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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 C l i n i c s i n Vancouver from 1945 to 1947 i n c l u s i v e  by Evelyn Marie Roberts  Thesis submitted i n P a r t i a l Fulfilment of the Requirements f o r the Degree o f MASTER OF SOCIAL WORK i n the Department of S o c i a l Work  1949 University o f B r i 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 viewpoint 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 intelligence 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 crosssection 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 proportion 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 disorganization 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 C l i n i c and the schools would be b e n e f i c i a l . The enlargement o f the Mental Hygiene C l i n i c s t a f f t o include s o c i a l workers would r e s u l t i n a better integrated c l i n i c a l service. A t h i r d p s y c h i a t r i s t on the C h i l d Guidance C l i n i c s t a f f would overcome some of the present lacks i n c l i n i c services. A treatment and observation centre f o r emotionally disturbed children i s greatly needed i n t h i s community. In many instances, s t a f f members o f s o c i a l and health agencies responsible f o r the preparation o f s o c i a l h i s t o r i e s would benefit from b r i e f c l i n i c a l o r i e n t a t i o n and discussions with the members o f the c l i n i c team on the subject of h i s t o r y taking. The addition of a group worker to c l i n i c teams would enhance the services to maladjusted c h i l d r e n .  ACKNOWLEDGEMENTS  I wish to acknowledge great indebtedness to Dr. &.L. Crease, P r o v i n c i a l Psychiatrst, and Dr. C.H. Gundry, Director of the Mental Hygiene D i v i s i o n of the Metropolitan Health Committee f o r their permission to u t i l i z e the c l i n i c records f o r research purposes. I am also indebted to Dr. U.P. Byrne, Director o f the Child Guidance C l i n i c , and to Dr. C.H. Gundry f o r t h e i r 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 S o c i a l Work who gave generously of h i s time and professional advice during the preparation of t h i s study.  TABLE OF CONTENTS  Chapter 1.  Child Guidance  Clinics  The development of c h i l d guidance.Contributions of Meyer, Freud, and Rank. Varying conceptions of the role of the c l i n i c i n r e l a t i o n to parents of children. Goals and methods of treatment. Chapter 2.  The C l i n i c s i n Vancouver  P o l i c i e s , functions and procedures of the C h i l d Guidance C l i n i c and the Mental Hygiene C l i n i c . Work loads of each of the c l i n i c s . Chapter 3.  The patients and Their Families  Sources of r e f e r r a l . D i s t r i b u t i o n o f cases according to symptoms presented, and age, sex, i n t e l l i g e n c e , etc., of patients. Family disorganization f a c t o r s . R a c i a l o r i g i n , r e l i g i o n , residence of parents. Size of f a m i l i e s and o r d i n a l p o s i t i o n of patients. Chapter 4.  Social Histories  The purpose o f a s o c i a l h i s t o r y . Data concerning children and t h e i r parents revealed i n the h i s t o r i e s . Gaps i n the s o c i a l h i s t o r i e s . Chapter 5.  S o c i a l l y Unacceptable Behaviour  Incidence of symptoms i n various age groups. S o c i a l disorganization factors. High incidence of unfavourable circumstances i n f i r s t three years of p a t i e n t s l i v e s . Case i l l u s t r a t i o n s . 1  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 d i s c i p l i n e . Case i l l 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 f a m i l i e s . Marked parental discord as a contributing f a c t o r . Case i l l u s t r a t i o n s . Chapter 8.  Children Showing D i s a b i l i t i e s i n School Subjects  Incidence i n various age groups. Less evidence of family and s o c i a l disorganization factors. High incidence of unfavourable c i r cumstances during the f i r s t three years. Case i l l u s t r a t i o n s .  Chapter 9.  Recommendations and Results  Five c l a s s i f i c a t i o n s o f approaches to treatment. indicated i n c l i n i c records. Chapter 10.  Results as  Future Goals  C l i n i c expansions during the post-war period. Need f o r improved community resources. Public r e l a t i o n s of c l i n i c s . S o c i a l case work i n the schools, and i n the Mental Hygiene C l i n i c . Extension of treatment services. Group work representation on c l i n i c teams.  Appendices: A. B. C. D. E.  Mental Health C l i n i c s i n Canada Forms i n use by the C h i l d Guidance C l i n i c Forms i n use by the Mental Hygiene C l i n i c Schedule used i n c o l l e c t i n g information from c l i n i c records Bibliography  TABLES AND CHARTS IN THE TEXT (a) Table  1.  Table 2.  Tables  Page  D i s t r i b u t i o n of Cases by Examining C l i n i c and Problem Referred  28  D i s t r i b u t i o n of Cases by Source of Referral  29  Table  3.  Boys and G i r l s i n Various Groupings  32  Table  A.  D i s t r i b u t i o n of Cases by Age  35  Table  5.  D i s t r i b u t i o n of Cases by Intelligence Level  36  Table  6.  D i s t r i b u t i o n of Cases by Family Disorganization Factors  4-0  Table  7.  D i s t r i b u t i o n of Cases by Other Contributing Factors  41  Table  8.  D i s t r i b u t i o n of Cases by Size of Family  42  Table  9.  D i s t r i b u t i o n of Cases by Ordinal Position i n Family  A3  Table 10.  D i s t r i b u t i o n of Cases by Length of B r i t i s h Columbia Residence  AA  Religious Denominations  46  Table 11.  Page Table 12.  Parents' Formal Education  50  Table 13.  School Record  63  Table 14. Frequency of Types of Recommendations Made at Clinic  Table 15.  Conferences  122  Adjustment Status of Patients  131  (b) Fig. 1. Fig. 2.  Charts  Distribution of Cases i n Both Clinics According to Age Proportion of Cases i n This Studytothe Total Number  26  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. ( A l l private cases 6 to 12 years - 1947)  38  1 CHAPTER 1.  CHILD GUIDANCE CLINICS  Psychiatric c l i n i c s f o r children on t h i s continent have passed through three main phases of development.  The f i r s t of these was the  early work of mental h o s p i t a l s and schools f o r the feeble minded.  This  was concerned c h i e f l y with reducing the number of admissions to i n stitutions.  The c l i n i c opened i n 1897 under the d i r e c t i o n of Dr. Walter  Channing a t the Boston Dispensary marking the beginning of c l i n i c a l work with children.  Dr. Channing was p a r t i c u l a r l y interested i n the problem  of feeblemindedness.  Other state h o s p i t a l s began t o offer c l i n i c ser-  v i c e s , and by 1914 i n both New York and Massachusetts, provision was made f o r the establishment of out-patient departments and c l i n i c s i n each h o s p i t a l .  Each of these was to serve as the mental health centre  in i t s district.  However, most of these e a r l y 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 f o r 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 h i s associates i s given c r e d i t f o r the inauguration of the f i r s t coordinated e f f o r t i n c h i l d guidance i n 1909. with the Chicago Juvenile Court.  This was i n connection  Healy's work created a wide-spread  i n t e r e s t i n c h i l d l i f e and there was r a p i d growth i n the number of c l i n i c s functioning with courts, schools, general hospitals, medical schools and mental h o s p i t a l s .  Most of these i n t h e i r 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 Commonwealth 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 undertaken 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 i s : 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 life history, his intellectual and physical equipment in order to understand his disorder, was an important contribution. To Freud, child guidance owes three important concepts, 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 unconscious 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 emphasized the constructive capacities of the human w i 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 difficulties.  He may meet conflicts by striking out at himself or at his  environment; he may try to deny them by withdrawing from reality and manufacturing 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 life 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 will respond to the new internal situation after each successive attempt to satisfy his needs. Tre tment of symptoms, without alleviation of either the ina  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 fourfold 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 expected 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 treatment 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 possible, 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.personality 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 t o divergent conceptions about the r e l a t i o n 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 i n s t i t u t i o n s have t r a d i t i o n a l l y operated more f o r the benefit of society than f o r t h e i r patients.  Their s o c i a l ob-  j e c t i v e s are the protection of society from further inconveniences and damage.  Early c l i n i c s became another part i n the i n s t i t u t i o n a l apparatus  of schools, churches, courts, etc., which moulds the i n d i v i d u a l t o soci e t y ' s needs. The f i r s t c l i n i c s dealing with mentally defective and a n t i s o c i a l 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 d e c i s i o n t o en-  l i s t the c l i n i c ' s help was not l e f t to persons most immediately concerned, namely, the patients and t h e i r parents, but came u s u a l l y from those who found the children troublesome, such as schools, courts, and s o c i a l agencies.  Therefore, many came to c l i n i c under authoritative pressure  and consequently were not i n c l i n e d to be cooperative. The c l i n i c interpreted i n terms of the removal of objectionable behaviour.  was It is  hard f o r such c l i n i c s to reinterpret t h e i r objective, because patients and parents s t i l l f e e l that they have no choice as t o whether they attend c l i n i c or not. (•^Witmer, Helen Leland, Psychiatric C l i n i c s f o r Children, New York, The Commonwealth Fund, 1940, PP. 353-366.  8 An a l t e r n a t i v e point of view about c h i l d 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 h i s own kind of adjustment, l e s s handicapped by emotional turmoil.  This approach recognizes that there are  many ways i n which i n d i v i d u a l s f i n d s a t i s f a c t i o n i n l i f e .  I t also  recognizes that there are many circumstances beyond the c l i n i c ' s cont r o l which influence the patient's a b i l i t y t o desire professional s k i l l s of c l i n i c i a n s and to benefit from them.  This i s based on the b e l i e f  that under reasonably favourable circumstances each i n d i v i d u a l human being contains within himself forces that favour s o c i a l adjustment. According t o Freud, the demands of society are not a l i e n to the c h i l d exposed to favourable conditions, but rather early i n h i s l i f e become an i n t e g r a l part of h i s personality. only be helped to f i n d h i s own  Dr. Rank holds that the patient can  solution to h i s d i f f i c u l t i e s , and that  the t h e r a p i s t "must r e f r a i n from moral evaluation of every kind". C l i n i c s which accept these theories of i n d i v i d u a l needs and capacities do not become a part of the network of regulative i n s t i t u t ions which attempt to adjust children to accepted s o c i a l standards. Such c l i n i c s seek recognition i n the community as the agency of those i n d i v i d u a l s who  desire t h e i r 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 c h i e f l y 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 f o s t e r homes or i n s t i t u t i o n s , or attempt to remodel the old onej the l a t t e r may  be done by modifying parental attitudes or r e l i e v i n g t h e i r  tension, i n t e r p r e t i n g the c h i l d to h i s 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 f i n d new  outlets f o r the patient's energies or capacities, by the  b u i l d i n g up of new r e c r e a t i o n a l i n t e r e s t s , f o s t e r i n g 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 f i n d sucdess. A t h i r d method i s that of remedying the patient's s p e c i f i c d i s a b i l i t i e s , physical and i n t e l l e c t u a l , that i s , of removing certain s p e c i f i c i n t e r n a l obstacles so that he i s put on a par with h i s fellows.  A fourth pro-  cedure i s that of d i r e c t dealing with the patient's psychic problems, the methods varying with the d i f f e r e n t t h e r a p i s t s .  This approach i s  based on the assumption that the patient can make h i s own adjustment i f he i s helped to overcome to some extent h i s anxieties and h i s f e a r s . p r a c t i c e most c l i n i c s use a combination of these four approaches. who  In  Those  tend to emphasize s e l f - d i r e c t i o n f o r the patient tend t o favour  psychotherapy. C l i n i c i a n s of most schools agree that the f i r s t l m i n therapy a  i s to create a s i t u a t i o n i n which the patient i s free to express what he w i l l without the usual danger of i n c u r r i n g disapproval. vironment i s the t r a d i t i o n a l mental hygiene method.  T  Modifying  en-  he Mental Hygiene  movement o r i g i n a l l y aimed at providing a more understanding environment f o r the psychotic patient, and eventually moved i n t o the f i e l d of c h i l d guidance because i t found that some of the conditions presumably leading  10 to psychoses were to be found in the misunderstandings and other environmental 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 environment 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 i e 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 child s feelings and desires. 1  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 p a t i e n t s . The c l i n i c a l i n t e g r a t i o n of the c o n t r i b u t i o n s of p s y c h i a t r y , p h y s i c a l medicine, psychology and s o c i a l work i n the study of maladjusted c h i l d r e n 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 s h e d i n Toronto through the Canadian branch of the N a t i o n a l Committee f o r Mental Hygiene.  I t was a part of the Commonwealth Fund program of  s e t t i n g up demonstration c l i n i c s .  Since then, c h i l d guidance or mental  h e a l t h c l i n i c s have been established i n a l l provinces i n Canada except Prince Edward I s l a n d and New Brunswick. (1) A u n i v e r s a 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 s u l t i n g curtailment of  s e r v i c e s during a time when many c h i l d r e n as w e l l as a d u l t s were exposed t o greater emotional s t r a i n s created an increased demand on c l i n i c f a c i l i t i e s as the nation emerged i n t o the post war p e r i o d .  Undoubtedly  experience of s t a f f members who had been engaged i n p s y c h i a t r i c work i n the armed services was i n v a l u a b l e i n t h a t the r e s u l t s of childhood maladjustments were demonstrated again and again i n d e a l i n g w i t h s e r v i c e personnel who needed treatment f o r p s y c h i a t r i c d i s o r d e r s .  R e j e c t i o n as  w e l l as discharge revealed a high percentage of severely maladjusted adults.  I n the words of D r . J.H.W. van Ophuijsen, Chief of the P s y c h i a t -  r i c C l i n i c of Lenox H i l l H o s p i t a l "the war has shown w i t h c r u e l c l a r i t y how s i c k a n a t i o n can be and has unmistakably i n d i c a t e d t h a t a f t e r  the  f i g h t against t u b e r c u l o s i s , 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 t o be the p s y c h i a t r i c d i s o r d e r , i n the f i r s t place i n the form of psyche-neurosis. ( 1 ) 11  ^ 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 r e a l i t i e s . «(D  The home, the school and  the community each have important roles i n 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 symptoms of unsatisfactory deviation i n mental and emotional development. The Provincial Child Guidance Clinic was opened i n 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 i n 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 desired.  Other than surveys of work loads for annual reports, there has  been no research in- either c l i n i c .  Directors of both services welcomed  a study of c l i n i c cases, and f i l e s were readily made available for this purpose. ^ W h i t e House Conference on Child Health and Protection quoted by National Committee for Mental Hygiene, Mental Hygiene Bulletin. JanuaryFebruary 1931, page 1. (2)ihis refers to Greater Vancouver, throughout this study unless otherwise indicated.  14. The P r o v i n c i a l C h i l d Guidance C l i n i c This c l i n i c was formed i n Vancouver a f t e r a request by the P r o v i n c i a l P s y c h i a t r i s t t o the National Committee f o r Mental Hygiene f o r help i n a program f o r the prevention of mental i l l n e s s .  The Committee  was instrumental i n obtaining the s e r v i c e s of the f i r s t p s y c h i a t r i c s o c i a l worker and paid her s a l a r y for one y e a r . c l i n i c team f i v e years l a t e r . only.  A psychologist was added t o the  A t f i r s t the c l i n i c was open f o r half-days  The services have expanded g r e a t l y i n the i n t e r v e n i n g p e r i o d . The Vancouver C h i l d Guidance C l i n i c operates throughout the  week.  Usually 18 complete examinations per week are made.  The p a t i e n t s  come from Vancouver, North Vancouver, West Vancouver, and Burnaby. P a t i e n t s from New Westminster, r e f e r r e d by S o c i a l Welfare Branch only, are a l s o examined.  During the years 1945-47 i n c l u s i v e the number of  p a t i e n t s given f u l l c l i n i c a l examinations a t 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 c h i l d r e n who are given c l i n i c a l examinations range between the age of 6 months and 18 y e a r s .  Adults whose maladjustments may con-  t r i b u t e t o emotional disturbance of c h i l d r e n are frequently the subject of c o n s u l t a t i v e conferences between the r e f e r r i n g agency and the c l i n i c . In a l i m i t e d number of cases, such a d u l t s are examined a t  clinic.  The c h i l d r e n studied at C h i l d 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 c h i l d r e n who  express t h e i r l a c k of adjustment i n symptoms of various k i n d s , i n the home, the school or the community.  These  symptoms may take the form of  undesirable h a b i t s , p e r s o n a l i t y t r a i t s or behaviour. ( ) B y r n e , U . P . , " C h i l d Guidance C l i n i c s 1  n  I n the second group,  typewritten interdepartmental paper.  15 are  the  "dependent"  c h i l d r e n , who b e c a u s e  neglect  of parents,  o r homes b r o k e n b y d i v o r c e ,  during  their  foster  homes.  lectual the  Lastly,  the  ment after  there  services  diagnosis  diagnosis,  they  (3)  are  direction  psychiatrist.  private  patients^)  or f o r  institutions  social This  patients  or  will  or intel-  successfully  in  them.  C h i l d Guidance C l i n i c  are  (1947-48)  described  (1)  as  treat-  Treatment cases are. those i n which  seen by the  or by c l i n i c  the  work r e q u i r e d o f  consultation.  patients  or death  compete  S o c i a l Welfare Branch  interview basis, of  are unable to  g i v e n by the the  abandonment  c h i l d r e n who show r e t a r d a t i o n i n  intellectual  Annual Report of  (2)  are  such t h a t  ordinary types of  in  desertion  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,  development  The  of i l l e g i t i m a c y ,  psychiatrist  on a  treatment-  workers and p s y c h o l o g i s t s service  is  available for  r e f e r r e d by agencies  under the  on a  the  clinic's  co-operative  basis.( ) 2  C h i l d Guidance C l i n i c agencies  or by m e d i c a l and h e a l t h  Each  " c h i l d and h i s  trie  and p s y c h o - s o c i a l  blems  cases r e f e r r e d to  situation  is  diagnosis  agencies are studied is  contained within these areas  Clinic,  however,  has  no a c t i v e  the  c l i n i c by  given diagnostic  i n whole  or i n p a r t ,  made a n d p o s s i b l e  part i n the  subsequent  service.  a psychia-  solutions  are then presented.  social  to  pro-  The C h i l d Guidance progress  of  the  (1)Private p a t i e n t s a r e those r e f e r r e d t o c l i n i c not by s o c i a l or h e a l t h agencies but by t h e i r parents, p r i v a t e p h y s i c i a n s , speech t h e r a p i s t s , kindergartens, etc.  (2) Cases presented  for  c l i n i c a l examination and found t o  intensive  p s y c h i a t r i c treatment,  regularly  at  to  give  other  the  clinic.  services  to  are i n  The a g e n c y the  child  be i n need  some i n s t a n c e s ,  making the and h i s  *  referral  family i n  of  interviewed may  such  continue  cases.  16. case.  The value of t h i s service depends on the responsible agency ade-  quately equipped t o make the s o c i a l study, t o make use of the c l i n i c ' s findings, and to carry out the c l i n i c ' s p s y c h i a t r i c recommendations. In the diagnostic service, treatment i s delegated by the c l i n i c p s y c h i a t r i s t i n conference to the r e f e r r i n g agency. A consultative service i s one i n which the c l i n i c ' s services are given t o any person interested i n the c h i l d , but where there may be no actual contact on the part of the c l i n i c with the c h i l d .  S o c i a l and  health workers have used the service t o discuss the p s y c h i a t r i c problems of t h e i r c l i e n t s with the p s y c h i a t r i s t 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 C l i n i c  f o r Family Welfare Bureau or Children's A i d Society consultations.  