidence of a group worker or recreation leader being invited to or attending a c l i n i c conference. The extent to which recommendations for educational adjustment was carried out was d i f f i c u l t to determine. It i s probable that the con-(1) Menninger, William C., Psychiatry: Its Evolution and Present Status Cornell University Press, Ithica, New York, 1948. p. 101. 124. ferring of nurses and teachers was more frequent than progress reports indicated. The adjustment of grade placement was not approved by school principals i n 4. out of the 11 cases i n which the consideration of this was recommended. These 4 were cases i n which pupils' intelligence quot-ients indicated that they would be able to make progress i n a higher grade. If the school principal's had been present at the conferences i n which these recommendations were made, i n a l l probability they would have given their reasons for not considering this a suitable plan. Such dis-cussion by the principals might have been valuable to members of the c l i n i c team and others at the conference, i n clarifying the school's point of view. At the Child Guidance ^ l i n i c , where the schedule i s such that us-ually 4 patients per day are examined, i t i s frequently d i f f i c u l t to arrange the conferences at such a time that i t w i l l be convenient for the principals or teachers to attend. They are invited, however, whenever such action appears feasible except where parents are not willing to have their child's problem discussed with representatives from the school. Conferring with the principal or teacher about the patient's school record, attitudes, group adjustment, etc., from time to time after the c l i n i c a l examination as well as before has shown good results i n the cases i n which this was done by the Child Guidance Clinic social workers. (1) Frequently, however, the only contact with the school was prior to the c l i n i c a l examinations* The extent to which recommendations concerning the improvement of physical health were carried out was indeterminable from the information (1) The case of Stephen described in Chapter 8, pp. 117-119 i l l u s t r a t e s t h i s . 125 contained i n the c l i n i c records. One instance i n which this was not car-ried out was referred to i n Chapter 7. Direct treatment of the patients was recommended i n 15 (28 per cent) of the sample cases. "This child should be in a treatment and ob-servation centre i f one were available" and similar statements were found in 6 out of the 15 cases i n which recommendations for the direct treat-ment of the patients were made. The examining psychiatrists made this comment to stress the seriousness of the patient's problems as well as to provide a means of determining i n part at least the number of children requiring a period of time i n a treatment and observation centre. In these 6 cases as well as others i n which direct treatment of the child was recommended the social workers in the c l i n i c or i n family and child-ren's agencies were given direction by the examining psychiatrist. Op-portunities for consultation with the psychiatrist were provided for the social workers i n the course of. their intensive case work with the child-ren and i n some instances the patients were re-examined by the psychia-t r i s t . The case of Ralph B., aged 9 years 3 months when he was refer-red to the Child Guidance Clinic, i l l u s t r a t e s the role of the worker i n the practice of "social work undertaken i n direct and responsible working relation with psychiatry".( 1) It il l u s t r a t e s , too, some of the many com-munity resources which may be of v i t a l importance i n helping a child whose maladjustment i s serious, and whose home i s unable to meet his needs. Some of Ralph's symptoms and some of the underlying causes of these have (1)Psychiatric social work as defined i n the By-laws of the American Association of Psychiatric Social Workers. Article VI, Section IA. 126. already been mentioned i n Chapter 5. Five months before Ralph came to the Child Guidance Clinic, he had been referred to the Mental Hygiene Cl i n i c . At that time, his mother and teacher had described his symptoms as "swearing, poor application at school, poor group adjustment and poor control of temper". The Mental Hygiene Clinic had found that there were many unfavourable conditions i n the home and considered that i t was "doubtful i f the home environment could be materially changed". One of the outstanding d i f f i c u l t i e s i n the home at that time was the presence of the elderly paternal grandmother, who was senile and had marked paranoidal tendencies. The father who did not appear to be able to cope with family d i f f i c u l t i e s had broken 2 appointments for an interview with the mental hygienist. Ralph's parents referred him to the Child Guidance Clinic, on the advice of the social worker from the Provincial Mental Hospital who had visited the home to prepare the social history of the grandmother who had been committed to the hospital. The parents told of Ralph's aggressive behaviour at home. He some-times kicked his mother and frequently struck, kicked and b i t his father. He had broken windows and the glass i n doors by striking with his clenched f i s t s . The symptoms which had led to his examination by the school c l i n i c persisted. The history of Ralph's earlier years revealed that as a baby he had cried a great deal, he had "cradle cap" i n infancy and his hands had been tied to prevent him from scratching his head. There had been feeding d i f f i c u l t i e s during infancy. He had had many colds, high fevers, and running ears. When Ralph was 14- months old, a second child was born, but died shortly after birth. During this pregnancy, and after childbirth, the mother had been seriously i l l . The paternal grandmother had lived i n the home from the time of the parents' marriage u n t i l Ralph was over 9 years old. There were many family tensions as a result of this. The grandmother who frequently c r i t i c i z e d the mother's handling of the boy was l e f t to care for him at times while the mother worked outside of the home. The grandmother made threats of physical injury to the child and frequently told him that his habit of masturbating "would ruin him". 127 The paternal grandfather had died i n a mental ho s p i t a l before Ralph's b i r t h . He had been hospitalized f o r many years because of manic-depressive psychosis. The father was very much concerned about the p o s s i b i l i t y of h i s own mental breakdown be-cause of hereditary factors. When younger he had v o l u n t a r i l y consulted a p s y c h i a t r i s t . His reaction to the patient's v i o l e n t behaviour was frequently that of weeping and saying "This w i l l k i l l me." The mother sought release from the d i f f i c u l t s i t u a t i o n i n which she found herself, by gradual withdrawing. I t was hardly surprising that the complete examination of Ralph by the c l i n i c revealed that the boy was severely disturbed. His i n t e l l i -gence was superior. At the conference the examining p s y c h i a t r i s t pointed out that the p o s s i b i l i t y of schizophrenia must be considered. The inten-sive case work treatment of the c h i l d as well as work with the parents was recommended by the p s y c h i a t r i s t . In the course of carrying out t h i s recommendation the s o c i a l worker frequently consulted the p s y c h i a t r i s t . The patient was interviewed by the psy c h i a t r i s t 3 times a f t e r the f i r s t examination and a diagnosis of severe psycho-neurosis was made. During the f i r s t 6 months of the s o c i a l worker's contact with the parents and patient, 72 hours were devoted to t h i s case. I f the resources of a treatment and observation centre for emotionally disturbed children had been available, some of the temporary measures which had to be used would not have been necessary. Lacking t h i s , however, other community resources, some of which were not designed for such purposes, were marshalled to help t h i s boy and hi s parents. Interviews with the parents, some j o i n t l y and others with each parent separately were held frequently. There were also play periods and interviews with Ralph. The school was v i s i t e d and the worker conferred with the school p r i n c i p a l , the nurse and the teacher on several occasions. A f i n a l assessing of the i n a b i l i t y of the parents to take t h e i r place as "partners- i n treatment" with the c l i n i c was made. The father, an anxiety-ridden person for many years, was on the 128. verge of a mental breakdown and asked to have the child re-moved from