Such  conferences are arranged f o r other agencies when requested. (2) There are f i v e procedures within the C h i l d Guidance C l i n i c , i n the study of patients, namely, the s o c i a l h i s t o r y , the physical, psychol o g i c a l and p s y c h i a t r i c examinations and the conference. In the s o c i a l h i s t o r y a v i v i d picture of the c h i l d l i v i n g with h i s parents or f o s t e r parents, i n h i s home, school and community i s desirable.  A p s y c h i a t r i c s o c i a l h i s t o r y o u t l i n e ^ ) i s provided by the  "Annual Report 1947-48", Welfare Branch of the Department of Health and Welfare. King's P r i n t e r , V i c t o r i a , 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 h i s t o r y  (one f o r each member of the c l i n i c team) should be received at c l i n i c a t l e a s t 2 days p r i o r t o the examination.  In compiling the s o c i a l h i s t o r y ,  the s o c i a l worker describes the various aspects of the c l i n i c a l examination, i n order that the parents may prepare the c h i l d f o r the new perience of attending c l i n i c .  ex-  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 r e c e p t i o n i s t several days before t h e i r appointment date. The physical examination(^) i s necessary i n recognizing those cases i n which the disturbance i s due to organic l e s i o n 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, b i r t h marks and other d i s f i g u r i n g features which may have a damaging psychological e f f e c t on the c h i l d . The c l i n i c nurse prepares each patient f o r the physical exami n a t i o n , 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 t e s t (speaking v o i c e or audiometer), weighing, measuring, and u r i n a l y s i s are done by the nurse.  Following these t e s t s ,  the nurse a s s i s t s the p s y c h i a t r i s t with the physical examination. The physical room a t the c l i n i c i s set up to appear l e s s austere than a general h o s p i t a l examining room.  The p s y c h i a t r i s t does  not don the t r a d i t i o n a l 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 f a s t rules regarding l y i n g f l a t on the examination t a b l e , undressing completely, or saying "ah".  When treatment of physical defect  i s recommended, the child's parents or guardians are referred t o 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 h i s behaviour. These observations which are usually made over a longer period of time and under circumstances 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 evaluation of the child's innate a b i l i t i e s , educational achievements and special aptitudes.  In making t h i s 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 t o predict within certain l i m i t s 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) ( ) Appendix B U) 2  (^Appendix B (5) l i s t s the tests used by psychologists at the Child Guidance C l i n i c .  19.  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 initial 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 prospects of attaining them. This may involve a decision to use direct therapy, treatment of one or both parents, manipulation of the environment or a l l three. All plans are subject to revision i f changing circumstances 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 hygieni s 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 b e l o w . ^ The object of the program of the Mental Hygiene D i v i s i o n i s the promotion of mental health.  Types of problems s u i t a b l e f o r study by the c l i n i c are  outlined as follows: "Poor group adjustment - timid, insecure children the nervous c h i l d . Poor a t t i t u d e toward authority - dependent, unresponsive children, disturbing behaviour. Physical disturbances associated with emotional tension - t i c s , speech defects, unco-ordinated movements. Presence of neurotic symptoms - tendencies t o make use of symptoms to evade challenging s i t u a t i o n s . Delinquency problems - s t e a l i n g , l y i n g , truancy, begging, etc.'! School nurses are expected to consider that problems of behaviour 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 correction of early f a u l t s i s emphasized as a means of future health.  Parents,  as well as nurses may  the  safe-guarding  school medical o f f i c e r s , teachers, and  others  make r e f e r r a l s t o the c l i n i c .  C l i n i c s are held i n the o f f i c e s 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 u n i t .  (2) Teachers wishing to have children examined at c l i n i c discuss the matter with t h e i r principals. (1) Nurses' Manual "Metropolitan Health Committee F a c i l i t i e s f o r Diagnosis, Treatment or Consultation". Gundry, C.H. - Memorandum f o r Directors of Units, Metropolitan Health Committee, and School P r i n c i p a l s . Re Mental Hygiene C l i n i c s , 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 consent 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 purpose 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 counsellor) . Written reports are also sent to social agencies and to private physicians in cases in which they are concerned. Six months after the. i n i t i a 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 patients 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 will need a l l of the services discussed in connection with the "average" children. Besides these they may need additional services. 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 inquiry, but may be referred to where relevant. A detailed study of faci l i t i e s 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 t o t a l number of cases examined by the two c l i n i c s during the years 1945-47 i n c l u s i v e , which met c r i t e r i a outlined above was 257* In t h i s general survey, the following points were noted:  age of c h i l d , pre-  senting problem, address, length of c h i l d ' s residence i n B.C., source of r e f e r r a l , i n t e l l i g e n c e r a t i n g , number i n family, ordinal p o s i t i o n i n family, r a c i a l extraction, r e l i g i o n , and marital status of parents (married, common-law, divorced, separated, deceased), absence of father from home i n m i l i t a r y 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 a t t i t u d e s contributed t o maladjustment. These 257 cases were c l a s s i f i e d according t o the problems which l e d t o the patients being referred to the c l i n i c s examination.  The  c l a s s i f i c a t i o n s were (1) s o c i a l l y 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  f i v e cases i n each of the above-mentioned categories was selected a t random, and a more d e t a i l e d s t u d y ^ of t h i s 20 per cent sample was made.  (•^The schedule used i n c o l l e c t i n g 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.  26.  H P .  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 A c c o r d i n g t o Ape.  1.  C.G.C.  ( 1 U 0 )  Children  Adults  19Af> - LI  (inclusive) M.H.C. 19^.6  U] M  l  d  (  U  7  )  A  d  u  I  t  s  ( 9 )  -a  (inclusive)  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  Fig.  2. to  P r o p o r t i o n o f C a s e s i n This Studyt h e T o t s ] Number o f ^ h i I d r e n , E x a m i n e d .  , > 1. 1  ''! 11  (1600)  (116) (141) Legend Child  Guidance  Clinic  Mental Hygiene  Clinic  Cases o u t s i d e  limits  o f survey  Figure 2 shows the proportion of children surveyed i n t h i s study t o the t o t a l 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 f o r t h i s study.  28  CHAPTER 3. THE CLINIC PATIENTS AND  THEIR FAMILIES  In the period covered by t h i s study (1945-1947 i n c l u s i v e ) the number of elementary school children of at l e a s t normal i n t e l l i g e n c e received c l i n i c a l p s y c h i a t r i c examinations was 2 5 7 * O f  who  these, approx-  imately 55 per cent were examined at the M e n t l Hygiene C l i n i c . a  Because  the bulk of t h i s 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 C l i n i c i n a period of 3 years.  Not only because the  Child Guidance C l i n i c examines children as young as 6 months, but a l s o because much of i t s time was devoted t o "dependent" children, there were comparatively fewer C h i l d Guidance C l i n i c cases which came within the scope of t h i s study. Table 1  DISTRIBUTION OF CASES BY EXAMINING CLINIC AND PROBLEM REFERRED  Personality Habit Examining Socially School Total C l i n i c Unacceptable Reactions Disorders D i s a b i l i t i e s Behaviour  p.c.  M. H. C.  42  48  23  28  141  54.86  C. G. C.  58  32  16  10  116  45.14  100  80  39  38  257  100.00  Total  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 l i m i t s of the c r i t e r i a f o r s e l e c t i o n 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 School Source of Socially Personality Habit Total p.c. Referral Unacceptable Reactions Disorder Disabilities Behaviour 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  0  0 38  Health 2 0 Agencies Total 100 80 ft Bureau of Measurements. ±k Family Welfare Bureau  39  .78 2 257 100.00  30. It is encouraging to note that parents referred 20 per cent of these children. This is the highest percentage among 13 sources of referral. However, i f persons connected with the school system, namely, principals, 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 maladjustment.  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 initiative 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 examination 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 examinations 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 companions, 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'fclessness, 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 diffi-  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 disability. 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 unacceptable behaviour, although he may also have presented a habit disorder 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  105 74.56  36  Total  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  77 66.38  39  Total  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 similarly disproportionate number of boys in the school population.^ Moreover, this survey of Vancouver's clinic patients bears a marked similarity 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 population. 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.  34of 500 children examined by the Institute of Juvenile Research in Chicago^) included 62 per cent boys. "Delinquent" populations, as reflected in juvenile court statistics, reveal an even greater disparity between the sexes in social adjustment. 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 cultural 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 ± 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. n  35. Table 4  DISTRIBUTION OF CASES BY AGE  School Ages of Socially Personality Habit Total p.c. Patients Unacceptable Reactions Disorders Disabilities Behaviour 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  39  37  Total  100  80  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 average of over 550 more pupils per year i n 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 recognized 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 maladjustment 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  School Intelligence Socially Personality "Habit Total p . c Quotients Jnacceptable Reactions Disorders Disabilities Behaviour 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  2  7  2  0  11  4.28  100  80  39  38  Not Stated (but apparently average) Total  257 100.00  37.  The  i n t e l l i g e n c e quotients of the patients ranged from 80 (the  lower l i m i t set i n selecting cases) t o ] S l .  The 4-28 per cent of the  cases, i n which the i n t e l l i g e n c e was not stated, but was apparently a t l e a s t average, were cases examined by the Mental Hygiene C l i n i c where routine psychological t e s t s were not always given.  In summary then,  approximately 84. per cent of the patients had average i n t e l l i g e n c e . The d i s t r i b u t i o n of various i n t e l l i g e n c e l e v e l s of c l i n i c cases shown i n Figure 3 bears a marked contrast to the theoretic d i s t r i b u t i o n of i n t e l l i g e n c e as shown i n Figure 4.  Fig. 3. I.Q. 140 & o v e r t 120 - 139 110 - 119 90-109 . 80 - 89 not stated  Distribution of Cases by Intelligence 10 p.c.  Legend C  Fig. U. I.Q. 1/.0 & over • 120 - 139 • 110 - 119 • 90-109 • 80-89 m 70-79 • Below 70 •  20 p.c.  30 p.c.  Levels.  10 p.c.  50 p.c.  Child Guidance C l i n i c Mental Hygiene C l i n i c  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 distribution. A comparison of the proportion of children of "low average" intelligence to those of "average" intelligence shows that the former comprise 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 Vancouver clinics represent a cross-section of the general population with regard to intelligence. There is a marked tendency toward a largerthan-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 children 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 o f C h i l d Guidance C l i n i c  Cases.  ( A l l p r i v a t e c a s e s , c h i l d r e n 6 t o 12 y e a r s - 19A7)  I.Q. 110 6 over  10 p.c. • • • •  120 - 139 • • • • » • •  20  p.c.  30  p.c.  AO  p.c.  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 maladjustment may show up in poorer academic progress. This theory can be substantiated by the Child Guidance Clinic case records of numerous private 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 i n t e l l i g e n c e t e s t i n the classroom.  In an i n d i v i -  dual t e s t given a f t e r several v i s i t s t o the Child Guidance C l i n i c , she was found t o have an I.Q. of 155. One of the outstanding features of the study of the f a m i l i e s of which the 257 patients were members i s that, i n one out of every 3 serious f a c t o r s of f a m i l y disorganization were considered by the examining psyc h i a t r i s t s t o have affected the personality development of patients. Table 6  DISTRIBUTION OF CASES BY FAMILY DISORGANIZATION FACTORS  Factors  Marked Parental Discord  Personality Habit School Total Socially Unacceptable Reactions Disorders D i s a b i l i t i e s Behaviour  7  7  7  3  2A  11  A,  A  1  20  Father Deceased  6  3  1  1  11  Desertion  6  1  -  7  Separation  3  2  -  1  6  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  AO  27  13  6  86  Divorce  Common Law  Total  (1) Only includes cases i n which mother's i n s e c u r i t y about t h i s type of marriage affected c h i l d r e n .  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 t h i s f a c t o r was noted.  In 7.78 per cent parents were divorced.  In many of these, there were i n -  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 r e s u l t i n g i n mother's i n s e c u r i t y , contributed t o childrens' maladjustment.  Other f a c t o r s were mental i l l 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 t o Maladjustment  Habit Total School Personality Socially Unacceptable Reactions Disorders D i s a b i l i t i e s Behaviour  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 living 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 f a m i l y disorganization such as marked discord, divorce, desertion and separation.  S i m i l a r l y , boys appeared t o be l e s s vulnerable than g i r l s to  such environmental f a c t o r s 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 factors 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 nationalities 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 Socially Personality Habit School Total p.c. Children Unacceptable Reactions Disorders Disabilities in Family Behaviour 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  -  10  3  -  100  80  Total  -  -  -  39  38  3  .00 1.17  257 100.00  43 The largest percentage of patients  ( 3 3 . 8 per cent) were members  of f a m i l i e s i n which there were only two children.  Sibling rivalry, re-  s u l t i n g i n a f e e l i n g 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 f a m i l i e s , but appeared t o be more marked where there were only 2 children.  "Only" children repre-  sented the second l a r g e s t group ( 2 3 . 4 per cent).  Eighty-eight  per cent of  a l l children considered i n t h i s study came from f a m i l i e s i n which there were not more than A children. [fable 9  DISTRIBUTION OF CASES BY ORDINAL POSITION IN FAMILY  Habit School Total Personality Ordinal Socially P o s i t i o n Unacceptable Reactions Disorders D i s a b i l i t i e s i n Family Behaviour  p.c.  Only C h i l d  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  100  80  39  38  257  100.00  Total  With regard t o ordinal position, there was a higher incidence of maladjustment i n oldest children i n f a m i l i e s , 81 of the patients per cent) being i n t h i s group. l a r g e s t group. while 60 (23.4 55 (21.4  (31.5  Youngest children comprised the second  Sixty-one children (23.7  per cent), were i n t h i s category?  per cent) were "only" c h i l d r e n .  "Middle" children numbered  per cent). Mobility of f a m i l i e s does not appear t o be a s i g n i f i c a n t factor  i n the emotional disturbances of children who were examined a t c l i n i c s .  44. Twenty-three per cent of the patients were born outside of B r i t i s h Columbia.  The population of t h i s province has increased by over 35 per cent  since 1939. Allowing f o r natural increase, within the province, there i s no doubt that more than 23 per cent of the increase i n population may be a t t r i b u t e d to immigration from other parts of Canada and elsewhere. In one quarter of the cases i n which the patients were born outside of B r i t i s h Columbia, the records contained no information about the length of residence^ ) i n t h i s province. 1  Table 10 shows the d i s t r i -  bution of cases i n which the length of B r i t i s h Columbia residence was stated.  Table 10  DISTRIBUTION OF CASES BY LENGTH OF B.C. RESIDENCE  Habit Personality lesidence i n School Total Socially British Unacceptable Reactions Disorders D i s a b i l i t i e s Behaviour Columbia  p.c.  L0 y r s . *  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  24  9  6  4  43  100.00  Total  ± Up t o 10 years 11 months, and s i m i l a r l y f o r 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 denominations of the general population with that of the parents of the clinical population.  Table-ill  RELIGIOUS DENOMINATIONS Population of Vancouver according t o 1941 census-*per cent Protestant 81.67  Roman C a t h o l i c Buddhist and Confucian  10.92 3.88  Jewish  .99  Greek Orthodox  .64.  Other and not stated Total  1.90 100.00  Parents of c l i n i c a l population2  per cent 86.77 5.06 . -  .78 1.16 6.23 100.00  ^-Based on Table 17 R e l i g i o u s 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 O r i e n t a l s have tended t o 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 t o be predominantly a d u l t males.  This i s a p a r t i a l explanation f o r the absence of p a t i e n t s from  f a m i l i e s adhering t o the Buddhist and Confucian r e l i g i o n s . P a t i e n t s from Roman C a t h o l i c 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 comp r i s e d 10.92 per cent of the t o t a l population of Vancouver i n 1941.  Of  the Roman C a t h o l i c p a t i e n t s examined, only one was attending a p a r o c h i a l 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 c h i l d ' s f a m i l y through a request of t h e Dependent's Allowance Board. This showing r a i s e s the question: Why are c h i l d r e n attending  47. parochial schools not referred f o r p s y c h i a t r i c examinations?  One evident  reason i s that the services of the Mental Hygiene D i v i s i o n of the Metrop o l i t a n Health Committee are not available t o parochial or other private schools.  Although p r o v i n c i a l and municipal funds pay the bulk of the  f i n a n c i a l costs of Metropolitan Health Services, a grant from the Vancouver School Board r e s t r i c t s the school health services t o public schools. At present, 2 school nurses, whose s a l a r i e s are paid through Community Cest Funds, are administering t o the health needs of over 4,800 children i n attendance at more than 30 widely scattered parochial schools. One school dentist .attends t o these pupil's dental needs. school medical o f f i c e r .  There i s no  I t i s understandable, that under such circum-  stances, emotional i l l n e s s e s of pupils might be overlooked. However, the services of the p r o v i n c i a l Child Guidance C l i n i c are available to those attending parochial and private schools.  None of  the 257 children i n t h i s study was attending a non-sectarian private school a t the time of r e f e r r a l f o r examination.  Both c l i n i c s examined a  number of children who had attended private schools e a r l i e r . A study of the addresses of the 257 patients revealed that the maladjusted children came from a l l sections of Greater Vancouver. d i s t r i b u t i o n of cases i n the various areas was f a i r l y even.  The  School  a u t h o r i t i e s and s o c i a l agencies referred nearly a l l of the cases i n the parts of the c i t y which on the basis of Juvenile Court reports are c l a s s i f i e d as "delinquency areas".  4S.  CHAPTER 4. SOCIAL HISTORIES In the preceding chapter, which d e a l t , with the 257 cases used as a basis f o r t h i s 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 examinations of maladjusted children.  This chapter w i l l deal with 52 cases,  which are a 20 per cent sample of the t o t a l number of cases surveyed.  A  more d e t a i l e d study of the c l i n i c records of these 52 cases was made and reveals that other s i g n i f i c a n t data, about parents, s i b l i n g s and the patients themselves were a l s o omitted.  Not only w i l l these omissions be  pointed out, but an analysis of the information contained i n the s o c i a l h i s t o r i e s w i l l be made. A clear picture of the family c o n s t e l l a t i o n i s important i n making an accurate p s y c h i a t r i c 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 f r e quently involve treatment of the parent-child r e l a t i o n s h i p .  