the home. The mother too made this request. It had been d i f f i c u l t i n the past for her to maintain equilibrium while she endeavoured to support and strengthen her emotionally disturbed husband and son. At this point a conference between the c l i n i c and a child-ren's agency was held. The outcome of this conference was that Ralph was placed i n the Receiving Home of the child placing agency. This was a temporary measure, as the Receiving Home was set up and financed to serve a different group of children. While Ralph was l i v i n g at the Receiving Home, arrangements were made for a 2 week period i n camp. This, too, was a tempor-ary measure and from the point of view of the c l i n i c and the child placing agency was expedient. Although recognizing that Ralph was too emotionally disturbed to derive much benefit from camp experience, the c l i n i c saw this move as providing an opportunity to work more closely with the parents. The camp was not geared to deal with boys whose maladjustments were as severe as Ralph's, but the camp director, aware of the urgency of c l i n i c ' s need for time to help the parents i n their decision, accepted the boy as a camper. Soon after camp, Ralph expressed the desire to return to his own home. This was arranged but again his parents were un-able to deal with his extremely aggressive behaviour. On one occasion Ralph and his parents became so disturbed that the c l i n i c psychiatrist advised that the worker should recommend that a private psychiatrist should be called by the parents for the boy. This was carried out and the psychiatrist who came to the home recommended that Ralph should be removed from his parents immediately. Mr. and Mrs. B. agreed that this was necessary and the psychiatrist took Ralph to the Receiving Home of the child placing agency. Again the c l i n i c looked for community resources acceptable to the child and parents. Ralph wanted some of his home; the parents did not want to relinquish their guardianship and custody of the boy. A lack of recognition of either the boy's or the 129. parents' desires might have precipitated the further breakdown of each member of t h i s family. A private boarding school seemed to be the best solution. However, the e a r l i e r evaluation of the. f i n a n c i a l status of the family had revealed that outside help was needed. A suitable private boarding school was sought, and at the same time possible community resources f o r the f i n a n c i a l support of such an arrangement were investigated. At t h i s time, the case was transferred to a male worker, because i t appeared that the boy whose relationship with h i s father was so poor, might benefit by t h i s . The s o c i a l worker found a private boarding school, the p r i n -c i p a l of which was interested i n t r y i n g to help Ralph. The boy's d i f f i c u l t i e s and needs were ca r e f u l l y discussed by the s o c i a l worker and the p r i n c i p a l . The s o c i a l worker also found a service club which was interested i n financing the boy's education. Here, too, i t was necessary f o r the s o c i a l worker to outline the nature of Ralph's d i f f i c u l t i e s and possible ways of a l l e v i a t i n g these. This club was prepared to assume f u l l f i n a n c i a l r e s p o n s i b i l i t y f o r the school fees u n t i l such time as the parents were able to contribute toward t h i s . During the period of more than 2 years which Ralph has been i n the private school, case work has continued with the boy and h i s parents. The f i r s t year, Ralph was interviewed at l e a s t once a week by the s o c i a l worker. During the second year interviews were held once every 2 weeks. During the current year the same frequency of interviews continues. -The mother returned to part time employment, and the parents have gradually been able to assume greater f i n a n c i a l r e s p o n s i b i l i t y for Ralph's attendance at the school. Mean-while, the service club has been kept informed of Ralph's progress. Summer placement i n a r u r a l foster home, with b r i e f periods at home during school holidays have been arranged. Both the boy and h i s parents are aware that fo r a l l concerned . longer v i s i t s are not yet advisable. Throughout Ralph's period i n the school, there have been frequent discussions between the p r i n c i p a l and the s o c i a l worker about h i s development. Ralph, whose group adjustment had been extremely poor, has for some time been enjoying a boy's s a t i s f a c t i o n of teing able to make friends with h i s classmates. He has been able to 130. contribute to the group i n both studies and sports. His school reports describe excellent progress and he received the Junior Athletic Award at the end of his second year in the school. Ralph has become more aware by his own problem, and i s gradually recognizing that the almost complete i n a b i l i t y of his father to assume the role of a parent i s l i k e l y to be permanent. At present, i t appears that this boy and his parents w i l l desire and need the continued help of the c l i n i c over a period of several years. The grave proportions which this boy's maladjustment had grown before treatment began, necessitated a great deal of activity on the c l i n i c ' s part to prevent the total disintegration of this family. Accurate evaluation of the outcome or the after-effects of follow-up i s very d i f f i c u l t . Not only i s i t impossible to gauge the effect of influences other than those of the c l i n i c or other agencies, but also the reports of results of the work with and for patients varies with the judgment and experience of those who make the evaluation. The likelihood of inaccuracies i n the estimations of the adjustment status of children must be kept i n mind i n considering this compilation of results, based on reports of adjustment as found i n the c l i n i c records. 131 Table 15 ADJUSTMENT STATUS OF PATIENTS Results Socially Unacceptable Behaviour Personality Reactions ttabit Disorders School Dis a b i l i t i e s Average* | per cent per cent per cent per cent per cent No follow-up or progress report 20.0 31.25 25.0 37.5 27.0 No improvement 5.0 6.25 12.5 12.5 7.7 Partial Adjustment 15.0 12.5 12.5 37.5 17.3 ^Wked I. Improvement 60.0 37.5 50.0 12.5 4A..2 Satisfactory-Adjustment - 12.5 - 3.8 ft Based on the total sample of 52 cases. In over one third of the sample cases examined by the Mental Hygiene Clinic there were no progress reports although such reports are requested by this c l i n i c . In the Child Guidance Clinic cases referred by health or social agencies for diagnostic services, there were no progress reports, unless patients returned to the c l i n i c for repeat examinations, or consultative conferences were held. This i s i n keeping with the Child Guidance Clin i c policy which does not request progress reports except as in the above-mentioned cases. The cases i n which there were no follow-up or progress reports comprised more than one quarter (27 per cent) of the total number of sample cases from both c l i n i c s . According to the above table, the percentage of patients showing satisfactory adjustment (3.8 per cent) was only half as large as the per-centage showing no improvement (7.7 per cent). However, c l i n i c records indicate that in more than half of the cases (51.5 per cent) varying degrees of improvement were noted. 133. CHAPTER 10. FUTURE GOALS some of the limitations of the c l i n i c services which have been indi-cated in cases described i n the preceding chapters have been remedied to a certain extent during the years under consideration as well as i n 1948 and the current year. It might be well to review b r i e f l y some of the recent expansions i n each of the c l i n i c s before pointing out further needs. ^uring most of 1945, the f i r s t year included i n this study, the psychiatric examinations were made by psychiatrists from the Provincial Mental Hospital. There were staff shortages at the Mental Hospital too, during this period and consequently there were limitations i n the time which the psychiatrists could spend at the Child Guidance C l i n i c . At the beginning of 194&, 2 psychiatrists were appointed. One was the c l i n i c director, who, when not engaged in the work of travelling c l i n i c s , acts as psychiatrist at the consultative conferences in which social and health agencies seek help i n understanding the psychiatric imp-lications of the problems of some of their clients. The director also examines a number of patients. The other psychiatrist wofcks f u l l time at the Vancouver c l i n i c . There has also been a gradual expansion i n the social work staff of the c l i n i c , during half of 1945 the c l i n i c supervisor's time was divided between the c l i n i c and the social service department of the 134. Provincial Mental Hospital. Later i n the year, one social worker was em-ployed for f u l l time work at the c l i n i c . In 1947, a c l i n i c supervisor was appointed. At the present time there are 6 social workers (including the supervisor) on the c l i n i c staff. One social worker spends part time as a member of the travelling c l i n i c team. The number of c l i n i c a l psychologists has increased from 3 i n 1945, to the present psychological staff of 5. Two psychologists are en-gaged in travelling c l i n i c part of the time. The nursing staff, too, has been enlarged. In 1945 there was one nurse at the c l i n i c j at present there are 3 nurses. More office space and diagnostic equipment has also been provided to keep paoe with staff expansion. Through the federal health grants, 4 members of the c l i n i c staff (one from each profession of the c l i n i c team) have each completed one year's advanced university training. In the Mental Hygiene Clinic, too, there has been an enlargement of staff. An assistant mental hygienist was appointed i n 1948, f a c i l i t -ating the extension of c l i n i c a l services to include the examination of children under school age. In the same year a psychologist was also added, to the Mental Hygiene Division, making possible the psychological exam-ination of patients who attend school i n areas not served by the Bureau of Measurements, as well as children of pre-school age i n Greater Van-couver. The appointment of a psychiatric social worker i s included i n this c l i n i c ' s proposed plans. 135. Turning now to the 257 cases which are the subject of this study, i t was noted earlier that they comprised only 13 per cent of the total number of children (1) examined by the 2 c l i n i c s . In other words approx-imately only 1 patient out of 8 was an elementary school child of normal intelligence l i v i n g with parents or relatives. Two reasons for this showing were revealed in the course of the selection of cases which came within the limits of the specified c r i t e r i a . The f i r s t of these reasons i s that many patients between the ages of 6 and 12 years and l i v i n g with their own parents and relatives had intelligence quotients below 80. some of these were brought back to the c l i n i c , 2, 3 and even A times, because the parents did not accept the fact that their children were mentally retarded. Not only did these children i n many instances not derive any benefit from the examinations, but the c l i n i c time spent on such cases might have been used advantageously for emotionally disturbed children. In some of these cases, the patients lived at too great dis-tance from public school special classes to attend, although their i n -telligence was not too low for such classes. The early detection of mental deficiency i n Child Health Centres, and interpretation of this to the mothers would be beneficial to both children and parents. With this help, many mothers would be able to face the situation, and plan accordingly. Too often, mothers try to register in Grade 1, children with I.Q.'s below 50, who to a l l except the parents are obviously defective. Frequently family tensions are increased and siblings become maladjusted when the community lacks resources for children whose i n t e l -^ P a t i e n t s up to 18 years of age. 136 lectual limitations are great. The 2 c l i n i c s as well as social and health agencies might furnish information as to the extent which this problem i s apparent i n their cases, which might i n turn give impetus to more adequate planning for severely retarded children. In Winnipeg, the Child Guidance Cli n i c (1) was instrumental i n the forming of 3 "occupational" classes for feebleminded children with I.Q.'s of approximately 50 or below. In Vancouver, St. Christopher's School (under private auspices) i s a boarding school for boys of limited intelligence. There i s no such school for g i r l s , but many parents have made inquiries about such resourr ces. xhe only other institution available for mentally defective children i s the Provincial Training School i n New Westminster. There are so many demands for such an institution that with the present f a c i l i t i e s of this school i t i s sometimes necessary for children to wait i n the Provincial Mental Hospital at Essondale for several months before entering i t . Many parents find this a d i f f i c u l t situation and some remove their children from the hospital. Anxiety during this waiting period sometimes in-creases the family tensions rather than lessening them. Another reason for the small proportion of children i n the category surveyed i n this study, i s that disturbed children are frequently not brought to the c l i n i c s for help unless the disturbance shows up i n the school situation or family d i f f i c u l t i e s are sufficiently acute that a social agency i s called i n . Parents' lack of awareness of the availabi-l i t y of c l i n i c services i s apparent in many records. (l^This c l i n i c i s jointly sponsored by the City Health Department and the Winnipeg School Board. 137. In one case, a mother's comment on how she had learned about a c l i n i c i s significant "I had been worried about Frank for over 3 years. I tried everything I could think of, and just about everything anyone suggested. I was desperate. One day, my neighbour noticed that I had been crying. She suggested that the Child Guidance C l i n i c might help us. She said that she had heard something about the c l i n i c at a banquet once." Another mother, whose daughter had been involved i n small thefts commented thus when she terminated her contact with the Child Guidance Clinic: "More parents should know about this c l i n i c . I had noticed in the newspapers that Juvenile Court cases are sent here and I thought that maybe the c l i n i c could help us with Peggy, even though she had not been in court yet." Parents sometimes learn of the c l i n i c services through their friends. Firm one city block i n less than one month came 3 severely dis-turbed children. The f i r s t patient came to c l i n i c as a result of referral by the family doctor. Through his parents another boy's mother learned of the c l i n i c and referred her child for c l i n i c a l examination. This mother, in turn, told the parents of another child about the c l i n i c and a third patient was referred for examination. In a murier of other cases, parents of patients were informed of the c l i n i c a l services by the parents of for-mer patients who had f e l t that they had benefitted by contact with the c l i n i c . Recent newspaper publicity about the Crease C l i n i c as well as one short a r t i c l e i n a cit y paper about the Child Guidance C l i n i c have brought a deluge of requests for help with problems of long standing. The importance of early treatment for disturbed children, and of the value of 138 parents taking the i n i t i a l step in seeking help for these children, is recognized by the clinics. In view of this i t appears that some investi-gation on the part of these clinics into the ways and means of acquainting the general public with the availability of their services would be advan-tageous. There are indications in some of the Child Guidance Clinic re-cords that some of the school principals, nurses and teachers lack infor-mation about the Child Guidance Clinic. There appears to be some feeling on the part of persons in the schools, that i f a child is a pupil he should be examined by the school clinic. Xhe rights of parents to seek help for their children from whichever clinic they choose is not always recognized. At times, too, there appears tote the attitude "He's a good pupil. Why should he be examined?", which overlooks the fact that boys and girls are members of a family too and that parents may observe symptoms at home which are not apparent in the school. Such attitudes may in part be attributable to a lack of close cooperation between the school and Child Guidance Clinic in the past when staff shortages made frequent contacts with school personnel almost im-possible. These misunderstandings are not insurmountable, and may in the future be overcome to a certain extent by the more frequent conferences between school and clinic personnel which staff expansions have made pos-sible. A spirit of mutual understanding and cooperation might be promoted more readily however, i f by some means, the functions and procedures of the Child Guidance Clinic were made known to the School Principal's Association and other similar groups. 