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 t h e i r own f a m i l i e s .  A very small number were  i n f o s t e r homes with substitute parents, although u n t i l at l e a s t the age of 5 years they had l i v e d with t h e i r natural f a m i l i e s .  Although s o c i a l  h i s t o r y 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 t h i s information was ent i r e l y omitted. stated.  In another 13 per cent the age of only one parent was  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 population, 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 relationship 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, t h i s 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 e n t i r e l y 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 t o post graduate work i n university.  On the basis of those cases i n which information was a v a i l a b l e ,  fathers of patients had a s l i g h t l y 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 c l a s s i f i c a t i o n s of symptoms. Table 12  PARENTS' FORMAL EDUCATION Children's Symptoms S o c i a l l y Unacceptable  Behaviour  Personality Reactions  Mothers (Grade)  Fathers (Grade)  8.4.  9.5  10  10.5  Habit Disorders  8  8.4-  Special School D i s a b i l i t i e s  9.6  10.2  From the foregoing table i t w i l l be seen that parents of c h i l d ren whose maladjustments were c l a s s i f i e d as "personality r e a c t i o n s " had more formal education than those of children who were examined because of " s o c i a l l y unacceptable behaviour , "habit disorders", or " s p e c i a l school 11  disabilities".  The parents who had the second highest degree of educ-  .51a t i o n , were those of c h i l d r e n who had " s p e c i a 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 p a t i e n t s 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 , semis k i l l e d and s k i l l e d l a b o u r e r s . business men.  The other one-sixth were p r o f e s s i o n a l and  The a c t u a 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 ( 4 2 . 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 t a t e d , had been engaged i n c l e r i c a l work previous t o marriage while 8.3 per cent had been members of p r o f e s s i o n s .  The remaining 66.7 per cent had been em-  ployed at u n s k i l l e d and s e m i - s k i l l e d l a b o u r . I n 9.6 per cent of the sample cases mothers were engaged i n work outside of the home at the time of p a t i e n t ' s r e f e r r a l f o r 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 d i v o r c e or d e s e r t i o n .  The other  mothers were working t o 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 w i t h regard to h e a l t h of parents.  The Mental Hygiene C l i n i c o u t l i n e 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 i n c l u d e d .  I n 28.8 per cent of the sample cases, there was no  mention of the mother's h e a l t h , 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 h e a l t h was stated to be "good" or " e x c e l l e n t " .  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. l i s t e d were:  Other i l l n e s s e s of mothers  a r t h r i t i s , asthma, varicose veins, mental depression,  neurodermatitis, h y s t e r i a , 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  i l l n e s s e s of fathers were schizophrenia, psychoneurosis,  u l c e r s , defective  v i s i o n , stomach disorder, hemorrhoids and venereal disease. Besides the diagnosed mental i l l n e s s e s mentioned above, i n 25 per cent of the sample cases, mothers were described i n terms which i n dicated varying degrees of mental disturbance.  Such terms as "unstable",  "inadequate", "extremely tense", "immature", were used i n these s o c i a l histories.  In 19.2 per cent of the cases fathers were described i n simi-  l a r terms.  Half of these fathers used alcohol t o excess.  -Several were  chronic gamblers. The s o c i a l h i s t o r y outline i n use f o r Child Guidance C l i n i c examinations suggests that information about habits and s o c i a l behaviour of parents should be obtained.  Presumably t h i s would include at l e a s t  some d e s c r i p t i o n of the i n t e r e s t s and recreation of parents.  However,  i n the sample cases, there was no information on t h i s subject f o r 80.6 per cent of the mothers, and 69.1 per cent of the f a t h e r s .  Social hist-  ories indicated that 7.7 per cent of the mothers and 5.8 per cent of the  53 fathers had no i n t e r e s t s or recreation outside of t h e i r work. "Problem" children frequently have "problem" parents.  Dr. M.  Levine, Professor of Psychiatry at the University of C i n c i n n a t i College of Medicine, describes f i v e types of problem parents as follows: 1.  The p e r f e c t i o n i s t parent, whose own neurotic need to be perfect  causes i n s e c u r i t y i n a c h i l d by over-emphasis 2.  on prestige and success.  The antagonistic or r e j e c t i n g parent, who arouses fear and insecurity  in a child.  Such r e j e c t i o n may be concealed under the guise of over-  solicitousness, over-prptectiveness, and  "smother-love".  3.  The over-indulgent parent, whose c h i l d faces inevitable f r u s t r a t i o n .  4.  The dominating parent, whose attitudes may lead to undue submissions  or undue rebelliousness i n a c h i l d . 5.  The i d e n t i f y i n g parent, who acts as i f the c h i l d i s s t i l l a part of  her body, making i t d i f f i c u l t f o r the c h i l d t o learn  independence.  Numerous examples of each of these f i v e types of "problem" parents were found i n the sample-cases.  In many instances, s o c i a l h i s t -  ories indicated the nature of parental a t t i t u d e s toward the patients.  In  others, t h i s information was found i n the p s y c h i a t r i s t ' 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 r e j e c t i o n 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 t h e i r attitudes toward children than were the mothers. children.  On the other hand more fathers tended t o dominate t h e i r  " P e r f e c t i o n i s t " parents of both sexes were found.  a few instances of " i d e n t i f y i n g " mothers.  There were  In some cases, one parent  was  extremely r e j e c t i n g of the patient, while the other parent was over-indulgent.  In other instances, one parent's attitude toward the patient  was a p o s i t i v e one while that of the other parent was a detrimental one. In some cases, of course, the attitudes of both parents appeared t o be favourable. Negative parental attitudes such as those described above have t h e i r basis i n the p e r s o n a l i t i e s of parents, which i n turn are the res u l t of parents' own heredity and environment.  In a l a t e r chapter i t  w i l l be seen that i n both c l i n i c s the recommendations f o r treatment are l a r g e l y 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.  I t w i l l be d i f f i c u l t , i f not impos^  s i b l e , f o r t h i s public health nurse or the s o c i a l worker who i s responsi b l e f o r follow-up work t o help parents e f f e c t t h i s change, i f she hers e l f has no knowledge of the etiology of t h e i r present a t t i t u d e s . The Child Guidance C l i n i c s o c i a l h i s t o r y outline suggests that information about paternal and maternal r e l a t i v e s should be included i n the family h i s t o r y .  In one-third of the s o c i a l h i s t o r i e s of children  examined at Child Guidance C l i n i c , clear pictures of family backgrounds shed considerable l i g h t on the reasons f o r parents being the kinds of persons they were.  In the other two-thirds of the cases there were  55.  varying degrees of information of t h i s kind. In marked contrast to t h i s , i n only one-quarter of the Mental Hygiene C l i n i c s o c i a l h i s t o r i e s was there information about the parents' family backgrounds.  A small number of these were f a i r l y d e t a i l e d .  In  the remaining three quarters of the Mental Hygiene C l i n i c cases, no i n formation whatever was a v a i l a b l e about f a c t o r s which might account f o r the parents' personality traits.(1)  Another important aspect i n the  study of f a m i l i e s i s that of interpersonal relationships between patients and t h e i r brothers and s i s t e r s .  Other than data on age and education,  information about s i b l i n g s was lacking i n more than h a l f of the s o c i a l histories. While a l l of the s o c i a l h i s t o r i e s of Child Guidance  Clinic  patients i n t h i s sample of cases were prepared by s o c i a l workers, only 17 per cent of the Mental Hygiene C l i n i c cases were prepared by members of t h i s profession.  Public Health nurses were responsible f o r the pre-  paration of the remaining 83 per cent of the s o c i a l h i s t o r i e s of the Mental Hygiene C l i n i c patients. A p a r t i a l explanation of the difference i n t h i s matter between the s o c i a l h i s t o r i e s prepared by s o c i a l workers and those prepared by public health nurses may be that more emphasis i s placed on family h i s t ory i n the Child Guidance C l i n i c outline.  The work of the Mental Hygiene  C l i n i c according t o i t s stated policy " i s t o be considered a f i e l d of prevention rather than treatment", and "cases found to require repeated treatment sessions are referred t o a private physician, Child  Guidance  (•^The Case of Tom Z. described i n Chapter 5, i l l u s t r a t e s t h i s 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 assumed 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 background 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 importance of intrafamilial relationships in the development of personality. The acquiring of skill 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 life 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 p a r t i c u l a r l y  applicable i n preparing a s o c i a l h i s t o r y , where informants may have f e e l i n g s of resentment, suspicion, apprehension, or g u i l t .  Care, courtesy,  time and patience are required i f parents are t o be expected t o give an accurate picture, as they see i t , of the c h i l d i n the family c o n s t e l l a t i o n . Parents, i n giving information about the c h i l d , often i n d i r e c t l y give much information about themselves. t a i n and u t i l i z e t h i s material.  A s k i l l e d interviewer learns t o ob-  On her a b i l i t y t o 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 c h i l d . The s o c i a l 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 recommendations.  Gordon Hamilton i n her recent book Psychotherapy i n Child  Guidance c a l l s the parent the s o c i a l worker's "partner i n treatment".  (3) With t h i s i n mind, i t behooves the interviewer, whether s o c i a l worker cr public health nurse, t o aim toward establishing rapport between h e r s e l f and the parent during t h e i r f i r s t contact. Not only w i l l t h i s promote a ( ^ I n s t i t u t e f o r 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, c i t e d by H a l l , 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 r e l a t i o n s h i p i n the carrying out of treatment plans, but i t w i l l a l s o insure a more complete s o c i a l h i s t o r y .  There w i l l be l e s s with-  holding of information i f the interviewer can help the parent r e a l i z e that her opinions are respected, and that her r e l a t i o n t o the c l i n i c w i l l be a p a r t i c i p a t i n g one, a j o i n t attempt t o work out a clearer understanding of the problem. When a child i s r e f e r r e d t o c l i n i c by a s o c i a l agency, the school or the court, there i s p a r t i c u l a r need t o help the parent as well as the patient, t o understand that the purpose of the c l i n i c i s t o cons u l t with her and help her i n the care of her c h i l d .  The interviewer,  w i l l have d i f f i c u l t y i n e s t a b l i s h i n g 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 s o c i a l h i s t o r y o u t l i n e . Frequently parents are so concerned with the immediate s i t u a t i o n which has arisen that they emphasize present symptoms rather than e a r l i e r ones and give no consideration t o an underlying cause.  Such parents have  not thought i n terms of a gradual process culminating i n a group of symptoms.  An opportunity t o t a l k about the symptoms often has therapeutic  value f o r these parents.  At the same time the public health nurse or  s o c i a l worker may glean s i g n i f i c a n t f a c t s about both parents and patients. Gordon Hamilton i n her previously quoted study, writes thus on t h i s subject: "The h i s t o r y t e l l s when some deviation started, and knowing when i t started, and under what circumstances we are i n a better p o s i t i o n t o know what i t i s today. The h i s t o r y seeks knowledge of the past because i t i s a part of the present structure.  59.  One can only t r e a t "current" personality i n i t s present circumstances, but one can understand the person best by knowing when deviations and f i x a t i o n s occurred and what were the traumatic incidents which are now scars and t o which he i s s t i l l r e a c t i n g . I t i s the i n appropriate persistence of the past i n t o the present which A clear picture of the onset and development of the c h i l d ' s d i f f i c u l t i e s as well as the p r e c i p i t a t i n g cause of h i s coming f o r the c l i n i c ' s help i s an important part of a s o c i a l h i s t o r y .  Skilful  viewing i s necessary i n order t o obtain t h i s information.  inter-  I t may be  necessary f o r the person preparing the h i s t o r y t o d i r e c t the interview toward discussion of e a r l i e r symptoms.  In 15.4 per-cent of the sample  cases, there was a complete lack of information about the onset and development of the patients' d i f f i c u l t i e s .  In 4 6 . 1 per cent of the cases  s o c i a l h i s t o r i e s gave some information on t h i s subject, while i n the r e maining 38.5 per cent a clear, detailed d e s c r i p t i o n 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 d e t a i l e d picture of their c h i l d ' s development from b i r t h t o the time of the c l i n i c a l examination.  Parents may need help i n understanding the s i g n i -  ficance of the questions put to them before they are prepared or able to give a valuable account of t h e i r c h i l d ' s personal h i s t o r y . In giving t h i s information parents may gain some understanding of the strains and stresses which have contributed t o the creation of the patient's maladjustment.  Parents may, f o r the f i r s t time, look a t  (•^Hamilton, Gordon, Psychotherapy Press, New York, 1 9 4 7 . p. 3 5 .  i n C h i l d Guidance. Columbia University  60.  the t o t a l picture of t h e i r various methods of attempting a s o l u t i o n of the d i f f i c u l t y and a r r i v e a t some evaluation of these methods.  At the  same time the interviewer may gain information as to whether parental d i s c i p l i n e has, on the whole, been sound and r a t i o n a l , or whether i t has been harsh, unreasonable,  inconsistent or weak.  Ideally, parents should be given some opportunity t o t a l k about t h e i r child's problem soon a f t e r a r e f e r r a l i s made f o r 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 s o c i a l agency have made the r e f e r r a l . . In actual practice, a t ^ h i l d Guidance C l i n i c p a r t i c u l a r l y , there i s frequently a delay of one or two months between the r e f e r r a l and the f i r s t interview. Such delay, although unavoidable, often exposes the patient t o parents' frenzied search f o r other methods of dealing with the problem. An enuretic c h i l d who has already received corporal punishment, d i s approval and r i d i c u l e may be forced t o launder h i s own l i n e n , eat s a l t y sandwiches or t o endure some other i n e f f e c t u a l or harmful "remedy". The large caseloads and manifold duties of s o c i a l workers and p u b l i c health nurses appear to be one of the chief reasons f o r t h i s delay.  Another  reason i s that with the e x i s t i n g c l i n i c a l f a c i l i t i e s , appointments f o r examination are frequently f i l l e d f o r several months i n advance. In 28.8 per cent of the s o c i a l h i s t o r i e s information was given about b i r t h , feeding, weaning, t o i l e t t r a i n i n g , walking, t a l k i n g , and teething.  In 34*6 per cent of the cases, s o c i a l h i s t o r i e s gave f a i r l y  d e t a i l e d information about most of these f a c t o r s .  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 t h a t they could not remember d e t a i l s of the c h i l d ' s e a r l y life.  I n 23.1 per cent of the cases, no e a r l y developmental information  was g i v e n .  In a number of the s o c 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 t o r y 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 l a c k information i n whole or i n part of the e a r l y development of p a t i e n t s necessitate the examining p s y c h i a t r i s t devoting a p o r t i o n of h i s i n t e r v i e w s t o t h i s subject. s i g n i f i c a n t f a c t o r s such as feeding d i f f i c u l t i e s ,  In many instances  sudden weaning, e a r l y  and r i g i d t o i l e t t r a i n i n g were revealed t o the p s y c h i a t r i s t . I n nearly a l l of the sample cases, the medical h i s t o r i e s of p a t i e n t s were c a r e f u l l y w r i t t e n . one or more serious i l l n e s s e s .  The majority of the p a t i e n t s had had Over o n e - t h i r d (34.6 per cent) had under-  gone t o n s i l and adenoid operations. operation t w i c e .  A small number of p a t i e n t s had had appendectomy and  mastoidectomy operations. fractured l i m b s .  Several of these c h i l d r e n had t h i s  Over 12 per cent of the c h i l d r e n had suffered  The age at which a c h i l d i s h o s p i t a l i z e d f o r an oper-  a t i o n , h i s psychological preparation f o r i t , and h i s r e a c t i o n t o i t , are of importance i n a s o c i a l h i s t o r y .  I n 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 b r o n c h i 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, n e p h r i t i s and r i c k e t s . had one or more communicable diseases.  In n e a r l y a l l cases c h i l d r e n had A number of c h i l d r e n appeared to  62. be "accident prone". The health history of Tim J . , although somewhat extreme, will 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 children 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 t h e f t s . Information about the school's attitude toward patients was given l e s s frequently i n Child Guidance C l i n i c cases.  However, i n t h i s  c l i n i c ' s s o c i a l h i s t o r i e s , the parents' attitudes toward the school and toward t h e i r children's academic progress or lack of i t were more c l e a r l y delineated, than i n Mental Hygiene C l i n i c cases.  The marked tendency t o  omit such information i n the school c l i n i c ' s s o c i a l h i s t o r i e s may be a t t r i b u t e d , i n part, t o the absence of any s p e c i f i c reference t o school i n the outline. Table 13 i s a summary of the school h i s t o r i e s 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 s l i g h t l y higher than the percentage who had f a i l e d i n one or more grades. Table 13 School Record Excellent  p.c. 3.85  Good  26.92  Fair  17.31  Poor  21.15  F a i l e d 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 l e s s than one-third of the patients who were i n school were making s a t i s f a c t o r y academic progress. Although there was a wide range i n the q u a l i t y of the descriptions, a l l of the s o c i a l h i s t o r i e s i n t h i s 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 h i s t o r y had had l i t t l e or no d i r e c t contact with the patients.  Those h i s t o r i e s which included the interviewers'  observations of the patients as well as the statements made by  own parents  and others, contained more d i s t i n c t portrayals of the c h i l d r e n as persons. Interests and forms of recreation are s i g n i f i c a n t i n the study of maladjusted  children.  In the choice of recreation each i n d i v i d u a l  seeks to s a t i s f y some inner need.  S.R.  Slavson, a recognized authority  on group therapy, describes play i n the following terms: "To the c h i l d , play i s of utmost importance, f o r i t i s through h i s play that he learns the world. Play i s the means whereby the c h i l d i n fantasy, comes to know r e a l i t y . The c h i l d 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 c h i l d threatening and f o r bidding, and i n play he reduces i t s complexity to the l e v e l of h i s powers and understanding. As he grows and i s able to deal with t h i s world, h i s play a c t i v i t i e s gradually fuse with r e a l i t y , u n t i l the l a t t e r becomes predominant. Through play, also, the c h i l d d i v e r t s h i s aggressions, which are part and parcel of h i s b i o l o g i c a l 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 s o c i a l i z i n g him. Where there are no sublimations or substitutions, the child antagonizes other c h i l d r e n and adults; and as a r e s u l t of t h e i r r e j e c t i o n and punishment, he grows r e s e n t f u l and maladjusted. 5(1)  (l)Slavson, S.R., Recreation and the T o t a l Personality Associated Press, New York, 19-46. p. 2-3.  65. In l e s s than two-thirds  (63.46 per cent) of the s o c i a l h i s t o r i e s  mention was made of the patients' i n t e r e s t s and recreation.  Very few of  the h i s t o r i e s outlined the opportunities f o r the pursuit of i n t e r e s t s or for play, provided i n the patient's environment. On the subject of group adjustment, ( s o c i a l i z a t i o n i n situations involving other children) there was more adequate coverage by the s o c i a l histories.  In 9.6  per cent of the cases, however, no reference was made  to t h i s important aspect of development.  The summary of the reports on  t h i s topic indicates that group adjustment was  "poor" i n 63.8  the cases, " f a i r " i n 27.7 per cent and "good" i n 8.5  per cent.  per cent of In other  words, i n the cases i n which group adjustment was described, at l e a s t 9 out of every 10  children had some d i f f i c u l t y i n t h i s area, and that f o r  more than 6 out of 10  the d i f f i c u l t y was marked.  The conclusion reached, through t h i s study of s o c i a l h i s t o r i e s 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 c h i l d himself should be a v a i l a b l e , and i n order that the s o c i a l and c u l t u r a l atmosphere i n which he i s being reared may be considered i n a.  r e l a t i o n to h i s problem, s o c i a l h i s t o r i e s should contain information about the parents' n a t i o n a l i t y , i s l i g i o n , age, education, i n t e l l i g e n c e , occupation and earning capacity, habits, a t t i t u d e s 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 s i s t e r s should a l s o be described, p a r t i c u l a r l y with regard to t h e i r attitudes toward him.  66. CHAPTER 5. SOCIALLY UNACCEPTABLE BEHAVIOUR  One hundred of the 257 children given p s y c h i a t r i c were referred because of s o c i a l l y unacceptable behaviour. represents almost 39 per cent of the t o t a l number of cases.  examinations This number The highest  incidence, (22 per cent), of t h i s type of problem occurred i n the 7 to 8 year old group.  The second highest number of cases, (20 per cent),  occurred i n the 11 t o 12 year old group.  The other age groups are  represented i n decreasing order as follows:  9 t o 10 years - 18 per cent;  8 t o 9 years - 17 per centj 10 to 11 years - 13 per centj and 6 t o 7 years - 10 per cent. The 7 t o 8 year old boys and g i r l s whose behaviour was s o c i a l l y unacceptable represented 46.8 per cent of a l l the children of t h i s age examined.  The 11 t o 12 year old children i n t h i s group comprised 51.28  per cent of a l l patients of t h i s age. "Only" children represented 24- per cent of the c l i n i c patients showing s o c i a l l y unacceptable behaviour.  Patients from f a m i l i e s of 2  children comprised 21 per cent of the cases i n t h i s c l a s s i f i c a t i o n of symptoms, while those from f a m i l i e s 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 t h e i r behaviour was s o c i a l l y unacceptable came from families i n which there were not more than 3 c h i l d r e n . f a m i l i e s were represented i n t h i s group of patients as follows:  Larger 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. patients  1  In the matter of  ordinal positions i n f a m i l i e s , "oldest" children comprised the  l a r g e s t group (34 per cent) "middle" children comprised the second l a r g e s t (27 per cent), "only" children the t h i r d l a r g e s t , (24 per cent) and "youngest" children the smallest group (12 per cent). In 40 per cent of the cases i n t h i s group there was evidence of family d i s o r g a n i z a t i o n . ^ was present i n U  The single f a c t o r most prevalent, divorce,  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 h o s p i t a l were l e s s frequent. In 45 per cent of the cases i n t h i s group there were f a c t o r s contributing to maladjustment of children, (2) other than those which constitute "broken f a m i l i e s " .  These unfavourable circumstances, i n de-  creasing order of incidence were:  interference by grandparents and other  r e l a t i v e s 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 s o c i a l l y unacceptable behaviour, 6 out of every 10 children had d i f f c u l t y i n t h e i r group adjustment.^) (^Table 6, p. 40.  Some of these children refused t o  '  (2) Table 7, p. 4 1 . (3) The information i n the remainder of t h i s chapter, and corresponding sections i n subsequent chapters i s based on the t o t a l c l i n i c study of each case, and not as i n Chapter 4 , s o l e l y on the s o c i a l h i s t o r y .  68 p a r t i c i p a t e 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 t h e i r aggressive behaviour. Ralph, (aged 8 years 11 months) was completely ostracized by children i n the neighbourhood because h i s v i o l e n t temper tantrums a t home and on the street (he struck and b i t h i s parents, broke windows, swore profusely, etc.,) had gained f o r him the r e putation of being "a holy t e r r o r " . Some of these patients preferred playing with children much older or much younger than themselves.  A b r i e f sketch of one boy's at-  tempts to f i n d s a t i s f a c t i o n s i n h i s 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 t h e f t several times. At school he was unpopular with children of h i s own age. Classmates considered him "a cheat and a t a t t l e - t a l e " . For some time George had r e l i e d on younger c h i l d ren f o r companionship, but t h i s brought more r i d i c u l e from h i s own age group. He turned l a t e r t o teen-aged boys but was rebuffed by them. In h i s search f o r recreation and friendship George found t r a n s i t o r y s a t i s f a c t i o n i n h i s 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 e f f o r t s toward group  adjustment are outlined below. Dorothy, an 11 year old g i r l , referred f o r examination because of repeated t h e f t s over a period of more than 3 years, was called "robber" by her classmates. She was " p o l i t e and well l i k e d by adults", but had no friends of her own age. Frequently, with stolen money, she bought things t o share with other c h i l d ren, and so the v i c i o u s c i r c l e continued. She l i k e d to play "cops and robbers", and f o o t b a l l with the boys i n the neighbourhood. On rare occasions when the boys accepted her i n t h e i r games, Dorothy was subjected to further r e j e c t i o n by g i r l s of her own age, who c a l l e d 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 adjustment was obviously a r e f l e c t i o n of the treatment he himself had received i n h i s home. Dick was nine and a h a l f years of age when he was r e f e r r e d f o r c l i n i c a l examination. His symptoms were "bullying, l y i n g , f i r e s e t t i n g , stealing and negativism". In school, Dick's a t t i tude to authority was unsatisfactory. He was described as "only reacting t o force". Sick was the seventh c h i l d i n a family of 10 children. He had 5 older brothers. Dick's father was " a r b i t r a r y and r i g i d " i n h i s attitude toward h i s wife and children. The" older boys, four of whom had had "some contact with an underworld crowd", imitated t h e i r father. They dominated younger members of the family, p a r t i c u l a r l y Dick. Dick played only with children young enough or small enough f o r him to b u l l y . He said that he had "a d e v i l inside", which made him cruel and disobedient. In 34- per cent of'the sample cases of children whose behaviour was s o c i a l l y unacceptable^ patients' school reports indicated that they were not making s a t i s f a c t o r y progress i n t h e i r academic work.  Compared  with the three other c l a s s i f i c a t i o n s of symptoms, children i n t h i s group had the l e a s t 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 a p p l i c a t i o n at school, poor group adjustment and poor control of temper". Frequently he refused to attend school. In the group t e s t given by the Bureau of Measurements, Ralph's i n t e l ligence quotient was 109. Five months l a t e r Ralph became so unmanageable at home that the parents sought help from the Child Guidance C l i n i c . On an i n d i v i d u a l t e s t at t h i s c l i n i c , Ralph's i n t e l l i g e n c e 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. S i b l i n g r i v a l r y was apparent i n 70 per cent of the sample cases. In some instances t h i s seemed to be closely related t o the mother's  70. r e j e c t i o n of children of an e a r l i e r 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 C l i n i c a t 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 t o run away, and cruel t o her half-brother". To the mother the c h i l d 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 t o be " j u s t l i k e her father". The mother's second marriage was a s a t i s f y i n g r e l a t i o n ship f o r her. The c h i l d of t h i s marriage, 3 years younger than the patient, was preferred by the mother. She r e a l i z e d 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 t h i s s i t u a t i o n , and openly showed her resentment of the step-brother who r e c e i v e d so much of her mother's a f f e c t i o n . In several other cases, parents openly promoted s i b l i n g r i v a l r y by such remarks as: get  "Wait t i l l your brother s t a r t s t o school.  He'll  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)•  " G i r l s are so much easier t o bring up.  when Jack was born.  I had hoped f o r a g i r l .  I was very disappointed  I t was a happy day when  Angela came" (said i n the presence of Jack, whose resentment of h i s younger s i s t e r was marked.) In one h a l f of the sample cases, one or more s i b l i n g s of patients showed some form of maladjustment.  ^h±3 i s more marked than in-any of the  three other c l a s s i f i c a t i o n s of symptoms. One mother, a widow with 4 sons, requested c l i n i c a l examination f o r Mike, her t h i r d c h i l d , who was truanting from school and s t e a l i n g . She had found the c l i n i c h e l p f u l 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 t o make f r i e n d s " .  71  Norman (aged 10 years) was referred f o r examination by the Juvenile Court because of "breaking and entering and petty thievery" had one s i s t e r who was an unmarried mother, and another s i s t e r who had been a "pickpocket" and a truant. Dick (previously mentioned with regard to group adjustment) had A older brothers who were not able t o make s a t i s f a c t o r y work adjustment, ^-hey t r i e d to "make an easy l i v i n g " by contact with "an underworld crowd". Arthur, an 11 year old boy examined at the request of the Juvenile Court, because of h i s s t e a l i n g had a s i s t e r who had spent a year i n a G i r l ' s I n d u s t r i a l School on a charge of sexual immorality. L e s l i e , a boy (aged 10 years and 8 months), was said by his mother to be i n c o r r i g i b l e . His symptoms were s t e a l i n g and truancy. This boy's s i s t e r (10 years older) became an unmarried mother at the age of 16, became involved with youthful criminals of both sexes, and l a t e r was imprisoned because of drug addiction. In 80 per cent of the sample cases i n t h i s c l a s s i f i c a t i o n of symptoms, patients had experienced unfavourable circumstances i n the period  between b i r t h and the end of t h e i r second year.  This i s a higher per-  centage than was found i n any of the other three c l a s s i f i c a t i o n s 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 f o r part of the time during infancy by h i s e l d e r l y paternal grandmother who had l i v e d with h i s parents from the time of their marriage. There was considerable tension i n the home. The c h i l d ' s father was not a well adjusted person. He said that he had had several "nervous breakdowns". He had always been dominated by h i s mother who was showing signs of s e n i l i t y before Ralph was born. The father was not able to help h i s wife withstand the domination of her mother-in-law. The baby had "cradle cap" during the f i r s t 6 months of h i s l i f e . His hands were frequently t i e d t o keep them away from h i s head. When Ralph was 5 months old, the mother became pregnant, and was at times very i l l during the pregnancy. The second c h i l d died shortly sifter b i r t h . Soon a f t e r t h i s the mother worked i n an o f f i c e half-days, leaving Ralph with h i s 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 parents said that children were not wanted because of poor financial circumstances, 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£) will be described.  73  This c h i l d l i v e d i n a good r e s i d e n t i a l d i s t r i c t . She was the eldest c h i l d i n a family of 3 c h i l d r e n . A children's agency received several complaints from neighbours that the mother Was whipping the c h i l d severely.- The mother frankly admitted that the reports were true. She t o l d of Margaret's temper tantrums and f l u c t u a t i n g behaviour and r e a d i l y accepted the agency's o f f e r of c l i n i c a l examination f o r the c h i l d . In the course of the study of t h i s c h i l d i t was learned that the mother had used t h i s method of punishment f o r several years. Another mother, said that her daughter, (aged 11 years 10 months) was i n c o r r i g i b l e .  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 p s y c h i a t r i c help f o r 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 c h i l d ) ; she t r i e d t o keep her daughter busy with household duties and homework, r e f u s i n g to l e t the g i r l go to f r i e n d s ' homes or have f r i e n d s v i s i t her. When the g i r l r e b e l l e d a t t h i s i n j u s t i c e she was beaten, v e r b a l l y reprimanded i n a des t r u c t i v e manner, and threatened with p o l i c e , i n d u s t r i a l school, e t c . E a r l i e r i n t h i s chapter i t was pointed out that the highest incidence of patients showing s o c i a l l y 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 C h i l d Guidance C l i n i c were used by a s o c i a l worker i n a family agency. Peter was brought t o Child Guidance C l i n i c when h i s mother expressed concern to a s o c i a l worker i n a family agency about h i s defiance, disobedience and "whining". The s o c i a l worker i n t h i s agency, t o which the mother had gone f o r help with a marital problem, prepared the s o c i a l h i s t o r y . Peter's home was a small, crowded, d i r t y apartment, but i n a good neighbourhood. His father, aged 35 years, had had Normal School t r a i n i n g , but at the time Peter was examined, aspired t o a p o s i t i o n of public accountant i n the U.S.A. and was t r y i n g t o get American c i t i z e n s h i p papers. The mother, on  74. the other hand, had refused t o sign the necessary form f o r c i t i z e n s h i p papers. The father seldom l i v e d with h i s family but when he d i d come home, Peter was witness t o b i t t e r quarrels between h i s parents. The father wanted a divorce, but the mother f l a t l y opposed,it. Peter remembered c l e a r l y that h i s father had gone away f o r quite a while before h i s baby brother was born. Perhaps Peter remembered too that h i s father had l e f t the family f o r a long time before the b i r t h of h i s s i s t e r when the l i t t l e boy was only 4- years o l d . Peter's mother was 2 years older than h i s father. She had f i n i s h e d Grade 8, and had l a t e r become a clerk i n a small store. Peter was Mrs. G.'s f i r s t c h i l d , and she said that she had wanted a baby very much. She t o l d 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 t h i s period. Family finances had never been very good, but they were p a r t i c u l a r l y 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 f o r only 2 weeks. She changed to bottle-feedings when the baby seemed t o be "always hungry". The story of when and how he was weaned from the b o t t l e wasn't t o l d but the mother d i d s a y that Peter had been a "problem" ever since he was 3 years o l d . He was "slow" i n learning t o i l e t t r a i n i n g , and mother was not very successful with t h i s 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 a t Child Guidance C l i n i c , he had begun s o i l i n g under the bed. Mother thought that t h i s was sheer "spitefulness". The s o i l i n g continued. Besides Mother, s i s t e r , 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 d i r t y apartment with Peter. Grandmother said that her husband, l i v i n g i n Manitoba, was a successful business man. She d i d 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 k n i f e . The s o c i a l worker i n the family agency was not the f i r s t person who had t r i e d t o help Peter. his  When the l i t t l e boy had f a i l e d i n Grade 1  teacher and the school p r i n c i p a l had conferred about him and decided  that "special c l a s s " might offer t h i s p u p i l better opportunities. They had reached t h i s decision a f t e r taking i n t o consideration the boy's score  75 on a group i n t e l l i g e n c e t e s t . The special class teacher reported that Peter was not a "problem" i n school* and that he seemed happier than when he was i n 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 s u l l e n with h i s mother, he always "sided f i e r c e l y " with her against h i s father during the parents' frequent quarrels. The father thought that there was "nothing wrong with the boy except h i s mother's s p o i l i n g " . The boy had had severe bronchitis 4 months before he came to Child Guidance C l i n i c . This had recurred frequently; i n f a c t , i t had not r e a l l y "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 h i s 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 i n t e l l i g e n c e . 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 a t Child Guidance C l i n i c , case work with mother was recommended. Peter needed more security and more consistent handling. Event u a l foster home placement seemed indicated, and i t was recommended 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 s i t u a t i o n . The second conference (consultative), was held and a s o c i a l worker from a children's agency was present.  The family agency's supple-  mentary h i s t o r y covered the 2 month i n t e r v a l , between the conferences and was as follows: Peter had been i n hospital twice during the 2 months. Each time he had had severe b r o n c h i t i s . He seemed t o enjoy being i n h o s p i t a l . His grandmother had said that the l i t t l e boy "did not get proper r e s t " . He was frequently up u n t i l 11 p.m. There had been constant q u a r r e l l i n g whenever father returned to the home. Peter's mother became "upset and h y s t e r i c a l " a f t e r each of father's v i s i t s . Grandmother complained that she was i l l and wanted to leave B r i t i s h 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 engaged 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 conference 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 placement 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 immaturity and discord, should become maladjusted i s not surprising. The social work implications in this case are numerous. Perhaps the outstanding one i s the limitations of a social agency when the problem has existed for many years before i t i s 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 i n which to take roots and grow. If the problem had been detected and referred to the fami l y agency during Mrs. G.'s pregnancy or confinement i t i s 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  d i f f i c u l t y had reached the serious proportions described, a te cher in a 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 i n a special c l a s s a necessary, but only p a r t i a l , solution of h i s problem. When the family agency arranged to have Peter re-examined at Child Guidance C l i n i c 1 year and 4- months a f t e r the conference,  the  value of continued case work with the G. family was apparent. Following the second conference at Child Guidance C l i n i c , the s o c i a l worker had suggested that Mrs. G. should discuss with the family doctor the p o s s i b i l i t y of Peter's admission to the Solarium. Mrs. G. r e a d i l y accepted t h i s suggestion. The doctor examined Peter again and made a diagnosis of bronchial asthma, but d i d not consider the l i t t l e boy e l i g i b l e f o r care i n the Solarium. The mother c a r e f u l l y administered the medication which the doctor prescribed, and the improvement i n Peter's physical health was encouraging to her. Mrs. G. t o l d the s o c i a l worker about Peter's increasing appetite. Later she t o l d that he was sleeping w e l l . There were discussions between the mother and the s o c i a l worker about consistency i n dealing with Peter and h i s s i b l i n g s . The grandmother l e f t the G. home, ^he mother gradually faced the r e a l i t y of her husband's l o s s of i n t e r e s t i n 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 h i s wife and family. With l e s s anxiety about family finances (Mrs. G. had been t o t a l l y dependent on her parents f o r support f o r 2 years before) the mother's own health improved and her a b i l i t y to care f o r 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 s o c i a l worker as they became apparent to her. She was able to accept the case worker's explanation that her small daughter's masturbation indicated a need f o r greater s e c u r i t y rather than punishment. When the family doctor t o l d her that her youngest c h i l d needed a serious operation urgently, Mrs. G. discussed with the s o c i a l worker her unwillingness to increase her- already large debt to the doctor. The s o c i a l worker, u t i l i z i n g her knowledge of community resources, t o l d the mother about the out-patients' department of the Vancouver General H o s p i t a l . As a r e s u l t of t h i s , arrangements were made f o r the nedessary operation, the postponement of which might have had serious e f f e c t s on the l i t t l e boy's health.  78 Peter's second examination at C h i l d Guidance C l i n i c revealed that h i s physical health had improved a great d e a l . His emotional adjustment showed even greater improvement. The examining p s y c h i a t r i s t noted that Mrs. G. was l e s s anxious and l e s s worried about the future than at the time of her f i r s t i n t e r view at Child Guidance C l i n i c . She showed improved health and her whole attitude toward her family was better. The p s y c h i a t r i s t advised that although marked progress had been made, the mother needed continued contact with the family agency. Much of the progress i n t h i s case may be attributed to the f a c t that throughout a d i f f i c u l t 2 year period, Mrs. G. had a continued support i v e r e l a t i o n s h i p with one well-trained and experienced s o c i a l worker. This non-judgmental,  h e l p f u l r e l a t i o n s h i p was i n marked contrast t o Mrs.  