139 T h e r e a r e i n d i c a t i o n s t h a t a more s a t i s f a c t o r y w o r k i n g r e l a t i o n -s h i p between t h e 2 c l i n i c s i s b e i n g s o u g h t . I n F e b r u a r y o f t h i s y e a r , a m e e t i n g between t h e S u p e r v i s o r o f t h e M e t r o p o l i t a n H e a l t h N u r s e s , t h e C h i l d G u i d a n c e C l i n i c D i r e c t o r and S u p e r v i s o r , and t h e E x e c u t i v e D i r e c t o r s o f s e v e r a l s o c i a l a g e n c i e s was h e l d . A t t h i s m e e t i n g some o f t h e m i s u n d e r -s t a n d i n g s r e g a r d i n g r e l a t i o n s h i p s between t h e 2 c l i n i e s a n d between t h e s c h o o l c l i n i c and s o c i a l a g e n c i e s were d i s c u s s e d and some a g r e e m e n t s a b o u t o v e r c o m i n g t h e s e were r e a c h e d . An i l l u s t r a t i o n o f one t y p e o f m i s u n d e r -s t a n d i n g w h i c h h a s o c c u r r e d f r e q u e n t l y i s shown i n t h e c a s e o f 10 y e a r o l d S a l l y whose p a r e n t s became c o n c e r n e d a b o u t h e r temper t a n t r u m s and s u i c i d a l t h r e a t s . I n J u l y , t h e p a r e n t s a r r a n g e d f o r S a l l y ' s e x a m i n a t i o n a t C h i l d G u i d a n c e C l i n i c w h i c h was t o t a k e p l a c e a few d a y s a f t e r s c h o o l r e - o p e n e d . S a l l y was t o b e g i n G r a d e 5. The s c h o o l was c l o s e d a t t h e t i m e o f t h e p r e p a r a t i o n o f t h e s o c i a l h i s t o r y b u t t h e mother had s a v e d a l l o f S a l l y ' s r e p o r t c a r d s i n c l u d i n g t h o s e f r o m k i n d e r g a r t e n . S a l l y h e r s e l f t a l k e d v e r y f a v o u r a b l y about s c h o o l , h e r o n l y c o m p l a i n t b e i n g t h a t she was "no good i n a r i t h m e t i c " . A l l o f t h i s I n f o r m a t i o n was em-b o d i e d i n t h e e d u c a t i o n s e c t i o n o f t h e s o c i a l h i s t o r y , and t h e r e was d i s c u s s i o n w i t h t h e mother a b o u t s e e i n g S a l l y ' s t e a c h e r s when s c h o o l r e - o p e n e d . The m o t h e r , a v e r y t e n s e and e x t r e m e l y t a l k a t i v e p e r s o n , gave numerous r e a s o n s why she d i d n o t want t h e s c h o o l t o know t h a t S a l l y h a d been examined a t C h i l d G u i d a n c e C l i n i c . I t was o b v i o u s t o t h e s o c i a l w o r k e r t h a t t h e mother was s o c o n c e r n e d a b o u t h e r own c o n t r i b u t i o n t o w a r d S a l l y ' s m a l a d j u s t m e n t t h a t she wanted t o keep t h e c h i l d ' s p r o b l e m c o n c e a l e d f r o m t h e s c h o o l . To t h e w o r k e r ' s e x p l a n a t i o n t h a t a n u n d e r s t a n d i n g t e a c h e r c o u l d do much t o w a r d h e l p i n g a n unhappy d i s t u r b e d c h i l d , mother gave v e r b a l a c c e p t a n c e , b u t i m m e d i a t e l y added " W e ' l l t a l k i t o v e r l a t e r a b o u t t h e s c h o o l , b u t f i r s t I ' d l i k e t o S3e how much we c a n do f o r h e r a t home." The e x a m i n i n g p s y c h i a t r i s t , aware o f t h e m o t h e r ' s f e e l i n g a b o u t any c o n t a c t w i t h t h e s c h o o l , s u g g e s t e d t o b o t h p a r e n t s t h a t S a l l y ' s s e l f -e s teem was e x t r e m e l y l o w , and t h a t i n t h e home, t h e s c h o o l , a n d t h e oom IAD munity she could be helped to reach out for- experiences i n which a sense of achievement could be gained* In the course of the f i r s t home v i s i t after Sally had returned to school, the mother mentioned that the l i t t l e g i r l liked her new teacher. After discussing with the social worker the value of art lessons for Sally, the mother said that she intended to go to the school soon to inquire about Saturday morning art classes. Sally had asked her to do this. A few days later, before the social worker had seen the mother again, the supervisor of nurses in the area i n which Sally lived, phoned the worker. She said that the school nurse had learned that Sally had been examined at Child Guidance Cl i n i c during the summer. The supervisor wondered why the school had not been contacted, and i n no uncertain terms informed the worker that the school had a great deal of information about children, and that a very valuable resource had been overlooked i n the prepara-tion of the social history. She went on to say that the school had been very concerned about Sally, and that she thought that i t was most unfortunate that the Child Guidance Clinic had not been more cooperative. The social worker commented that evidently the parents had been even more concerned than the school. Her explanation that the social history was prepared during school holidays, but that the child's report cards were taken into consideration, was not well received. The supervisor suggested that the School Board should have been contacted so that the worker might have arranged an interview with the school principal. The worker then explained that Sally's mother had as yet been un-willing to bring the teacher or school nurse into the plan of treatment. However, the Clinic saw the need for this and was working toward helping the mother recognize this. The whole idea of "accepting the client where she i s " , and of parents' rights to seek psychiatric advice where they choose, seemed completely foreign to the supervisor of nurses. The social worker agreed to v i s i t the parents soon, and to bring to their attention the school's concern about Sally and i t s desire to learn about the findings and recommendations of the C l i n i c . The social worker asked how the school nurse had learned about Sally's examination at Child Guidance Clinic, saying that mother would need an explanation of t h i s . Had the school nurse learned through Social Service Index? •'•he supervisor did not know. Had she learned through Sally herself? Again the supervisor did not know. The telphone conversation ended on a somewhat happier note when the worker agreed to contact the school after the next i n -terview with the mother, and said that she would l e t the principal 141 . know i f the parents s t i l l refused permission; i f , on the other hand, the parents agreed the social worker would arrange to see the principal, nurse and teacher. Sally's mother welcomed the social worker's suggestion of a v i s i t to the home, saying "I have something good to t e l l you". The mystery of how the school nurse had learned of the examination was solved when the mother told the "something good" at the be-ginning of the interview. She related the story of having gone to the school tolalk to the teacher about Sally's art class. 'I hadn't intended to mention Child Guidance Clin i c that day, but the teacher was so nice that I just up and told her everything. She was very interested. I hope you w i l l go to the school and talk with them about Sally." The pooling of information and the joint approach to helping Sally, which evolved from the social worker's v i s i t to the school had encouraging results. Sally's mother was later a b l e to say how much better she and her husband f e l t about their role of parenthood. "It's a big job, and i t has i t s ups and downs, but we don't have to grope along alone when we're puzzled about how our children are developing." It i s unlikely that this mother would have learned a new approach to her child i f the decision about contacting the school had not been l e f t to her. Misunderstandings such as the one just described as well as others might have been overcome i f members of the social work profession had been included i n the Mental Hygiene Cl i n i c personnel. In 1939, the future plans of this c l i n i c included the addition of. a social worker to the c l i n i c team. Ten years later, the proposed plan appears nearer to fulfilment, a grant having been made for the salary of a psychiatric social worker. A recent survey^) of the role of the school social worker, demonstrated by means of an experimental study in one elementary school, (l)Thompson, Mary A. The Social Worker i n the School University of Brit i s h Columbia thesis 1948. 1 4 2 . that the "inclusion of s o c i a l work p r i n c i p l e s and techniques are a l o g i c a l and s o c i a l l y desirable next step" i n Vancouver Schools. In the present study,, the complexity of i n t r a f a m i l i a l relationships and s o c i a l problems i n c l i n i c cases, indicates the need for the use of the p r i n c i p l e s and tech-niques of s o c i a l work along with those of other d i s c i p l i n e s . Not only more adequate s o c i a l h i s t o r i e s but also better follow-up might be expected i f s o c i a l workers were included i n the mental health program for schools. The value of the m u l t i - d i s c i p l i n e team i n the study of emotion-a l l y disturbed patients i s described by one neuropsychiatrist(l) as follows: "Modern diagnosis and therapy i s not best accomplished by an in d i v i d u a l p s y c h i a t r i s t . A l l patients need careful s o c i a l ser-' vices and psychological work-up and follow-up A s k i l l e d p s y c h i a t r i s t who knows the functions of the nurse, s o c i a l worker and c l i n i c a l psychologist, and has some experience i n group work can adequately handle 5 to 1 0 times as many patients as he can alone. He can not only care for more but the quality of care i s markedly enhanced." This leads to a consideration of the functional structure i n some c h i l d guidance c l i n i c s which u t i l i z e s to the maximum the contributions of members of the mu l t i - d i s c i p l i n e team. In many c l i n i c s the team c o n t r i -butes to the study of the " c h i l d as a whole" both i n diagnosis and i n tr e a t -ment. The diagnostic s t a f f conference i s the formal meeting of the t o t a l professional s t a f f of the c l i n i c and i s held f o r the purpose of reviewing, evaluating and a r r i v i n g at a decision as to the nature of the child's problem, as well as the need for and f e a s i b i l i t y of treatment. ( ^ B l a i n , Daniel, "Some Essentials of Mental Health Planning" B u l l e t i n of the Menninger Clinic„ Nov. 194-6. p. 184. 143. In the course of treatment i t i s often necessary for the team members to formally confer together. Such a meeting i s a treatment confer-ence called for the purpose of evaluating the over-all direction of the work on the case, for the making of new plans i f necessary, or for c l a r i -fying the current situation. This conference may be called by any member of the team involved i n the treatment of the child. Other community per-sons also active i n the situation may also be invited. The over-all de-cision for the termination of treatment of a patient i s also jointly ar-rived at through a conference of the entire staff i n such c l i n i c s . At present, the structure referred to above as i t concerns diag-nostic and treatment conferences has not been possible i n the Vancouver Child Guidance Clinic. The diagnostic conference has been used both for diagnosis and formulation of treatment plans and community persons have been invited to attend. No f a c i l i t i e s for treatment conferences of the entire team have been afforded. However, i n treatment cases the social worker or psychologist consults with the psychiatrist during the limited time he has available between his daily duty of 4 physical and psychiatric examinations of patients and the 4 conferences which follow. Because of the division of treatment between psychiatrists, social workers and psy-chologists the lack of time for conferences around patient's progress i n treatment i s a serious handicap and places heavy responsibility on the discipline within the team directly involved with treatment. The addition of another psychiatrist to the Child Guidance Clinic staff would help i n remedying this d i f f i c u l t y . . Under existing circumstances, more careful selection of cases on 144. the part of social and health agencies would conserve the psychiatrist's time and make him more available for direction of treatment of emotionally disturbed children. Again when social and health agencies bring i n patients with emotional disturbances beyond the ordinary case work services of the agency there has been manifest i n workers of the referring agency an unwillingness to relinquish the patients for treatment by the Child. Guidance Clin i c team. This may be attributed i n part to a lack of recognition by workers i n social and health agencies of the specialized s k i l l of the disciplines which go to make up the c l i n i c team. The Child Guidance Clin i c has offered a cooperative service i n an attempt to meet the agencies' need of treatment services for their clients. Lately the demand on the part of agencies for this service has grown, but so have the demands of parents and general practitioners. So that onee again Child Guidance Clinic i s faced by the limitations of the time the psychiatrist has available for direction of treatment. The high incidence of poor group adjustment found i n the cases i n this study as well as the frequency of recommendations regarding this sym-ptom, suggests that good working relationships between the c l i n i c s and group work agencies are imperative. In the developmental stages of the 2 c l i n i c s the value of such relationships i f recognized, does not appear to have been put to practical use to any extent. Too frequently, c l i n i c re-cords contain information that has not been made knoxm to group work agencies which might u t i l i z e i t to the advantage of the members concerned. Parental consent for the c l i n i c s and social agencies to divulge such i n -U 5 . formation might have been expected i n many cases, i f through careful case work the valid i t y of such action had been interpreted to the parents. Social group workers as well as case workers through their t r a i n -ing have some understanding of the dynamics of human behaviour. Group work agencies should therefore be one source of referrals to the c l i n i c s . In the past, maladjusted children have been referred by group work agencies to social or health agencies which i n turn sometimes seek the help of the cl i n i c s . The possi b i l i t y of direct referrals from group work agencies i n some cases should be investigated. Such action would necessitate increased knowledge of c l i n i c a l services on the part of group workers and vice versa. In many c l i n i c s , a group worker i s a member of the c l i n i c a l team and a recreation survey i s one of the procedures within the examination of patients. In such c l i n i c s , the group worker i s aware of recreation re-sources i n the community and has responsibility for helping to carry out the recommendations regarding group adjustment. The addition of a group worker to the Child Guidance Clinic team appears to be a lo g i c a l future development which would enhance services to children i n this city where the growth i n community centres i s marked. Such an addition to the Mental Hygiene Cl i n i c also might be considered after social case work services i n the schools i s established. One of the most apparent and urgent needs i n this community i s a treatment and observation centre for emotionally disturbed children. Such an institution, known as Alexandra Centre, was established i n Vancouver i n January 1939, and was i n operation u n t i l A p r i l 1943. This centre was the f i r s t and to date, the only one of i t s kind i n Canada. I t operated under 146. the auspices of a private organization, the Alexandra Children's Home Society, which had originally been founded for the care of dependent or neglected children. Admissions to the centre were made through the Child Guidance Clinic. The supervision of the centre were made through the Child Guidance Clinic. The supervision of the centre was at f i r s t the responsi-b i l i t y of a psychiatric social worker. Later re-organization of the centre resulted i n the appointment of a child psychologist as supervisor. Ik study of the adjustment of children at the time of discharge, and their later adjustment indicates that the centre was able to give help to a high percentage of patients whose disturbances were so sever© that they could not be treated successfully i n their own or foster homes.(1) Alexandra Cottage was closed when the report of the committee formed to study the wisdom of continuing the work of the centre indicated that the value of such an institution had been demonstrated but that "such an or-ganization should not be a further responsibility on community funds, but should be the responsibility of the Provincial Government. .