G.'s r e l a t i o n s h i p with her mother and her husband.  I t enabled her t o  u t i l i z e her own a b i l i t i e s with advantage to her children and h e r s e l f . The case of Peter i s not an extreme example.  As pointed out  e a r l i e r i n t h i s chapter, i n 4-0 of the 100 homes from which patients showing s o c i a l l y 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 r e l a t i v e s l i v i n g i n t h e i r homes. There were 16 instances of extremely poor or crowded housing. An example of a case i n which none of the above mentioned factors were apparent i s that of Tom Z., aged 7 years. Tom was examined at the Mental Hygiene C l i n i c because of marked disobedience a t school. He also t o l d many l i e s . He was referred f o r examination by a public health nurse. Tom's mother said that he was very jealous of h i s 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 s o c i a l history d i d not state when either parent had emigrated to Canada. The father had attended u n i v e r s i t y f o r 1 year and was  79  regularly  employed a t  9 education. that  She  semi-skilled  said  that  she  T o m ' s i m a g i n a t i o n was l i k e  house  i n a middle  thought  that  class  labour.  l i k e d to her  "family relationships  seemed n o r m a l " .  own.  neighbourhood.-  The age  of  The mother h a d a  write  stories  and  The f a m i l y l i v e d The p u b l i c h e a l t h  p a r e n t was  in" a  good  nurse  seemed g o o d a n d s o c i a l  neither  Grade  thought  standards  stated.  T h e m o t h e r ' s a t t i t u d e t o w a r d T o m was d e s c r i b e d a s one o f "sympathetic understanding". 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 exami 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 had been "hard t o wean". He h a d t o b e f e d u n t i l 2 y e a r s o l d " . Tom h a d e c z e m a , a n d 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 fever. H i s mother s a i d t h a t he h a d "always" 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 . Mrs.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 b e e n i n d i f f e r e n t t o discipline. She h a d f o u n d m a k i n g torn " s i t s t i l l o n 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 h a d 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 singing  voice  children.  was  and l i k e d t o  He was  r a t e d as  sing.  low average.  He h a d a  He p r e f e r r e d p l a y i n g w i t h  q u i c k tempered and r a t h e r rough i n h i s  good older  play  at  times. The e x a m i n i n g p s y c h i a t r i s t g a v e a d v i c e t o Tom's mother and his teacher. He r e c o m m e n d e d 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 a n d 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 . T o m ' s m o t h e r 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 . There i s half the  years brief  no p r o g r e s s  which hade social  elapsed  history  been v e r y wise i n h e r ability  to  carry  public health  out  nurse,  The c a s e the  parents  the  as w e l l  as  of  case.•  his  boy,  T i m M. the  that  past.  the  this  1  clinic.  In •  mother has  One m i g h t without  2 and  question help  not her  from a  worker.  illustrates  child.  during the  examination at  indications  Tom i n t h e  social  f a m i l y agency's h e l p by the private  are  on t h i s  c l i n i c recommendations,  or a  of  since  there  care  report  It  the  also  importance  illustrates  C h i l d Guidance C l i n i c  in  of the  the  learning use  of  treatment  about  a o f a.  80. Tim was 9 years old when he was referred to the c l i n i c 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 d i f f i c u l t i e s 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 c l i n i c social worker in preparing the history conferred 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 c l i n i c a l 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 c a l l 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 f a m i l y of 13 c h i l d r e n . There was a great deal of m a r i t a l discord between her parents. Her f a t h e r , 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 t u b e r c u l o s i s . I n t a l k i n g w i t h the s o c i a l worker t h i s mother appeared t o r e a l i z e that she was extremely anxious about health matters, and thought t h a t 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, p a r t l y t o escape the domination of her f a t h e r . However, she soon found h e r s e l f i n volved i n d i f f i c u l t i e s w i t h a dominating mother-in-law. Mr. M. was 21 years o l d 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 w i t h or near t h i s mother-in-law. There was constant b i c k e r i n g between Mrs. M. and her mother-in-law i n t h i s period. Mrs. M. thought that the b a s i s f o r 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 s t a r t e d t o school, a t the age of 6, h i s mother was working, so he was sent t o a boarding school f o r a year and a h a l f . When he returned home, there was d i s c o r d between the parents and separation was threatened. The s o c i a l h i s t o r y contained l e s s information about Mr. M.'s e a r l y 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 t o the c l i n i c , Mr. M. was i n a m i l i t a r y h o s p i t a l s u f f e r i n g from what h i s wife vaguely described as "war t r o u b l e " . For years he had been on a d i e t ( t o which he r a r e l y adhered), because of duodenal u l c e r s . He had had pneumonia several times, and he had been very i l l f o l l o w i n g an appendectomy. Obviously, i n much of h i s i l l n e s s , Tim had f o l l o w e d the pattern of the 2 a d u l t s nearest t o 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 p h y s i c a l neglect by h i s s i c k parents and his  i d e n t i f i c a t i o n w i t h these parents i n t h e i r r e t r e a t 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 i n t o consideration i n the casework s e r v i c e s of the c l i n i c .  82.  The mother, whose dependency needs had not been met i n her youth, responded well t o 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 t o gradually l e a r n a new approach t o the t r a i n i n g of her son. began to recognize the importance of consistency i n handling Tim.  She Tim's  stealing and l y i n g which had caused the mother so much concern, ceased as h i s environment became more s t a b i l i z e d .  These symptoms recurred however  when the mother became pregnant and again grew concerned about her health. During the t h i r d month of the pregnancy, the mother f e l l while leaving a street car. At t h i s point, the c l i n i c sought the help of another agency f o r Tim and h i s 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 a f t e r the b i r t h of the second c h i l d . family were met.  until  Again the dependency needs of t h i s  Mrs. M., with t h i s help was able to give Tim a greater  sense of security and h i s former symptoms disappeared. Mr. M.,  relieved  of some of h i s r e s p o n s i b i l i t i e s at home, found steady employment. able t o pay p a r t i a l l y f o r the v i s i t i n g homemaker's services.  He was  Shortly  after the b i r t h of the baby, the family moved t o another province (not the one i n which the mother-in-law l i v e d ) t o take advantage of a better work p o s i t i o n offered t o the father there. I t would be presumptuous t o p r e d i c t that there would be no more d i f f i c u l t i e s i n t h i s family which would require help from s o c i a l agencies. I t can be said however that casework services while the family were i n  83 t h i s c i t y 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 maladjustment and r e f e r r a l t o 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 i n seeking t o 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 f o r 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 i n d i c a t i o n s of maladjustment. cases.  This number represents 31 per cent of the t o t a l number of  The highest percentage of children showing symptoms of t h i s kind  were between the ages of 6 and 7 years and between 8 and 9 years. of these age groups comprised 21.25  Each  per cent of the 80 children examined.  In the order of decreasing percentages the other age groups were represented as follows:  9 t o 10 years - 17.5 per cent, 10 t o 11 years - 16.25  per cent, 11 to 12 years - 12.5 per cent, and 7 t o 8 years - 11.25  per cent.  The 6 t o 7 year old children whose symptoms were personality reactions comprised 42.25 per cent of a l l the patients of t h i s age group. The 8 t o 9 year old children showing these symptoms formed 35.41 of a l l the patients between these ages.  An equal percentage  per cent  ofithe c h i l d -  ren between 8 and 9 years showed symptoms i n the form of s o c i a l l y unacceptable behaviour. Almost one quarter (23.75 per cent) of the children examined who were manifesting unfavourable personality reactions, were "only" children i n t h e i r f a m i l i e s . prised 46.25 per cent.  Patients from f a m i l i e s of 2 children com-  In other words 7 out of every 10 children exam-  ined came from f a m i l i e s i n which there were only 1 or 2 children. f a m i l i e s were represented i n t h i s group of patients as follows: ren - 11.25  Larger 3 child-  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 t o 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 t h i r d largest (23.75 per cent) and "middle" children the smallest group (15 per cent). Turning now t o 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 t h e i r group adjustment.  There were varying degrees of maladjustment i n t h i s area.  Several  of the patients, though of high average average i n t e l l i g e n c e , d i d not play with children of t h e i r own age.  Some who associated with younger children  only, were aggressive and at times cruel i n t h e i r play, while others had no friends near t h e i r own age and r e l i e d on adults f o r companionship. A s p e c i f i c example of another form of unsatisfactory group adjustment i s that of B i l l , aged 8 years 11 months. B i l l had suffered from severe headaches and nausea i n t e r mittently f o r a period of 6 years. His I.Q. was 116. This boy had no friends, and used t o s i t outside alone f o r hours. He l i k e d k n i t t i n g , 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 i n t e r e s t i n outdoor sports. Denise, aged 10, with average i n t e l l i g e n c e , r e f e r r e d t o c l i n i c because of her daydreaming, "ugly moods" and awkward g a i t , t o l d the s o c i a l worker t h i s story: "George i s my only f r i e n d . I wish he could be i n my grade at school. (George was a 7 year old mentally retarded Hindu-; c h i l d ) . 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 r e a l slow so I won't have to go i n t o 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 i n q u i r i e s about what Denise l i k e d 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 l i k e s him. Sometimes I f i g h t 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 unfavourable 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 t h i s could not  be attributed to lack of i n t e l l i g e n c e , as the 2 i l l u s t r a t i o n s of P a t r i c i a and Sam show: P a t r i c i a , aged 8 years 10 months, was referred t o c l i n i c by her parents, because of her lack of self-confidence and constant quarrelling with her twin brother. P a t r i c i a showed l i t t l e i n t e r e s t 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 l a r g e f o r her age). She said that she could not do b e t t e r 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 h i s mother because he had "no sense of r e s p o n s i b i l i t y " and was " f u l l of f e a r s " . Sam's school r e p o r t indicated that he had a negative attitude toward learning. He seldom completed h i s work and showed no i n t e r e s t i n new lessons. Sam's I.Q. was 150, In h a l f of the cases i n t h i s sample, marked s i b l i n g r i v a l r y was apparent.  Examples of some of the forms of t h i s are i l l u s t r a t e d i n  the two following cases. Roger, aged 8 years, the eldest of 3 children, was referred to c l i n i c by h i s mother on the advice of the f a m i l y doctor. Of Soger's numerous physical complaints of several year's standing, b i l i o u s attacks were the most severe. He occasionally had v i o l e n t temper tantrums. Usually he showed  87  l i t t l e animation. Roger's father, whose employment had kept him away from home f o r months at a time spoke harshly to the boy during h i s short periods with the family. Often the f a t h e r added t o h i s reprimand the statement: "You're the oldest. You should have b e t t e r sense." The mother, i n the absence of her husband, expected Roger to assume many chores around the home, p a r t i c u l a r l y the r e s p o n s i b i l i t y of "keeping an eye" on h i s brother and s i s t e r . Roger had no time t o make friends or pursue any of the usual boyish i n t e r e s t s . Most of h i s small allowance was saved t o buy g i f t s f o r h i s 2 s i b l i n g s . I t appears that by t h i s gesture Roger was t r y i n g t o gain the approval of h i s parents. Their single favourable comment about him was: "One good thing about Roger i s that he's very u n s e l f i s h . He's always buying g i f t s . " This "unselfishness" may have been Roger's outward denial of h i s r e s e n t f u l feelings toward h i s s i b l i n g s , which were only r a r e l y exhibited by aggressiveness toward them. Sam,  the boy previously referred to i n the discussion of poor  school achievement, showed h i s f e e l i n g s of r i v a l r y toward h i s brother more openly.  Sam's mother said that she had t r i e d t o "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 c h i l d , John, was born 3 years after. Sam's b i r t h , the attending doctor t o l d the mother that she would not be able t o have any more c h i l d r e n . The mother said that t h i s had caused her t o " l a v i s h attention" on the younger boy. Both parents had found, John "more lovable". Sam showed h i s resentment of h i s brother with increasing vehemence. Before John was 5, one of h i s ear drums was punctured when Sam struck h i s head several times with part of a mechano set. In one quarter of the sample cases, the s i b l i n g s of patients showed varying degrees of maladjustment. P a t r i c i a ' s twin brother, Jack, was examined at c l i n i c too. Like h i s s i s t e r t h i s boy had very superior i n t e l l i g e n c e (I.Q. 127). The symptoms which l e d t o 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 t h i s group, patients had experienced unfavourable circumstances i n the period between b i r t h and the end of t h e i r second year.  Three examples w i l l show the serious-  88. ness of some of these experiences. Albert, breastfed from b i r t h , was suddenly changed t o b o t t l e feedings at the age of 1 month when h i s mother was hospitalized f o r 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, t h i s boy barely survived when pneumonia developed. Denise (whose poor group adjustment was previously described) was r e j e c t e d before b i r t h by both of her parents. The mother aged 45, "wished f o r death" during the pregnancy. The father consumed alcohol excessively during the pregnancy, and f o r several months afterwards causing many hardships f o r 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 r e j e c t i o n , Denise had the frightening experience of being badly b i t t e n by a dog before the age of 3 years. Harold, as an infant, was "held by the neck and beaten" by h i s father. The mother stated that the father would "throw him i n t o the c r i b " and refuse t o l e t her go to comfort the baby. Negative factors i n the period from the 3 to 6 years were present i n every case i n t h i s sample.  In none of the other three c l a s s i f i -  cations of symptoms were such factors apparent to t h i s degree.  As  was  pointed out i n the previous chapter 85 per cent of the children whose behaviour was s o c i a l l y unacceptable had met with d i f f i c u l t i e s or unfavourable circumstances during t h i s period. Jimmy, at the age of U, suffered concussion as a r e s u l t of a f a l l . The year before t h i s c h i l d was old enough t o attend school, the father, discontented with h i s work was unusually i r r i t a b l e . Part of the home i n which the boy l i v e d was sub-let to tenants who were noisy. The mother had many disputes with the tenants and the boy was constantly reminded to "be c a r e f u l about noise". Several children had t o n s i l s and adenoids removed before they began attendance a t school.  Some were inadequately prepared f o r t h i s  operation, being t o l d " i t won't hurt a b i t " .  89. Mary, aged Ak years, was suddenly separated from her mother who was sent t o a sanatorium. She was not t o l d why her mother had l e f t and was not given an opportunity to say good-bye t o her. For over a year before the mother had l e f t , she was run-down and apprehensive, and was a f r a i d at night when l e f t alone with the c h i l d while the father worked. The c h i l d 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 a l s o separated from a l l of her maternal r e l a t i v e s because her father feared that they, too, might have tuberculosis. She was passed from one to another of the father's r e l a t i v e s and f r i e n d s . Another f a c t o r which was more prevalent i n the sample cases of t h i s group, than i n the other three c l a s s i f i c a t i o n s of symptoms i s that of r i g i d or harsh d i s c i p l i n e of children by t h e i r parents, older s i b l i n g s orBlatives.  In 81.25  per cent of the cases, t h i s f a c t o r was  evident.  One boy's mother said that the only lemedy f o r h i s "sauciness" was  a "good slap i n the face".  The father's method of d i s c i p l i n e  that of "commanding" the boy i n a loud tone of v o i c e . ment was  "He just w i l t s when his father scolds  was  The mother's com-  him."  Another boy's father, a periodic deserter of the family, encouraged the c h i l d to disobey h i s mother. temper tantrums during which the boy was  Frequently t h i s father had  severely beaten.  D i s c i p l i n e came from several sources f o r the 8 year old Jack who was  " t a c i t u r n at school and aggressive i n an impulsive  way".  Jack l i v e d i n a home i n which there was considerable f r i c t i o n among the adults i n the family. During the b r i e f periods when the father was at home (the parents separated frequently) he ignored the boy. -*he maternal grandmother, an i n v a l i d , l i v e d i n the home, and frequently c r i t i c i z e d the boy and h i s mother's t r a i n i n g of him. A maternal aunt who also l i v e d with the family, worked i n an o f f i c e . She was tense and i r r i t a b l e a f t e r work, and constantly "nagged and scolded" the boy and h i s 3 s i b l i n g s . Besides using corporal punishment to d i s c i p l i n e the boy, the mother frequently  90 threatened him with "a v i s i t from the d e v i l who might t a k e him away a t n i g h t " . I t has been stated previously t h a t the highest percentages of p a t i e n t s showing unfavourable p e r s o n a l i t y reactions were found i n the age groups from 6 t o 7 years, and from 8 t o 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  e a r l y detection by the school of a c h i l d ' s maladjustment.  This case a l s o  i l l u s t r a t e s i n a p a r t i c u l a r way, the mental h y g i e n i s t ' s v i g i l a n c e i n d i s covering opportunities t o s t r e s s the aim o f the c l i n i c ' s program, the promotion of mental h e a l t h .  I t demonstrates too, the value of c a r e f u l  'follow-up" work by the p u b l i c 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 f e a r of new experiences, and h i s use of tears i n meeting whatever c o n s t i t u t e d f o r him a d i f f i c u l t s i t u a t i o n . These symptoms were brought t o the a t t e n t i o n of the school nurse, and the boy was examined a t 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 a d d i t i o n t o the above-mentioned symptoms, the school h i s t o r y revealed t h a t the p a t i e n t was e x c i t a b l e , wanted t o run home from school a t times, was "bossy" with other c h i l d r e n , and almost constantly rubbed h i s f i n g e r s against h i s sweater sleeve. The s o c i a l and f a m i l y h i s t o r y revealed t h a t the p a t i e n t l i v e d i n an e x c e l l e n t home i n a good neighbourhood. David's parents were w e l l 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 f a m i l y , '^he only s i b l i n g , a s i s t e r , 3 years younger, appeared t o 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, e x c i t a b l e and s e n s i t i v e . They s a i d t h a t f o r several years he had l i k e d t o rub fuzzy objects between h i s f i n g e r s . This h a b i t was f i r s t noticed when he rubbed the c r i b blanket before f a l l i n g o f f t o sleep. The parents a l s o commented on David's dawdling over h i s food, and h i s disobedience a t home. Bladder and bowel c o n t r o l had not been established u n t i l David was 3 years o l d . 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 a t t e n t i o n f o r several months.  91 David had not been i n school long enough to have been tested by the Bureau of Measurements.  He had not yet been examined by the school  doctor. The examining p s y c h i a t r i s t diagnosed David's case as "immaturity" and described the rubbing of fuzzy objects as a fetishism which was a regressive attempt to escape from c o n f l i c t . The p s y c h i a t r i s t considered David's i n t e l l i g e n c e to be normal, but at the conference recommended having an i n d i v i d u a l test done by the Bureau of Measurements. Further recommendations arrived at during the conference were: 1. Discussion with the mother regarding encouraging maturation. The mother should show l e s s 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 s i t u a t i o n s . 