(2) Twenty of the 257 patients studied i n this survey were described by examining psychiatrists as being i n need of treatment i n such a centre. The director of the Child Guidance Clinic has for 3 consecutive years made recommendations to the provincial government regarding the plans for a treatment and observation centre. Community interest i n an institution of this kind has been aroused by the Mental Hygiene Division of the Greater (^Munro, Marjory H. A General Survey and Evaluation of an Institution for  the Observation and Treatment of Problem Children. University of Bri t i s h Columbia thesis, 1946. pp. 45-4-8. ( 2 ) i b i d , pp. 109-110. H 7 . Vancouver Health League, The continued efforts of a l l person interested i n a centre of this kind may be required i n order to obtain governmental support. Numerous inadequacies i n the social histories were noted i n this study. In many instances these occurred i n the histories prepared for the c l i n i c s by workers i n other agencies referring children for examinations. In many cl i n i c s a l l histories are prepared by c l i n i c a l psychiatric social workers. This has not been the case i n the Vancouver Child Guidance Clini c except i n private cases. In the early stages of this c l i n i c ' s development, lack of c l i n i c personnel necessitated the delegation of this responsibility to workers i n referring agencies. Consideration of the educational value to agency workers of history taking also played a part i n this development. I t i s understandable that the psychiatric social worker by the nature of her work i n the c l i n i c should be able to prepare the kind of social history which would best serve a l l members of the c l i n i c a l team® In the c l i n i c , the social worker acts as integrator of the team. This inte-gration involves judgment on whether a request for service f a l l s within the c l i n i c ' s function of diagnosis and treatment. It also involves arr-angements for the appointments of the child with various members of the teaan as well as the interpretation to the parent of the function, purpose and findings of each member of the team, including the social worker. If the Child Guidance Clinic continues to. delegate responsibility for history taking to workers i n health and social agencies (and this seems l i k e l y ) , i t appears, that the c l i n i c i t s e l f should take more responsibility in showing these workers what i t considers essential i n social histories. This might be done to some extent by means of individual orientation periods 148. in clinic. (This method has already been used effectively for a limited number of workers). A second means of acquainting agency workers with adequate history taking would be the use of seminars in which a l l members of the clinic team participate. This study has shown that there has been continuous growth in the 2 clinics in Vancouver. Despite limitations in the number of clinic personnel as well as the serious and almost chronic nature of many cases referred, these clinics have been able to help a large number of children. In accomplishing this, the cooperation of the parents of patients as well as teachers, health and social agencies and others in the community has been invaluable. The constructive work of the Child Guidance Clinic and the Mental Hygiene Clinic in the promotion of mental health, and consequent human happiness, wi l l in the future as well as in the past be largely de-pendent on the good-will and understanding of the community which they aim to serve. APPENDICES 150 Appendix A. MENTAL HEALTH CLINICS IN CANADA Of the existing mental health c l i n i c s i n Canada several are under the auspices of provincial Departments of Health, or as i n British Columbia. (1) the Department of Health and Welfare. These provincial c l i n i c s are as follows, i n order of dates of inauguration: Manitoba (at Winnipeg) - 1919, Alberta (at Edmonton, Calgary and Lethbridge) 1929, Ontario (at Toronto, Brockville, Hamilton, Kingston and London) -1930, B r i t i s h Columbia (at Vancouver) - 1932, Saskatchewan (at Regina, Weyburn, Moose Jaw and North Battleford) - 1947. In Ontario additional c l i n i c s were located i n New Toronto from 1931 - 1937, O r i l l i a from 1931 - 1934, and Whitby from 1931 - 1942. Clinics have been held periodically at 11 other centres i n Alberta. A c l i n i c was established i n Victoria i n 1934, and travelling c l i n i c s have visited 12 other centres i n British Columbia. In the province of Quebec, the only mental health c l i n i c i s the Mental Hygiene Institute i n Montreal which i s financed entirely by the Welfare Federation. In Nova Scotia, an out-patient psychiatric c l i n i c operated by the Medical School of Dalhousie University, was opened i n Halifax i n 1941. This c l i n i c i s financed by a Rockerfeller grant. New Brunswick and Prince Edward Island have no mental health c l i n i c s . Under municipal authorities there are the following c l i n i c s , enumerated in the order of the dates of establishment. The Mental Hygiene Service of the Toronto Public Schools was organized and maintained by the Municipal Department of Public Health i n 1919. The Toronto Juvenile Court Psychiatric Clinic was opened in 1921. The Clin i c for Psychological Medicine which i s part of the Out-Patient Department i n the Toronto Hos-p i t a l for Sick Children was organized i n 1925. In Vancouver the Mental Hygiene Clinic for Public Schools opened i n 1936 under the auspices of a division of the Metropolitan Health Committee. The Winnipeg Child Guidance Clinic was organized i n 1941 by the City Health Department. Win British Columbia, Child Guidance Clinics are i n part under othe jurisdiction of the Department of the Provincial Secretary. iix B (1) FORMS IN USE BY THE CHILD GUIDANCE CLINIC S O C I A L H I S T O R Y O U T L I N E PSYCHIATRIC HISTORY OUTLINE for use both i n HOSPITAL and CLINIC CASES. Name: Address: C i t y : Telephone: Date of coming to Canada—Scheme—Voluntary. Steamship and ra i lway and port of entry: Naturalized? Date of entry to B . C . : B y whom referred: Complaint.—Pacts given by subject and relatives or friends, each i n their own words. The greatest divergencies are here possible. F o r example, i t is not uncommon to meet subjects who are without any complaints whatever, but who are the source of great distress to the environment. This w i l l illustrate the personal and social implications of psychiatric problems, and not always do they coincide-. Reliabi l i ty and the impression of informant: The way in ' which information was given — whether spontaneously, un-wi l l ingly , in response to direct questioning, or wi th much display of emotion. Development of Present Problem.—Secure careful picture wi th exact date of the onset and development of the subject's problem and the precipitating causes of his coming for treatment. Care should be taken to ascertain as accurately as possible the exact duration of the problem before examination. PERSONAL HISTORY. Development, Place and Date of Birth.—Mother's health, mental and ^physical, during pregnancy (desire for children). Na tu ra l - or instrumental bir th, difficult labour and length of labour— bir th injuries; weight at b i r th ; breast or bottle fed; age weaned and difficulties of weaning; age teething, walking, and ta lk ing (single words and sentence formation) ; was development apparently normal, both physically and mentally? Health.—What illnesses has the subject had, at what .age, wi th what sequelae? How has he reacted to these illnesses? Age of puberty, any accompanying emotional or physical distur-bances. Subject's attitude to health and his estimate as to his habitual degree of health, overconcern and overcompen-sation. Previous Examination.— (a) Hospital and Blood Tests. (6) Clinic. Habits.—Eating—regularity of meals, amount, fussiness, any unusual reactions to foods. Sleeping—hours, regularity, disturbed, peaceful, etc. Elimination—infantile habits and training, any enuresis or constipation and methods' of treatment. Other habits — thumb-sucking, nail-biting, masturbation, tics and habit spasms, stuttering, stammering, and patient's reactions to these. Education.—Age when starting school, private or public; age at leav-ing, grade obtained, character of work, grades in which he failed promotion, difficult subjects, attitude toward school, special interests, right- or left-handed and history of changes. School report — previous psychological ratings — teacher's. opinions — co-operation of parents with school authorities. Has this subject stood out from other pupils in behaviour or attainments? Work.—Positions held, earnings, promotions; frequent changes, i f so, why? If discharged, why? I f resigned, why? Has he ever been interested in or satisfied with his work? If changing frequently, secure the names and addresses of the last two or three employers. Atti tude to responsibility at work and satisfaction from it. The economic status—debts, responsi-bilities, habits of saving. I f on relief, how long, work relief. Interest and Recreation. — The subject's interest in religion, art, theatre, literature, sports, clubs, etc., of an organized as well as the more spontaneous personal type. Amount of money for leisure time activities. Use of alcohol, tobacco, and drugs. (This section is most important in view of the breakdown in patients, of the appreciation and utilization of native or acquired assets through neglect or lack of opportunity and other unwholesome rut formations. A n important therapeutic . hint is hidden in the careful check of the interests and habits.) Personality.