2. Encouragement of more companionship with the father. Four months a f t e r t h i s conference, the school nurse reported that the case had been closed because of the attitude of the parents and teacher.  A summary of t h i s report follows:  A l l recommendations except that of having a psychometric t e s t , had been c a r r i e d out. An i n d i v i d u a l i n t e l l i g e n c e t e s t had not been done because the teacher d i d not consider t h i s t o 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 d i d f a i r l y good work while c l o s e l y watched. He no longer cried i n school and d i d not want to run home. Following t h i s r e p o r t , a l e t t e r from the mental hygienist to the d i r e c t o r of the health u n i t was instrumental i n c l a r i f y i n g the funct i o n of the c l i n i c , and subsequently i n the reopening of the case.  In  t h i s l e t t e r the c l i n i c d i r e c t o r suggested that " i n the i n t e r e s t s of good education and public r e l a t i o n s " an attempt should be made "to get an understanding of the discrepancy between the o r i g i n a l a t t i t u d e of the parents and teacher and the present one".  The mental h y g i e n i s t further  92  emphasized the importance of a l l p u b l i c h e a l t h workers s t r e s s i n g the aim of the c l i n i c program which i s "to promote mental h e a l t h " , and not t o wait u n t i l the development of serious symptoms. In l e s s than a month there was a second progress r e p o r t from the school nurse i n which i t was revealed t h a t the teacher had not seen the mental h y g i e n i s t ' s r e p o r t containing the conference recommendations, a t the time she had s a i d t h a t a psychometric t e s t was unnecessary. Arrangements were now being made t o have t h i s recommendation c a r r i e d out. The teacher s a i d t h a t David's parents had been most cooperative with the school i n i t s attempts t o help the boy. The school nurse reported t h a t she would again have i n t e r v i e w s with the mother. Later, another progress r e p o r t was made. This summary of the r e p o r t i s as f o l l o w s : The r e s u l t s of the i n d i v i d u a l 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 t o be "average". (This t e s t was given 8 months a f t e r the above-quoted l e t t e r from the mental h y g i e n i s t ) . At school David had been placed i n the "A" c l a s s . He was repeating Grade 1. He was s t i l l somewhat immature and e x c i t a b l e , but there had been considerable improvement i n t h i s area. The parents and teacher were w e l l s a t i s f i e d w i t h the progress made by David. The f i n a l progress report was sent t o the mental h y g i e n i s t , 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" c l a s s i n Grade 2 and able t o keep up with h i s school work e a s i l y . At home, the parents had been able t o 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 . H i s former symptoms had disappeared. The case was c l o s e d . E v i d e n t l y , the teacher though instrumental i n having t h i s boy examined a t the c l i n i c , was unable t o attend the conference which followed the examination.  Although a l e t t e r containing the recommendations was  sent t o 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 p u p i l , the teacher and nurse confer from time to time.  The duties of p r i n c i p a l s are manifold, as l i k e -  wise, are those of public health n u r s e s . T h e  addition of p s y c h i a t r i c  s o c i a l workers to the Mental Hygiene C l i n i c s t a f f , and s o c i a l workers i n the schools should l i g h t e n the r e s p o n s i b i l i t i e s of nurses, and p r i n c i p a l s and make f o r closer cooperation among the various persons concerned with the welfare of the p u p i l s .  This closer cooperation and consequent better  understanding, together with the special s k i l l s of s o c i a l work would undoubtedly r e s u l t i n more adequate services t o emotionally disturbed children. The case of Sam G., aged 10 years 7 months, i l l u s t r a t e s the need f o r close contact between the parents and the c l i n i c i f the recommendations made after examination are t o be of value. Sam was isf erred t o the Child Guidance C l i n i c by h i s mother because he had "no sense of r e s p o n s i b i l i t y " and was " f u l l of f e a r s " . This boy's poor school achievement, although he had high i n t e l l i g e n c e , as well as h i s aggressive behaviour toward h i s brother have been r e f e r r e d to previously i n t h i s chapter. Both parents had high school education. Mrs. G. was 6 years older than her husband. The parents had several mutual i n t e r e s t s such as a t h l e t i c sports, reading, entertaining, and community a c t i v i t i e s . The father was not seen by the s o c i a l 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 l i v e d i n a comf o r t a b l e home i n a good neighbourhood. The father was a successf u l business executive.  Besides her work i n the school, each public health nurse spends some time i n Child Health Centres (Well-Baby C l i n i c s ) , v i s i t s tuberculosis cases i n her d i s t r i c t , and a s s i s t s with the program f o r the control of communicable diseases.  94. Sam was breast-fed f o r 2 months, and weaned from b o t t l e 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 t o "bring him up s c i e n t i f i c a l l y " . According t o the mother t o i l e t t r a i n i n g presented no d i f f i c u l t y and was completed before Sam was ife years o l d . At an e a r l y age (about 2 years) Sam plucked at h i s clothing, p u l l i n g out the threads. Shortly a f t e r t h i s thumb sucking, head scratching, and picking a t h i s ears, nose and f i n g e r n a i l s were "annoying h a b i t s " developed by Sam. These habits persisted up t o 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 b i t i n g h i s f i n g e r n a i l s . When Sam was 3, a baby brother was born. Because the parents had been t o l d that t h i s would be t h e i r l a s t c h i l d , they "lavished attention" on the baby. From the beginning Sam seemed to resent t h i s . The mother said that she f e l t that Sam had "suffered through l a c k of a f f e c t i o n 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 a f t e r he returned t o school, he became i l l and was h o s p i t a l i z e d f o r a month because of n e p h r i t i s . The mother s a i d that Sam had not entered i n t o active sports. "He always seemed to be a f r a i d of hurting himself. He's too cowardly t o catch a b a s e b a l l . His father and I are so disappointed. We were both a t h l e t i c . " Mrs. G. said that Sam had wanted h i s own way since infancy, had always been "fussy", and a "lone wolf". Mrs. G. also commented on Sam's fear of water, both a t the beach and i n the bath tub. He did not even l i k e t o wash, and i n s i s t e d on being bathed by h i s mother. The mother considered these "problems" more acute since Sam had had n e p h r i t i s . Sam's i n t e r e s t s were "mechanics, r i d i n g h i s b i c y c l e , making model aeroplanes, and boats." He was very interested i n science, e s p e c i a l l y 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 i n t e r e s t s . He d i d not have any f r i e n d s of h i s own age. The mother attributed t h i s t o h i s "bossiness". The parents had considered sending Sam to a private school f o r boys. I t was c h i e f l y f o r advice about t h i s that the mother sought the help of the c l i n i c . They thought that t h i s might be of help i n solving many problems, p a r t i c u l a r l y the constant q u a r r e l l i n g between Sam and h i s brother. Sam was examined shortly before the end of the school term. At the c l i n i c , Sam was uncommunicative concerning h i s f e e l i n g s  95. about h i s home and family, and about school.  His I.Q. was  150.  The recommendations of the c l i n i c were given d i r e c t l y to the mother by the examining p s y c h i a t r i s t .  I t was noted by the p s y c h i a t r i s t  that the mother appeared t o be very i n t e l l i g e n t .  She was somewhat tense,  and had prepared a l i s t of questions to ask the p s y c h i a t r i s t . f u l l y wrote down a l l of h i s recommendations. 1. 2. 3. 4.  These were as follows:  Attendance at Y. Camp f o r a period during the summer holidays. Private boarding school f o r at l e a s t a year. The boy should be given e l e c t r i c a l apparatus t o work with. Parents should not expect Sam to play with boys of h i s own age. They should not expect the younger brother t o keep up with Sam.  This boy was referred to the c l i n i c i n 1945, ages were acute. 1948,  She care-  when s t a f f short-  No follow-up work was done by the s o c i a l worker.  In  a f t e r there had been some enlargement of the c l i n i c s t a f f , i n q u i r i e s  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 c u r t a i l e d . was one of these patients.  Sam  The mother's r e p l y 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 t o a private boarding school i n the i n t e r i o r of B r i t i s h Columbia. They had remained there f o r 2 years. They were now at home and attending the public school i n the neighbourhood. Rather b i t t e r l y the mother said "Sara i s worse than ever, and John i s j u s t about as bad. They f i g h t more than ever, and neither of them have any sense of r e s p o n s i b i l i t y " . 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 d i d not enter i n t o active sports. His i n t e r e s t s were said to have dwindled to "only e l e c t r i c i t y and r a d i o s " . The mother commented on how much money had been spent i n sending  96  the boys t o private school and how discouraged she and her husband were with the r e s u l t s .  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 l i k e t o have the help of the c l i n i c .  This  case was assigned to a male s o c i a l worker and a summary of h i s 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 d i d not seem to understand how Sam could l e a r n to evade t h i s routine or be unhappy i n accepting the "more normal i n t e r e s t s " which the parents t r i e d t o impose upon him. . She refused t o see that environment had anything to do with the problem. Three weeks l a t e r , Sam was interviewed by the s o c i a l worker. The boy was described as "small f o r h i s age". Sam remarked that h i s father had t o l d him that he would probably "turn out to be a tramp radio man". The boy would not bring up any negative f e e l i n g i n r egard to the l i m i t a t i o n s set by h i s 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 d i d not understand one another. Sam showed very l i t t l e response to t h i s except i n terms of everything teing " a l l r i g h t " . I t was noted that the boy was extremely p o l i t e . A month l a t e r the worker v i s i t e d 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 d e f i n i t e " t o t e l l the parents. Mrs. G. quoted Sam's remarks a f t e r h i s i n terview with the s o c i a l worker: "What i s that Child Guidance C l i n i c ? A r e c r u i t i n g centre f o r Essondale?" During t h i s interview with the mother the worker pointed out that the parents methods of t r a i n i n g and t h e i r reactions to t h e i r c h i l d ren were natural ones a r i s i n g from the parents own experiences.  He t r i e d  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 t r a i n i n g .  97. The mother suggested that perhaps she and her husband had expected too much of the boys and had placed too many r e s p o n s i b i l i t i e s upon them. Mrs. G. accused Sam of being self-centred and "working i n reverse". At t h i s point the worker pointed out what Sam by h i s negativism and by passively working against the parents was showing strong resentment inside himself and r e a l f e e l i n g that he could not compete equally with other children. He said that the c l i n i c might help the parents f i n d out how Sam's resentment and pent-up feelings could be changed and p a r t i c u l a r l y how the parents' handling might change t o meet t h i s special s i t u a t i o n . The mother then said that perhaps her.husband would have time i n the next month to see the worker. She said that she would phone l a t e r and l e t the worker know about t h i s . The s o c i a l worker during h i s v i s i t s to the home.had observed the mother's negative methods i n handling the one and a h a l f year old boy (a t h i r d c h i l d had been bom while the 2 boys were attending the private boarding school). Mrs. G. shouted at t h i s c h i l d , and constantly followed him saying "No, no", "Don't touch", e t c . She said that she was determined that t h i s c h i l d would learn the meaning of "no". When Sam came home from school, he showed the worker h i s room and "radio l a b " . Again the boy was exceptionally courteous but completely uncommunicative on the subject of h i s f e e l i n g s about the home s i t u a t i o n . 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 t o o f f e r the c l i n i c ' s help. He phoned the mother and suggested that a plan t o a l l e v i a t e the s i t u a t i o n might be discussed. The mother said that a t the moment she was busy with the baby but she would phone back i n a few minutes. The mother d i d not phone. Two months l a t e r t h i s case was closed. The closing summary ended with the following comment by the worker. " I t appears that Sam's parents are not r e a l l y w i l l i n g t o look a t the problem or at t h e i r own approach t o i t , and i t seems t o be a situation where t h e i r negative and rather destructive methods cannot be changed at t h i s time." The extent t o which these parents would have been w i l l i n g 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 f o r a s o c i a l worker to maintain contact with the family immediately a f t e r Sam's examination, the c l i n i c recommendations might have been carried out i n a more satisfactory manner.  The  parents might have been helped t o recognize the advantages of t h e i r o r i g i n a l 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 h i s home would have been more i n keeping with Sam's needs.  Casework  services with the parents might have been b e n e f i c i a l to the other children i n the family as well as t o  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 f a i l u r e i n the past was a large obstacle to her a b i l i t y t o use casework services when they were offered. There was a-higher percentage of g i r l s i n t h i s group than i n other c l a s s i f i c a t i o n s 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 r e f e r r a l by the teacher t o the Mental Hygiene C l i n i c and aged 9 years when referred by her s i s t e r to the Child Guidance C l i n i c . The symptoms described i n the s o c i a l h i s t o r i e s 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 p s y c h i a t r i s t . This had been done because her older s i s t e r s urged the parents to do something about the child's maladjustment. The family finances, however, did not make i t possible f o r more than 2 interviews with the p s y c h i a t r i s t . The school teacher's report prepared f o r the c l i n i c revealed that she had observed the c h i l d closely and was  99. interested i n understanding the meaning of her behaviour. She was p a r t i c u l a r l y 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 g a i t was awkward. The c h i l d 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 t r i e d to " b u l l y " her mother. Denise showed l i t t l e or none of t h i s a t t i tude toward the teacher. Denise had started school when she was 5g years o l d . 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 s p e c i a l c l a s s . In neither her f i r s t nor second year at school had she shown very much progress. The s o c i a l h i s t o r y revealed Denise was the l a s t c h i l d 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 c h i l d during infancy. At the age of 3, Denise began p u l l i n g out her h a i r . F a c i a l twitching began about t h i s time too. She was described as a "very r e s t l e s s " c h i l d , with a marked tendency t o become "so sti£f and clumsy when excited" that she was hardly able t o walk. The mother said that Denise was "slow, f o r g e t f u l and usually'disobedient" and that she only obeyed "when a f r a i d of punishment". The iecommendations made at the conference were as follows: 1. In the t r a i n i n g and management of t h i s child the parents should be guided by the general p r i n c i p l e s of habit t r a i n i n g and the establishment of good emotional a t t i t u d e s . 2. The child should be enoouraged to do things f o r h e r s e l f at home. 3. T'he mother should avoid nagging. (The above recommendations were discussed with the mother by the mental h y g i e n i s t ) . 4. The c h i l d has normal i n t e l l i g e n c e and should be restored to regular class soon. The p s y c h i a t r i s t pointed out the p o s s i b i l i t y of s l i g h t b r a i n damage at the patient's b i r t h . The progress report 6 months a f t e r t h i s conference described improvement i n Denise's adjustment. She appeared to be more s e l f - r e l i a n t . Her g a i t was l e s s 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 c h i l d on the part of the teacher undoubtedly contributed much t o t h i s improvement.  The mother's  interview with the mental hygienist and home v i 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 s i t u a t i o n that t h i s case was closed. About 2 years a f t e r t h i s progress report the case was referred to the Child Guidance C l i n i c by one of the patient's older s i s t e r s 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 i n many respects they were i n t e n s i f i e d . The mother's anxiety about the c h i l d was increasing. In giving the information f o r the s o c i a l h i s t o r y there were many things about the c h i l d ' s e a r l i e r development which she could not remember. She mentioned her own tendency t o cry at the l e a s t thing and dried her eyes almost continuously during the interview. Mrs. C. said that Denise was "just an e n t i r e l y d i f f e r e n t c h i l d " from her other daughters and that she worried about her future. In her interview with the p s y c h i a t r i s t the mother questioned whether Denise would ever be self-supporting. She complained that the father had not given t h i s c h i l d any attention. Psychological t e s t s revealed that Denise had average i n t e l l i g e n c e . She appeared t o be very withdrawn throughout the t e s t . In the play room she seemed shy and immature. She spoke baby t a l k t o her mother but dropped i t when speaking t o others. She was rather c h i l d i s h and awkward with play things dropping toys and f a l l i n g on the f l o o r . At the conference i t was f e l t that there was a d e f i n i t e element of r e j e c t i o n of t h i s c h i l d and an accompanying oversolicitousness. Home relationships were considered poor and the family i n need of a good deal of help i n order to understand t h i s c h i l d . The mother h e r s e l f appeared quite disturbed and possibly tended t o be rather hypocondriacal. I t was the opinion of the c l i n i c team that the c h i l d had assets within h e r s e l f i f she could be better understood and her self-confidence and recognition of h e r s e l f as an i n t e g r a l part of the family could be b u i l t up. I t was recommended that continued casework  101 should be given t o the c h i l d and the parents. This case was transferred t o another s o c i a l worker a f t e r the c l i n i c a l examination. Rather e a r l y i n her contact with the second worker the mother revealed that she had only agreed t o come t o the c l i n i c f o r help because there had been so much pressure from her older daughters t o do t h i s .  One daughter i n p a r t 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 i n t e r e s t e d i n what the mother termed " t h i s new psychology s t u f f " . I n the weekly interviews which followed Mrs. C. poured out her f e e l i n g s 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 a t t e n t i o n from her. At f i r s t she seemed t o t r y t o t e s t the worker t o 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 t h a t ? " she would ask rather t a u n t i n g l y at times, The worker t r i e d t o i n t e r p r e t simply and gradually what "new psychology" would say, and the mother began t o recognize t h a t i n t e l l e c t u a l l y a t l e a s t t h i s was not so "new" t o her. "Do you think i t ' s a l l r i g h t f o r me t o go t o meetings?" ( r e l i g i o u s sect not approved of by the husband and daughters) l e d t o a b r i e f d i s c u s s i o n which apparently r e s u l t e d i n the mother's f e e l i n g t h a t she was accepted by the worker. The f o l l o w i n g week Mrs. C. remarked "I've been t h i n k i n g t h a t 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 t o give a" person the chance t o b u i l d up the good things i n themselves and they both say that people can help one another." Having released some of her resentment and f e a r s , Mrs. C. slowly began t o look f o r the p o s i t i v e t h i n g s which she might do t o help Denise. She was e a s i l y discouraged, however, and needed help i n understanding t h a t evidences of improvement might be gradual. No longer d i d she make such remarks as "She's a queer one. None of the p s y c h i a t r i s t s can f i g u r e her out." T h i s mother f i n a l l y developed the courage required t o face a serious s u r g i c a l operation which she had postponed f o r a long time. For 13 years she had suffered from a p h y s i c a l condition which caused almost complete l a c k of bladder c o n t r o l . There was an equal number of interviews with Denise during t h i s time.  