—The subject's estimate of himself—including wishes, day dreams, and remote ambitions — supplemented by the state-ment of others. Subject's personality previous to the develop-ment of the present problem. What were the subject's predominating characteristics — social and asocial? What personality changes has he shown and wheh did these changes become obvious? Expenditure of energy-—lively or inactive, sluggish or lazy, talkative or quiet. Habits of activity — Systematic, definite, consistent, efficient, practical or imprac-tical, desultory. Outgoing, friendly, good mixer or seclusive, shy and withdrawing, over-sensitive, cries easily, cheerful, B (1) FORMS IN USE BY THE CHILD GUIDANCE CLINIC composed or emotionally labile, irritable, obstinate, t imid, sulking, petulant, whining, tantrums or temper explosions, suggestible, holds grudges, affectionate, co-operative, abil i ty to get along with others, dependable, honest, mutually respectful, tolerant, personal appearance—cleanly, courteous, punctual, abili ty to take criticism. Marital Data.—Date and place of marriage; name, age, personality, occupation, religion, health, and apparent social standing of spouse, consanguinity; state whether marriage is happy or not. I f not, why? Sexual adjustment; relation of couple to parents on both sides. Army Service.—Regimental number; date of enlistment and rank, date of going overseas, dates and nature of illnesses or injuries while i n the service; pension; attitude toward service; date of discharge. Court Record. —P l a c e , date, charge, and disposition, and effect on subject's attitude. FAMILY HISTORY. Persons in the Home.—For each of the following persons give: age, education, health, outstanding personality traits, social be-haviour, adjustments to each other, attitude toward the subject being studied, and other pertinent facts, such as definite mental illnesses or other chronic systemic diseases for inherent biological patterns. Father.—Name, date and place of birth ( i f dead, give cause of death), race, religion, education, intelligence, occupations, health, war record, efficiency, habits, personality traits, any nervous or mental illness! Mother.—Maiden name in ful l , and same information as for father. Step-parents or Foster-parents, if any. Paternal and Maternal Relatives.—Record any outstanding known facts -as for parents. If any relatives have played important parts in the child's life, describe circumstances. Siblings.—Give names and ages in order of bir th; bir th date, includ-ing sti l l-births; and cause of death of a l l dead children. Fo r l iv ing siblings record, i f possible, school grade, occupation, behaviour, personality, health (note any "nervousness," retar- . dation, etc.); present whereabouts, attitude of each to subject. TENTATIVE SOCIAL PLAN. Havje you any other information which would be of value in making a social plan? What special help, financial, employment, or recreational, is available? How far w i l l relatives co-operate? AH histories should be signed by the worker and three copies submitted for clinics, but one only for hospital. 152. Appendix B (2) PHYSICAL EXAMINATION Doctor's name? Date of Examination: F i l e No Patient's Name: Bate of Birth: Height: Weight: APPEARANCE: Hair Eyes HEAD: Shape Size Injuries EYES: Vision Pupils Fundi EARS: Hearing Canals Drums NOSE: Septum Turbinates Discharge THROAT: Tonsils Enlarged Diseased MOUTH: Tongue Protrudes Teeth Enamel Gums NECK: Thyroid Enlarged Glands Enlarged URINALYSIS eoi. RESPIRATORY Inspection Reaction SYSTEM: Palpation Alb. Percussion Sug. Auscultation S.Go CIRCULATORY Inspection SYSTEM: Palpation Percussion Auscultation Pulse Rate V. R. T. B.p. Arteries ABDOMEN: Inspection Hernia Tenderness Rigidity Masses PRELIMINARY Speech Nerves NERVOUS SYMSTEM: Motor Sensory Tremors Co-ordination Reflexes Superficial Deep Babinski Oppenheim Rhomberg GAIT AND POSTURE: SKIN: EXTREMITIES: GENITO-URINARY: REMARKS: NURSES REMARKS: F181-40-500-149-7U2 ) 153. Appendix B (3) CHILD GUIDANCE CLINIC PLAYROOM OBSERVATIONS GENERAL: 1. Name of child, age and sex. Time of ar r i v a l , departure^ and absences from playroom. 2. Names, sex and relationship of adults accompanying the child. Age, sex and relationship of other children i n family party. Number and sex of other adults i n playroom. Number, age and sex of other children i n playroom. 3. Child's behaviour on a r r i v a l . How does he start to play? Describe play a c t i v i t i e s . How does he react to separation from parents? Other Children? How does he react to going home, etc.? Attitude of parent towards child and the child towards parents. The conversation of parent to child and the others waiting i n playroom regarding the child. SPECIFIC: 1. Energy - Over or under-active? Impulsive? Mischievous? 2. Social Habits - How does he get along with children? With Adults? Is he. shy? Polite? Seclusive? Need urging? Bold? Boisterous? Selfish? Show Off? Does he make a play for attention? Does he seem to prefer older or younger children, etc.? 3. Emotional Habits - Any evidence of instability? Easily moved to tears? Anger? Temper tantrums? Feelings easily hurt? Jealousy, etc.? 4. Work and Play Habits - Short span of interest and attention? Slovenly? Awkward? Neat? Dexterous? How does he react to suggestion and guidance, etc. 5. Physical Condition: Appear well, handicapped, etc. In what, manner does he compensate any physical handicaps, etc. 6. Other notes to suit peculiar situation. 154. Appendix B (4) Name; . . . . . . Address . . . . . Birthdate . . . . PSYCHOLOGIST'S REPORT . . • Date . . . School . . . . . . Grade Birthplace Sex Problem . Appearance: Attitude to Examiner and Test: Stanford Binet Form . Co-ordination: Handedness Mode of Reaction: Play-room Observation: 155. Tests Administered: Intelligence School Achievement Summary of Psychologist's Findings: « 2M-847-5338 Examiner. Appendix B (5) TESTS USED BY CLINIC PSYCHOLOGISTS IN THE VANCOUVER CHILD GUIDANCE CLINIC I Intelligence Tests 1. Wechsler-Bellevue Intelligence Test Forms I and II 2. Stanford-Binet Forms L and M 3. Cattell Infant Intelligence Scale U- Goodenough Intelligence Test 5. Kent Series of Emergency Scales 6. Porteus Maze - Vineland Revision 7. Nebraska Test of Learning ^ t i t u d e for Young Deaf Children 8. Chicago Non-Verbal Examination 9. Wechsler Memory Scale (sample) 10. Cattell Culture - free test II Personality tests 1. California Test of Personality Primary Series - Kind. Gr. 3 Elementary Series - Gr. 4-"9 Intermediate Series - Gr. 7-10 Adult Series - Gr. 9-college 2. Mental Health Analysis Elementary Series - Gr. 4--S Intermediate Series - Gr. 7-10 3. Thematic Apperception Test 4.. Bernreuter Personality Inventory - High School - College 5. Bell Adjustment Inventory Student Form Adult Form 6. Minnesota Multiphasic Personality Inventory - 17-adult. 157 7. Brown Personality Inventory for Children - 9-14 years. 8. Rogers Test of Personality Adjustment - 10 years. 9. Vineland Social Maturity Scale. 10. The Personal Audit - Sr. High School - adult 11. Problem Check L i s t III Vocational Tests INTEREST TESTS 1. Strong Vocational Interest Blank 2. California Occupational Interest Inventory 3. Kuder Preference Record - highschool - adult 4-. Primary Business Interests - highschool - adult 5. Brainard Occupational Preference Inventory (sample) Highschool - adult 6. Interest questionnaire for High School Students 7. Personal Test - Wonderlie (sample) 8. Hoppock Check Lis t for Self-Guidance (sample) 9. Hoppock Check L i s t for Occupations (sample) 10. Woman's Personnel Classification Test • APTITUDE AND ABILITY TESTS Clerical and Stenographic 1. Detroit Clerical Aptitude Test 2. Minnesota Clerical Test 3. N.I.IoP. Clerical Test Manual Dexterity Tests 1. Bennett-Hand-Tool Dexterity Test 2. Crawford Tridimensional Test of Special Relations 3. Minnesota Rate of Manipulation 158 4.. Purdue Pegboard 5. Tweezer Dexterity Mechanical Aptitude 1. Bennett Mechanical Aptitude 2. Detroit Mechanical Aptitude 3. Mac'Quarrie Test for Mechanical A b i l i t y 4-. Stanford Scientific Aptitude Tests • 5. Revised Minnesota Paper Form Board Miscellaneous Test of special aptitudes such as nursing, teaching, art judgment, etc. IV Achievement Tests  American School Achievement Tests 1. Form IA - Gr. 1 2. Form IIA - Gr. 2 and 3 3. Form IntA - Gr. 4-6 4. Detroit General Aptitudes Examination 5. Wide Range Achievement Tests Arithmetic 1. Stanford Arithmetic Test Primary - grades 2 and 3 Intermediate - grades 4-6 Advanced - grades 7-9 Reading and Vocabulary 1. dominion Achievement Tests in Silent Reading Word Recognition Phrase and Sentence Reading Paragraph Reading 159. 