Through play a t f i r s t (she was too withdrawn t o t a l k ) t h i s c h i l d  showed indications of her f e e l i n g s of r e j e c t i o n . A l l of the toy furniture associated with babies (high chairs, play pens, cradles, etc.) were thrown i n t o a room i n the d o l l house which Denise c a l l e d the a t t i c . "These people don't want any more k i d s . The mother says she's had enough babies" was her f i r s t remark while playing. Another day, repeating t h i s 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 t o have twins." The c h i l d f i n a l l y placed 7 baby d o l l s 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 f o r 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 t h i s 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 " I f I had a band-aid and s t u f f 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 " j u s t sometimes he's so mean". At f i r s t Denise used the term "one of my mother's daughters" rather than "my s i s t e r " . (The mother referred to her children as "my oldest daughter", "my second daughter", etc.) The c h i l d ' 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 f o r discussion of Denise's place i n the family group. The c h i l d appeared not too sure of her p o s i t i o n . There were i n d i c a t i o n s that she f e l t on the f r i n g e of the family c o n s t e l l a t i o n rather than a part of i t . She learned t o say " s i s t e r " , "niece", "nephew", "cousin", etc., and seemed both surprised and pleased when the worker referred t o her as "mother's youngest daughter". This c h i l d ' s gait became l e s s tense when she v i 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 " d i r t y looks" at others she met i n the c l i n i c corridors. Occasionally now she smiles at them. There i s l e s s f a l t e r i n g i n 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 f r i e n d s and she daydreams a great d e a l . The mother sees a s l i g h t improvement i n Denise's attitude toward small r e s p o n s i b i l i t i e s 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 i n helping t h i s c h i l d and  103.  her f a m i l y . once.  The f a t h e r and 3 of the older s i s t e r s were each interviewed  P o s s i b l y more i n t e r v i e w s w i l l be h e l d w i t h them.  t e s t s may be recommended l a t e r .  Neurological  The examining p s y c h i a t r i s t w i t h whom  the worker consults f r e q u e n t l y about t h i s case doubts whether a s a t i s f a c t o r y adjustment can be made by the c h i l d i n t h i s home, ^he f a t h e r ' s continued l a c k 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 s a t i s f a c t i o n s 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 g r e a t b e n e f i t .  Lacking t h i s , a boarding school or f o s t e r home may be  the means used. I n the case of Denise, the school recognized the maladjustment e a r l y , but the study made by the Mental Hygiene C l i n i c d i d 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 r e l a t i o n s h i p s which had such an important bearing on the c h i l d ' s maladjustment.  Closer follow-up or r e f e r -  r a l of t h i s case by the c l i n i c t o an agency which might have given case work services would undoubtedly have l e d t o b e t t e r r e s u l t s than were obtained. For c h i l d r e n showing unfavourable p e r s o n a l i t y r e a c t i o n s 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 t o c l i n i c was the same as f o r the c h i l d r e n 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".  i  herefore,  104. the average period of 3 years may be considered a more accurate i n d i c a t i o n of the duration of symptoms previous t o c l i n i c a l examination than i t was i n the case of patients showing s o c i a l l y unacceptable behaviour.  The  lack of awareness on the part of parents of the a v a i l a b i l i t y of c l i n i c a l services was i n many instances one reason f o r 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 o f the t o t a l number o f cases.  The highest incidence o f  t h i s 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 o f the number o f children whose chief symptoms were habit disorders. The other age groups are represented i n decreasing order as follows: 17.95  8 to 9 years -  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 t h i s c l a s s i f i c a t i o n of symptoms were the 7 to 8 year o l d children and those from 9 to 10 years represented i n the same proportion, (23.08 per cent) but also i n r e l a t i o n to the t o t a l number of patients In each age group the proportion was i d e n t i c a l (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 o f disorders i n habit formation.  Likewise, i n the 9 to 10 year o l d group, about 1 out o f every 5  patients were referred f o r t h i s reason. Patients from families o f 2 children represented the highest percentage of patients with habit disorders ( 2 5 . 6 4 per cent).  The second  highest incidence was found i n f a m i l i e s with one c h i l d (20.51 per cent). Patients from families of 3 children comprised 17.95 per cent.  Larger  families were represented i n t h i s c l a s s i f i c a t i o n 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 will 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 will 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 contributing 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 d i s orders i n habit formation, the c l i n i c studies indicated that i n only one out of every 4- cases o f t h i s kind children had d i f f i c u l t y i n group adjustment.  In t h i s respect children i n t h i s group showed l e s s maladjustment  than those i n the other c l a s s i f i c a t i o n s o f symptoms. One example o f 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 " s o i l i n g , enuresis, t i m i d i t y and quarrelsomeness". He complained that the boys o f h i s own age teased him and were "too rough". He c r i e d e a s i l y and usually sought the companionship of younger children. He i n s i s t e d on being . the "leader" with these children and was i n c l i n e d to be c r u e l , when h i s playmates opposed h i s leadership. Poor progress i n school was more apparent i n t h i s group o f patients than i n the two c l a s s i f i c a t i o n s 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 s u l l e n and uncooperative i n school. i n Grade 2 was slow.  His i n t e l l i g e n c e was "average".  His progress  Another boy who  was referred to the school c l i n i c by a family agency because of enuresis and s o i l i n g was doing Grade 1 work f o r the t h i r d year.  His i n t e l l i g e n c e .  was "low average". S i b l i n g r i v a l r y was apparent i n 37.5 per cent o f the sample cases.  In comparison with the other c l a s s i f i c a t i o n s o f symptoms, the  proportion of children with disorders i n habit formation showing s i b l i n g r i v a l r y was lowest.  Evidence of maladjustments i n patients' s i b l i n g s was  108. found i n 25 per cent of the sample cases. Seventy-five per cent of the patients i n t h i s group had met with unfavourable circumstances i n the period between b i r t h and the end of t h e i r second year. Harry, aged 6 years 9 months was referred to the C h i l d Guidance C l i n i c by a children's agency because of " s o i l i n g , enuresis, masturbation and destructiveness". This boy was the t h i r d o f f s p r i n g 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 b o t t l e feedings before the age of 10 months. The mother complained that although she had attempted to t o i l e t t r a i n 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 C l i n i c because of enuresis and excessive masturbation, Jane, the second c h i l d i n a family of U» had l i v e d 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 p o l i c e as "a hotbed of v i c e " . The father had spent some time i n prison f o r vagrancy and drunkenness. The mother, a promiscuous woman of borderline i n t e l l i g e n c e had deserted her children f o r several months when Jane was A« Before Jane was 5 years o l d , an e l d e r l y 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 parental d i s c i p l i n e which was harsh, r i g i d or inconsistent. Herman, a 7 year o l d boy whose chief symptom of maladjustment was s o i l i n g l i v e d with a mother who entered into a common-law r e l a t i o n s h i p when her husband deserted her. This boy who had received much blame and punishment from h i s own father met with harsh c r i t i c i s m s from h i s step-father and frequent deprivations  109. as well as "beatings" from'his mother. The case of Hubert S. i l l u s t r a t e s the importance of a c a r e f u l 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 c h i l d i n a family of 5 children. His mother, 43 years of age, was 8 years older than h i s father. The family's economic s i t u a t i o n had fluctuated a great deal, and there were many debts. The family had l i v e d i n several parts of Canada, and i n Alaska. Hubert had been i n Vancouver f o r only 1 year. The home was a f a i r l y large house i n the c i t y suburbs. The f u r n i s h ings were scant. There were no boys' clubs or community centres i n the neighbourhood. This boy had suffered a stomach i n j u r y as a r e s u l t of a car accident when he was only 18 months o l d . He had severe diarrhea for a short time a f t e r t h i s . The food fussiness which had developed around t h i s time had persisted. When he was about 3fe years o l d Hubert had f a l l e n o f f a dredge i n j u r i n g h i s head and remaining unconscious f o r several hours. The enuresis had begun shortly before the boy was 9 years o l d . His father was i n the Navy and away from the family when t h i s symptom developed. During the year previous to Hubert's examination a t the c l i n i c , the father's employment had kept him away from the family f o r months a t 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 r e sented the authority given to t h i s older brother. In school Hubert's work (grade 6) was average. His poor speech was observed by the teacher. The boy's group adjustment 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 contained i n the s o c i a l h i s t o r y were as follows: "complains of deafness", "choreaform movements" and "enuresis-sores on buttocks". The s o c i a l history made i t obvious that Hubert's environment such that emotional disturbances might be expected.  was  One of the most f a -  vourable aspects i n the family s i t u a t i o n was that the father had recently  110, returned to Vancouver and was seeking employment i n the c i t y which would make i t possible f o r him to l i v e at home. The mental hygienist«s interview with the mother revealed that she was "an excitable, dependent person". The recomraendations a r i s i n g out of the conference were? 1. The nurse should see the boy's father and form an opinion about h i s responsiveness to advice. The father should be encouraged to o f f e r the boy more companionship and encouragement. 2. An ear, nose and throat i n v e s t i g a t i o n should be made i n order to discover the cause of Hubert's deafness. 3. The boy should be given an opportunity to j o i n the Y.M.C.A. or the Boy Scouts. A. Although the enuresis might be based on anxiety, a u r i n a l y s i s should be made. The progress report 6 months a f t e r the c l i n i c a l examination was b r i e f and d i d not indicate the extent to which the above recommendations were carried out.  I t d i d reveal- however the v a l i d i t y of the recommend-  ation f o r u r i n a l y s i s .  Information contained i n the report was as follows?  Hubert had been severely i l l about 1 month a f t e r h i s examination a t the c l i n i c . He was taken to a h o s p i t a l where a diagnosis o f diabetes mellitus was made. Diet and i n s u l i n 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. been done u n t i l Hubert was hospitalized.  The u r i n a l y s i s had not  I t appears probable that the  recommendation regarding ears, nose and throat i n v e s t i g a t i o n 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 f o r c l i n i c a l examinations e a r l i e r than those having other symptoms of maladjustment.  How-  ever, the average period of time between the f i r s t occurrence o f symptoms  Ill and examination was 2 years and 5 months, and there are i n d i c a t i o n s that most of the patients were exposed to faulty methods of "curing" the d i s orders.  I n most instances, during t h i s period no attempt was made t o  seek for underlying causes.  These patients would undoubtedly have been  spared much discomfort, had they been r e f e r r e d f o r 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 r e ferred because they appeared to have d i s a b i l i t i e s i n s p e c i f i c school subjects.  This number represents l e s s than 15 per cent o f the t o t a l number  of cases.  The highest incidence (23.67 per cent) of t h i s problem was  found i n the 6 to 7 year o l d group,  ifiji equal percentage of cases (18.41  per cent) were found i n the 7 to 8 and 8 to 9 year o l d groups.  As might  be expected the occurrence o f t h i s 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 o l d children who were referred because o f d i s a b i l i t i e s i n s p e c i a l school subjects comprised 22.5 per cent of a l l the patients i n t h i s age group.  Reading was the school subject with which  the majority o f these patients as well as those i n other age groups had difficulty.  Arithmetic was second on the l i s t , while mirror writing was  the reason f o r examination i n only one of the cases. One h a l f of the patients with s p e c i f i c 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 o f the patients i n t h i s c l a s s i f i c a t i o n .  Pat-  ients from f a m i l i e s of 3 children comprised 18.42 per cent, and those from f a m i l i e s of 4. - 7.9 per cent o f the cases i n t h i s group. the patients came from families o f more than 4-.  None o f  113. A markedly high percentage (44.71) o f these patients were the "youngest" member of f a m i l i e s .  In no other c l a s s i f i c a t i o n o f symptoms as  well as i n no other category of the o r d i n a l positions i n the family was such a high percentage found.  The nearest percentage to t h i s was i n the  " s o c i a l l y unacceptable behaviour" c l a s s i f i c a t i o n i n which 37 per cent of the patients were the "oldest" i n t h e i r f a m i l i e s .  "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 h a l f as many (10.52 per cent) were "middle" children. Although i n 1 out of every 3 of the 257 c h i l d r e n examined there were factors of family disorganization which appeared to contribute to the patients' maladjustment  i n t h i s p a r t i c u l a r group such factors were  evident i n l e s s than 1 out o f 6 cases.  Marked discord between the parents  was the most frequently found factor of family disorganization, t h i s being apparent i n h a l f o f the cases i n which such influences were found. S i m i l a r l y , the three other f a c t o r s contributing to maladjustment, namely, absence o f the father while serving i n the armed forces, inadequate housing, and interference of r e l a t i v e s l i v i n g i n the home, were l e s s f r e quently found i n t h i s group than i n other c l a s s i f i c a t i o n s of symptoms. A comparison between the i n t e l l i g e n c e l e v e l s of the children who had d i s a b i l i t i e s i n s p e c i f i c school subjects and those o f children who were referred because of other symptoms reveals that i n the first-named group the i n t e l l i g e n c e quotients were "average" and "low average".  In  only one case (2.63 per cent) i n t h i s group was the i n t e l l i g e n c e "superior", and i n no cases were the t e s t r e s u l t s i n d i c a t i v e of "very superior" or "near genius" i n t e l l i g e n c e , although such r e s u l t s 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 entered 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 achievement. 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 disabilities 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 s i b l i n g r i v a l r y by attempting to arouse competition between patients and t h e i r s i b l i n g s .  An i l l u s t r a t i o n of t h i s  follows. One boy who had f a i l e d i n 2 grades c h i e f l y because of poor reading was told "Wait t i l l Jeannie starts to school. S h e ' l l learn quickly and w i l l soon be able to read the comics to you." In 37.5 per cent o f the sample cases, s i b l i n g s of patients showed  maladjustments.  In the case o f an 11 year o l d boy, h i s 13 year o l d s i s t e r had also been examined a t 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 o l d boy had a s i s t e r , aged 6, who was described as "destructive, and high strung". ( C l i n i c a l services were l a t e r requested by the parents f o r the younger c h i l d ) . In 75 per cent of the sample cases, patients had experienced unfavourable circumstances i n the period between b i r t h and the end o f t h e i r second year. Gerald, a 7 year old boy, who was examined because of a reading d i s a b i l i t y , was born i n t o a family where neither parent wanted a second c h i l d . The mother was quite i l l during most of the pregnancy and remained i n bed f o r 6 months a f t e r h i s b i r t h . The infant was cared f o r by r e l a t i v e s , friends and the father during t h i s time. Feeding d i f f i c u l t i e s arose. T o i l e t t r a i n i n g was begun early, and the mother was quite r i g i d and demanding i n the methods she used to e s t a b l i s h bladder and bowel control. This c h i l d was severely i l l with whooping cough i n h i s second year. E i l e e n (aged ll£ years) was referred to the c l i n i c because of reading d i s a b i l i t y , had been suffocated at b i r t h . The mother had not had medical assistance during confinement. When 10 months old t h i s c h i l d had an abscessed jaw. During her second year she had pneumonia. In her f i r s t 3 years, as well as l a t e r , t h i s c h i l d had l i v e d i n a family where there were many stresses such as discord between the parents, unemployment, and frequent changes i n residence.  116. Negative factors i n the period from the t h i r d 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 c l a s s i f i c a t i o n s , 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 t h i s period.  In 85 per cent of the cases i n which patients showed s o c i a l l y  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 t h i r d to sixth year period. Roy (aged 8 years) referred to Child Guidance C l i n i c because of i n a b i l i t y to l e a r n to read, had met with unfavourable experiences during h i s f i r s t 3 years (strong resentment at the b i r t h of a s i b l i n g , asphyxiation, and i n j u r y i n a car accident). I t was i n the period between h i s t h i r d 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 h i s t h i r d and fourth year. Each time he was " t r a i n - s i c k " . He had t o n s i l s and adenoids removed when he was about 4- years o l d . Soon afterwards the family went to l i v e i n the maternal grandfather's home. The grandfather i n sisted on quietness i n the house, and refused to permit other children i n 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 s i s t e r . Shortly a f t e r the boy was 5 years o l d he injured h i s head when he f e l l from a swing. He was hospitalized f o r a short time. A few months l a t e r he stood by and watched with terror, a r t i f i c i a l r e s p i r a t i o n applied to h i s younger'sister when she had almost drowned. At the age of 6 t h i s boy started to school r e l u c t a n t l y , not wanting to leave h i s mother who had been i n bed f o r several weeks because of rheumatic fever. Harsh, r i g i d or inconsistent parental d i s c i p l i n e was found l e s s 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 c l a s s i f i c a t i o n s of symptoms.  This was evident i n only  25 per cent of the cases i n t h i s group, whereas i n 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 o f the cases showing s o c i a l l y unacceptable behaviour such d i s c i p l i n e was apparent. Roy, referred to above, met with harsh words from h i s grandfather. Some o f his threats were: " I ' l l break your neck," " I ' l l knock the head o f f you", and " I ' l l turn you over to the p o l i c e " . Sometimes when the boy spoke a t 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 t h i s 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 f o r a family with children. They t r i e d to compensate f o r the grandfather's harshness by being over-indulgent with the boy and h i s s i s t e r . Eleven year o l d 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 h i s wife and c h i l d 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 o f the sample cases, disabi l i t i e s i n special school subjects were attributed to s o c i a l and emotional factors and the recommendations stressed the a l l e v i a t i o n of the adverse influences i n the c h i l d ' s environment.  Progress reports of such cases  indicated that as the environment became more s t a b i l i z e d , the d i s a b i l i t i e s i n s p e c i a l school subjects diminished or disappeared.  I n the case de-  scribed below, however, the c l i n i c a l diagnosis was "severe reading d i s a b i l i t y " and the c l i n i c a l recommendations centred around obtaining f o r the c h i l d d i r e c t help i n reading. Stephen W. (aged 7 years 2 months) was r e f e r r e d to the C h i l d Guidance C l i n i c by h i s mother on the advice of the school p r i n c i p a l . The symptoms presented v/ere "unable to read, and slow i n school".  