2. Grays Standardized Oral Reading 3. Haggerty Reading Examination - Gr. 1-3, Gr. 6-12 4. Monroe. Reading Form 1 tests 1 and 2 Form 2 Test 1 160 Appendix C (1) FORMS IN USE BY MENTAL HYGIENE CLINIC METROPOLITAN HEALTH COMMITTEE H 78 MLH Social and Family History Date 194-Name , Religion School Address . . . . . . Racial Origin Telephone Previous Addresses . Social Status (ChM, marital status, etc.) . . . . . . . . . . . . Social Service Exchange Record. . Family Physician. Referred by Sources of information Problem Family . -, Birth Date Birth School Place I Grade Reached Age of Leaving Occupation and notes Children s . . . . 1 ••••! Home Conditions; s o c i a l standards, type of neighbour-hood, others i n home. Relationships among  members of family Economic Security Developmental History Medical History Training Methods Attitude towards  Authority Social Adjustments Present d i f f i c u l t i e s  from family point of  view Information from  School Medical card Signature^ Nurse 162. Appendix C (2) H 81 M METROPOLITAN HEALTH COMMITTEE SCHOOL HISTORY Name School (Surname) Date of Birth Schools previously attended; Absences: Extent of . Reasons for Date of F i r s t Attendance (At any school). . . . . Present Grade Grades repeated Grades skipped Academic Achievement: (Standing this term with comments about achievement i n earlier grades.) Special A b i l i t i e s : Special Disabilities: DESCRIPTION OF CHILD'S PERSONALITY AND BEHAVIOUR Attitude towards Authority Participation i n Activities of own Age Groups Reaction to Success and Failure D i f f i c u l t i e s i n Behaviour Problem from Teacher's point of view Signature Ti t l e 164. Appendix C (3) METROPOLITAN HEALTH COMMITTEE Mental Hygiene Division Clinic No (For Central Office) PROGRESS REPORT Name Unit School . . . . . . . . ^hange i n Address (If any) Original Problem. Treatment RgCommended . . . . Treatment Carried Out or Factors That Interfered With Treatment . . . Progress and Present Status Reasons Case Closed Or Open . . Signature of Nurse Appendix C (A) H 50 M METROPOLITAN HEALTH COMMITTEE Name: Examined at: Clinic No: Addresses Bates of examinations 1. 1. 2. 2. 3. 3. A. A. Date of Birth: Age: Schools Attended: Birthplace: Sex: National Extraction: Started: Grades Age: Social Status: S. M. W. D, Sep. Reached: Grade: Age: Occupation: Psychometric Tests: Religion: Municipality: DATE C.A. M.A. I.Q. Years i n Municipality Years i n Canada: Referred by: Family Physician: Problem: Diagnosis: Physical Classification: Psychiatric Classification: Psychological Classification: Treatment: (l)This form i s used as a face sheet i n the Mental Hygienist's f i l e s . 166. Appendix D. SCHEDULE USED IN COLLECTING INFORMATION FROM CLINIC RECORDS Sources of referral. Reason for referral. Examining c l i n i c . Patient's Name Sex Age Intelligence Length of residence i n British Colubmia Ordinal position i n the family Parents' Racial Extraction Marital status (married, divorced, separated, common-law, widowed) Religion Number of children Presence of factors contributing to patient's maladjustment Absence of father while serving i n the Armed Forces Inadequate housing (poor or crowded) Interference of grandparents or other relatives l i v i n g i n the home *Patient School report Group adjustment Health Developmental history: birth to end of second year, third to sixth year, and later Age at time of f i r s t appearance of symptoms Interests and recreation Siblings - their adjustment, attitude toward patient Findings of c l i n i c a l examination Parents Age, education, occupation, marital adjustment, health, interests, general adjustment Attitude of each parent toward patient Family background Economic security Home conditions 4 This part of the schedule was used for the 20 per cent to the sample (52 cases) only. Previous section of schedule was used for the 257 cases 167. Recommendations of c l i n i c Extent to which recommendations were carried out i n follow-up work. Progress reports. 168. •ppendix E BIBLIOGRAPHY GENERAL REFERENCES Books All e n , Frederick H., Psychotherapy with Children, W.W. Norton & Co. Inc. New York, 1942. Bowley, Agatha H., The Psychology of the Unwanted Child . E. and S. Livingstone Ltd., Edinburgh, 1947. Crothers, Bronson, A P e d i a t r i c i a n i n Search of Mental Health, The Commonwealth Fund, New York, 1937. English, 0., and Pearson, G.H., Common Neuroses of Children and Adults, W.W. Norton and Co., New York, 1937. English, 0., and Pearson, G.H., Emotional Problems of Li v i n g , W.W. Norton and Co., New York, 1945. Ewen, John H., Mental Health, Edward Arnold and Co., London, 194-7. Harms, Ernest, ed., Handbook of Child Guidance, Child Care Publications, New York, 1947. Kanner, Leo, Child Psychiatry, Charles C. Thomas, Springfi e l d , 111., 1946. Lewis, Nolan D. and Pacella, Bernard L., editors, Modern Trends i n Child Psychiatry, International University Press, New York, 1946. Rennie, Thomas A.C., and Woodward, Luther E., Mental Health i n Modern  Society, The Commonwealth Fund, New York, 1948. Ribble, Margaret A., The Rights of Infants, Columbia University Press, New York, 1943. Strecker, Edward A., Beyond the C l i n i c a l Frontiers, W.W. Norton and Co., Inc. 1940. T r u i t t , Ralph p., The Child Guidance C l i n i c and the Community, The Commonwealth Fund, New York, 1928. Witmer, Helen L., ed. Psychiatric Interviews with Children, The Commonwealth Fund, New York, 194-6. Pamphlets, A r t i c l e s , Reports G r i f f i n , J.D.M., "Mental Hygiene i n Canada" Canada's Health and Welfare, Sept., 1946. Hincks, Clarence M., "Conserving Mental Health i n Canada" Canadian Journal of Public Health, July, 1947. L o u t t i t , CM., "The School as a Mental Hygiene Factor" Mental Hygiene Vol. 31. January, 1947. Ryther Child Centre, Monograph on Organization and Operation, Seattle, 1946. U.S. Children's Bureau Helping Children i n Trouble Publication 320, 1947. 169. SPECIFIC REFERENCES Books Bowley, Agatha H., The Problems of Family L i f e , E. and S. Livingstone Ltd., Edinburgh, 194-6. French, Lois M., Psychiatric Social Work, The Commonwealth Fund, New York, 1940. H a l l , Muriel B,, The Psychiatric Examination of the School Child, Edward Arnold and Co., London, 1947. Hamilton, Gordon, Psychotherapy i n Child Guidance', Columbia University Press, New York, 1947. Jewish Board of Guardians, The Caseworker i n Psychotherapy, Jewish Board of Guardians, New York, 194-9. Lowrey, Lawson G., Psychiatry f o r Social Workers, Columbia University Press, New York, 1946. Menninger, William C, Psychiatry: I t s Evolution and Present Status, Cornell University Press, Ithaca, New York, 1948. Rogers, Carl, The C l i n i c a l Treatment of the Problem Child Swift, Sarah H., Training i n Psychiatric Social Work, The Commonwealth Fund, New York, 1934. Towle, Charlotte, Social Case Records From Psychiatric C l i n i c s , University of Columbia Press, Chicago, 1941. Witmer, Helen L., Psychiatric C l i n i c s for Children, The commonwealth Fu Fund, New York, 1940. A r t i c l e s , B u l l e t i n s and Pamphlets B i r d , Brian, "Mental Health i n Canada" The Canadian Forum, May, 1947. B l a i n , Daniel, "Some Essentials i n National Mental Health Planning" B u l l e t i n of the Menninger C l i n i c , Nov. 1946. I l l i n o i s Children's Home and Aid Society, Plans f o r an I n s t i t u t i o n for the Treatment of Emotionally Disturbed Children, Chicago, 1946. Laabs, Alma, "Development of Social Work i n Education", The Compass, March 1945. Laabs, Alma, "When the School Child i s i n Trouble", The Child, Dec. 1947. Lowrey, lawson G., "Psychiatry for Children" American Journal of Psychiatry, Nov, 1944. Price, Morrish H. and Feldman, Yonata, L., "A Study of Re-opened Cases". The Family, June 1942. Reports "Annual Report of the So c i a l Welfare Branch of the Province of B r i t i s h Columbia for the year 194-7-48". Gundry, C.H., "Annual Report to the Metropolitan Health Committee of Vancouver" 1946, 1947 and 194-8. Report of Winnipeg Child Guidance C l i n i c , 1948. 170. Other Studies Thompson, Mary A., The Social Worker i n the School University of B r i t i s h Columbia thesis, 194-8. Munro, Marjory H., A General Survey and Evaluation of an I n s t i t u t i o n for the Observation and Treatment of Problem Children, University B r i t i s h Columbia thesis, 1946. 

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