118. Stephen's father was a t f i r s t reluctant to have the boyexamined. He had thought that the c l i n i c was "only f o r feebleminded children". The boy was the younger o f two children. His s i s t e r aged 11 had great d i f f i c u l t y i n learning arithmetic. The family l i v e d i n a comfortable home i n an average neighbourhood. This appeared to be a united family group and both parents seemed eager to give t h e i r children emotional security. They were concerned because Stephen had been teased by his c l a s s mates when he had f a i l e d i n Grade 1, and had since that time f r e 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 c h i l d having had a serious f a l l when only a few months o l d . She wondered too about a head i n j u r y Stephen had received when he was 2 years of age. She mentioned that the c h i l d had always been "rather slow". He had had many colds and frequent nose bleeds. The phsyical examination a t the c l i n i c revealed that Stephen had enlarged t o n s i l s and adenoids. The t o n s i l s 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 p s y c h i a t r i s t ' s interviews with the mother and c h i l d did not reveal anything negative.  1. his 2. re  The c l i n i c recommendations were: The c h i l d should be examined by the family doctor as t o n s i l s and adenoids require attention. S o c i a l worker should confer with the school p r i n c i p a l s p e c i a l tutoring d a i l y f o r the boy. The mother had already made an appointment f o r Stephen with the  family doctor before the s o c i a l worker's f i r s t v i s i t following the c l i n i c a l examination.  Both parents were encouraged by the knowledge that  Stephen had normal i n t e l l i g e n c e . The parents expressed willingness t o provide help f o r the boy i n the form of tutoring i n reading and asked f o r the s o c i a l worker's assistance i n f i n d i n g a suitable t u t o r .  119. When the s o c i a l worker conferred with the school p r i n c i p a l and teacher about t h i s she learned that there were no remedial classes i n the school. However, the teacher said that she would give Stephen special remedial reading every day i n i n d i v i d u a l work with him. Three months l a t e r , t h i s case was closed. Stephen's t o n s i l s and adenoids had been removed and already an improvement i n h i s health was noted. With the s p e c i a l help from his teacher, Stephen had made considerable progress i n reading. Both the teacher and the parents observed that Stephen was developing normal aggressiveness. He said that he l i k e d school better and t h i s was quite apparent to h i s teacher and parents. Two years l a t e r 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 f o r h i s s i s t e r . The r e s u l t s of the special lessons f o r the g i r l had been good. She, too, had been promoted each year and was enjoying school. The successful outcome of t h i s case may be attributed i n part to the school's recognition o f the problem and to the c l i n i c ' s diagnostic services.  However, neither of these would have been e f f e c t i v e 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 o f early recognition of maladjustment was more apparent i n the sample cases i n t h i s 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 r e f e r r a l , being 3 years and U months.  In these cases  as well as i n those of children showing s o c i a l l y unacceptable behaviour, unfavourable personality reactions, or disorders i n habit formation,  e a r l i e r recognition of the problem and thorough i n v e s t i g a t i o n of underl y i n g causes would have benefitted the patients.  121. CHAPTER 9. RECOMMENDATIONS AND RESULTS The major o b j e c t i v e i n the c l i n i c a l study o f each c h i l d i s the strengthening o f the p a t i e n t so t h a t l e s s 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 h i s formation and use o f unhealthy symptoms. I n both o f the Vancouver c l i n i c s the conference i s used f o r the formulation of plans which o f f e r the c h i l d help.  Frequently the forms o f  assistance which h i s home, school and community might give are d e l i n e a t e d . Besides these i n d i r e c t methods o f h e l p i n g 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 h i s welfare. These plans f o r treatment, d i r e c t and i n d i r e c t , are based on what i s known o f the c h i l d through the c l i n i c ' s study o f him as an i n d i v i d u a l and as a member o f h i s f a m i l y group and s o c i e t y .  His unmet needs i n the past  and h i s methods o f attempting t o meet these needs are taken i n t o considera t i o n by the persons formulating the plan. The four general types o f approach to treatment as already outl i 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 s environment (2) the f i n d i n g o f new o u t l e t s f o r the pat1  i e n t ' s energies or c a p a c i t i e s (3) remedying o f the p a t i e n t ' s s p e c i f i c p h y s i c a l 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) d e a l i n g d i r e c t l y w i t h the p a t i e n t ' s psychic problems.  Such approaches t o treatment were found i n  the recommendations made by the Vancouver c l i n i c s .  I n the samples o f case  studies given i n the preceding chapters s p e c i f i c recommendations o f the  122. examining c l i n i c were given i n d e t a i l .  In the accompanying table based on  the 20 per cent sample (52 cases), f i v e c l a s s i f i c a t i o n s of treatment recommendations are used, a separate category having been u t i l i z e d t o class i f y proposals f o r educational adjustment.  Table 1-4 FREQUENCY OF TYPES OF RECOMMENDATIONS MADE AT CLINIC CONFERENCES (Total of 52 cases.) Rank 1  2  Recommendation Adjustment of the home situation (a) Social or educational work i n the home (b) Advice regarding methods of t r a i n i n g (c) Suggestions regarding s i b l i n g r e l a t i o n s h i p s (d) More companionship with father (e) Consideration of placement S o c i a l Adjustment (a) Development of recreation and other specific interests (b) Opportunities f o r adequate s o c i a l r e l a t i o n s h i p s (c) "Summer camp  3 Educational Adjustment  (a) Advice t o teacher regarding handling of patient (b) Adjustment of grade placement (c) Change of school  No.  Rate Per Case 98 1.88  40 22  13 12 11 44  .84  16 15  13 27  12  .54  11 4  4  Improvement of physical health (a) Referred t o physician f o r treatment (b) Supplementary examinations  22  12 10  .42  5  Direct treatment of the patient  15  .28  206  3.96  Total  Clearly, many aspects of children's needs are recognized i n the c l i n i c s ' e f f o r t s t o f a c i l i t a t e the adjustment of patients.  I t w i l l be  noted that almost h a l f of the recommendations involved work with the patients' f a m i l i e s .  This indicates the c l i n i c s ' acceptance of the theory  123. that "the chief supports or hindrances f o r the i n d i v i d u a l i n h i s struggle to adjust himself are found i n the family. Whether he develops emotional maturity depends very l a r g e l y upon h i s home and h i s parents. "(1)  In the  preceding chapters s t a t i s t i c a l data and case i l l u s t r a t i o n s have demonstrated the m u l t i p l i c i t y of socio-economic f a c t o r s which impinge upon the personality development of children.  But diagnosis alone i s of no a v a i l  i f d e f i n i t e co-ordinated e f f o r t s are not made t o a l l e v i a t e the stresses which have created unhealthy symptoms. Although recommendations concerning s o c i a l adjustment  ranked  second i n frequency, progress r eports and case records d i d not indicate that careful attention had been given t o t h i s .  For example i n 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, s o c i a l h i s t o r i e s made such statements as "This boy spends most of h i s f r e e time a t X — H use (Community Centre)" 0  or "June belongs t o a g i r l s ' group a t  ". In only one of the sample  cases had a v i s i t been made t o the Centre named and i n q u i r i e s made about the c h i l d ' s p a r t i c i p a t i o n i n group a c t i v i t i e s , and h i s adjustment as observed 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 i n v i t e d to or attending a c l i n i c conference. The extent to which recommendations f o r educational adjustment was carried out was d i f f i c u l t t o determine. (1)  I t i s probable that the con-  Menninger, William C., Psychiatry: I t s Evolution and Present Status Cornell University Press, I t h i c a , New York, 1948. p. 101.  124. f e r r i n g of nurses and teachers was more frequent than progress reports indicated.  The adjustment of grade placement was not approved by school  p r i n c i p a l s i n 4. out of the 11 was recommended.  cases i n which the consideration of t h i s  These 4 were cases i n which pupils' i n t e l l i g e n c e quot-  i e n t s indicated that they would be able to make progress i n a higher grade. I f the school p r i n c i p a l ' s had been present at the conferences i n which these recommendations were made, i n a l l p r o b a b i l i t y they would have given t h e i r reasons f o r not considering t h i s a suitable plan.  Such d i s -  cussion by the p r i n c i p a l s might have been valuable to members of the c l i n i c team and others at the conference, i n c l a r i f y i n g the school's point of view.  At the Child Guidance ^ l i n i c , where the schedule i s such that us-  u a l l y 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 f o r the p r i n c i p a l s or teachers to attend.  They are i n v i t e d , however, whenever  such action appears f e a s i b l e except where parents are not w i l l i n g t o have their c h i l d ' s problem discussed with representatives from the school. Conferring with the p r i n c i p a l 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 r e s u l t s i n the cases i n which t h i s was done by the Child Guidance C l i n i c s o c i a l workers. (1) Frequently, however, the only contact with the school was p r i o r 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 i n Chapter 8, this.  pp. 117-119 i l l u s t r a t e s  125 contained i n the c l i n i c records.  One instance i n which t h i s was not car-  r i e d out was referred t o 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 i n a treatment and ob-  servation centre i f one were a v a i l a b l e " and similar statements were found i n 6 out of the 15 cases i n which recommendations f o r the d i r e c t treatment of the patients were made.  The examining p s y c h i a t r i s t s made t h i s  comment to stress the seriousness of the patient's problems as well as t o provide a means of determining i n part a t l e a s t the number of c h i l d r e n requiring a period of time i n a treatment and observation centre.  In  these 6 cases as well as others i n which d i r e c t treatment of the c h i l d was recommended the s o c i a l workers i n the c l i n i c or i n family and c h i l d ren's agencies were given d i r e c t i o n by the examining p s y c h i a t r i s t .  Op-  portunities f o r consultation with the p s y c h i a t r i s t were provided f o r the s o c i a l workers i n the course of. t h e i r intensive case work with the c h i l d ren and i n some instances the patients were re-examined by the psychiatrist. The case of Ralph B., aged 9 years 3 months when he was r e f e r red t o the Child Guidance C l i n i c , i l l u s t r a t e s the r o l e of the worker i n the p r a c t i c e of " s o c i a l work undertaken i n d i r e c t and responsible working r e l a t i o n with p s y c h i a t r y " . ( ) 1  I t i l 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 c h i l d whose maladjustment i s serious, and whose home i s unable t o meet h i s needs. Some of Ralph's symptoms and some of the underlying causes of these have (1)Psychiatric s o c i a l work as defined i n the By-laws of the American Association of P s y c h i a t r i c S o c i a l Workers. A r t i c l e VI, Section IA.  126. already been mentioned i n Chapter  5.  Five months before Ralph came to the Child Guidance C l i n i c , he had been referred t o the Mental Hygiene C l i n i c . At that time, h i s mother and teacher had described h i s symptoms as "swearing, poor application at school, poor group adjustment and poor control of temper". The Mental Hygiene C l i n i c 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 e l d e r l y paternal grandmother, who was senile and had marked paranoidal tendencies. The father who d i d not appear to be able t o cope with family d i f f i c u l t i e s had broken 2 appointments f o r an interview with the mental hygienist. Ralph's parents referred him t o the Child Guidance C l i n i c , on the advice of the s o c i a l worker from the P r o v i n c i a l Mental Hospital who had v i s i t e d the home t o prepare the s o c i a l h i s t o r y of the grandmother who had been committed to the h o s p i t a l . The parents t o l d of Ralph's aggressive behaviour at home. He sometimes kicked h i s mother and frequently struck, kicked and b i t h i s father. He had broken windows and the glass i n doors by s t r i k i n g with h i s clenched f i s t s . The symptoms which had l e d to h i s examination by the school c l i n i c persisted. The history of Ralph's e a r l i e r years revealed that as a baby he had c r i e d a great deal, he had "cradle cap" i n infancy and h i s hands had been t i e d t o prevent him from scratching h i s head. d i f f i c u l t i e s during infancy. running ears.  He had had many colds, high fevers, and  When Ralph was 14- months old, a second c h i l d was born, but  died shortly a f t e r b i r t h . the  There had been feeding  During t h i s pregnancy, and a f t e r c h i l d b i r t h ,  mother had been seriously  ill.  The paternal grandmother had l i v e d i n the home from the time of the parents' marriage u n t i l Ralph was over 9 years o l d . There were many family tensions as a r e s u l t of t h i s . 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 t o care f o r him at times while the mother worked outside of the home. The grandmother made threats of physical i n j u r y to the child and frequently t o l d him that h i s habit of masturbating "would r u i n him".  127 The paternal grandfather had died i n a mental h o s p i t a l before Ralph's b i r t h . He had been h o s p i t a l i z e d f o r many years because of manic-depressive psychosis. The f a t h e r was very much concerned about the p o s s i b i l i t y of h i s own mental breakdown because of h e r e d i t a r y f a c t o r s . 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 r e a c t i o n t o the p a t i e n t ' s v i o l e n t behaviour was f r e q u e n t l y t h a t 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 h e r s e l f , by gradual withdrawing. I t was hardly s u r p r i s i n g that the complete examination by the c l i n i c revealed t h a t the boy was severely disturbed. gence was superior.  of Ralph  His i n t e l l i -  At t h e conference the examining p s y c h i a t r i s t pointed  out t h a t the p o s s i b i l i t y of schizophrenia must be considered.  The i n t e n -  sive case work treatment of the c h i l d a s w e l l as work with the parents was recommended by the p s y c h i a t r i s t .  I n the course of c a r r y i n g 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 p a t i e n t was interviewed by the p s y 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 psychoneurosis was made. During the f i r s t 6 months of the s o c i a l worker's contact w i t h the parents and p a t i e n t , 72 hours were devoted t o t h i s case. I f the resources of a treatment and observation centre f o r emotionally disturbed c h i l d r e n had been a v a i l a b l e , some of the temporary measures which had t o be used would not have been necessary.  Lacking t h i s ,  however, other community resources, some of which were not designed f o r such purposes, were marshalled t o help t h i s boy and h i s parents. Interviews w i t h the parents, some j o i n t l y and each parent separately were held f r e q u e n t l y . There play periods and interviews with Ralph. The school and the worker conferred with the school p r i n c i p a l , the teacher on several occasions.  others with were a l s o was v i s i t e d the nurse and  A f i n a l assessing of the i n a b i l i t y of the parents t o take t h e i r place as "partners- i n treatment" with the c l i n i c was made. The f a t h e r , an a n x i e t y - r i d d e n person f o r many years, was on the  128.  verge of a mental breakdown and asked t o have the c h i l d r e moved from the home. The mother too made t h i s request. I t had been d i f f i c u l t i n the past f o r her to maintain equilibrium while she endeavoured t o support and strengthen her emotionally disturbed husband and son. At t h i s point a conference between the c l i n i c and a c h i l d ren's agency was held. The outcome of t h i s conference was that Ralph was placed i n the Receiving Home of the c h i l d placing agency. This was a temporary measure, as the Receiving Home was set up and financed t o serve a d i f f e r e n t group of c h i l d r e n . While Ralph was l i v i n g at the Receiving Home, arrangements were made f o r a 2 week period i n camp. This, too, was a temporary measure and from the point of view of the c l i n i c and the c h i l d 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 t h i s move as providing an opportunity t o work more c l o s e l y with the parents.  The camp  was not geared t o 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 f o r time t o help the parents i n t h e i r decision, accepted the boy as a camper. Soon a f t e r camp, Ralph expressed the desire t o return t o h i s own home. This was arranged but again h i s parents were unable t o deal with h i s extremely aggressive behaviour. On one occasion Ralph and h i s parents became so disturbed that the c l i n i c p s y c h i a t r i s t advised that the worker should recommend that a private p s y c h i a t r i s t should be c a l l e d by the parents f o r the boy. This was carried out and the p s y c h i a t r i s t who came t o the home recommended that Ralph should be removed from h i s parents immediately. Mr. and Mrs. B. agreed that t h i s was necessary and the p s y c h i a t r i s t took Ralph t o the Receiving Home of the c h i l d placing agency. Again the c l i n i c looked f o r community resources acceptable to the c h i l d and parents. Ralph wanted some of h i s home; the parents d i d not want t o r e l i n q u i s h t h e i r guardianship and custody of the boy. A lack of recognition of either the boy's or the  129. parents' d e s i r e s might have p r e c i p i t a t e d the f u r t h e r breakdown of each member of t h i s f a m i l y . A p r i v a t e boarding school seemed t o be the best s o l u t i o n . However, the e a r l i e r evaluation of the. f i n a n c i a l status of the f a m i l y had revealed that outside help was needed. A s u i t a b l e p r i v a t e boarding school was sought, and a t the same time p o s s i b l e community resources f o r the f i n a n c i a l support of such an arrangement were i n v e s t i g a t e d . At t h i s time, the case was t r a n s f e r r e d t o a male worker, because i t appeared t h a t the boy whose r e l a t i o n s h i p with h i s f a t h e r was so poor, might b e n e f i t by t h i s . The s o c i a l worker found a p r i v a t e boarding school, the p r i n c i p a l of which was i n t e r e s t e d i n t r y i n g t o help Ralph. The boy's d i f f i c u l t i e s and needs were c a 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 a l s o found a s e r v i c e club which was i n t e r e s t e d i n f i n a n c i n g the boy's education. Here, too, i t was necessary f o r the s o c i a l worker t o o u t l i n e the nature of Ralph's d i f f i c u l t i e s and p o s s i b l e 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 t o contribute toward t h i s . During the period of more than 2 years which Ralph has been i n the p r i v a t e 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 p a r t time employment, and the parents have gradually been able t o 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 f o r Ralph's attendance a t the school. Meanw h i l e , the s e r v i c e club has been kept informed of Ralph's progress. Summer placement i n a r u r a l f o s t e r home, with b r i e f periods a t home during school holidays have been arranged. Both the boy and h i s parents are aware that f o 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 f o r some time been enjoying a boy's s a t i s f a c t i o n of teing able t o make f r i e n d s w i t h 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 A t h l e t i c Award at the end of h i s second year i n the school. Ralph has become more aware by h i s own problem, and i s gradually recognizing that the almost complete i n a b i l i t y of h i s father to assume the r o l e of a parent i s l i k e l y to be permanent. At present, i t appears that this boy and h i s 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 t h i s boy's maladjustment had grown before treatment began, necessitated a great deal of a c t i v i t y on the c l i n i c ' s part to prevent the t o t a l d i s i n t e g r a t i o n of t h i s family. Accurate evaluation of the outcome or the a f t e r - e f f e c t s 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  e f f e c t of influences other than those of the c l i n i c or other  agencies,  but a l s o the reports of r e s u l t s of the work with and f o r patients varies with the judgment and experience  of those who  make the evaluation.  The  l i k e l i h o o d of inaccuracies i n the estimations of the adjustment status of c h i l d r e n must be kept i n mind i n considering t h i s compilation of r e s u l t s , 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  Personality School abit Average* Socially Unacceptable Reactions Disorders D i s a b i l i t i e s Behaviour | per cent per cent per cent per cent per cent  No follow-up or progress report No improvement Partial Adjustment  tt  20.0  31.25  25.0  37.5  27.0  5.0  6.25  12.5  12.5  7.7  15.0  12.5  12.5  37.5  17.3  Improvement  60.0  37.5  50.0  12.5  4A..2  SatisfactoryAdjustment  -  12.5  ^Wked I.  -  3.8  ft Based on the t o t a l sample of 52 cases. In over one t h i r d of the sample cases examined by the Mental Hygiene C l i n i c there were no progress reports although such r e p o r t s are requested by t h i s c l i n i c .  In the Child Guidance C l i n i c cases referred by  health or s o c i a l agencies f o r diagnostic services, there were no progress reports, unless patients returned t o the c l i n i c f o r repeat or consultative conferences were held.  examinations,  This i s i n keeping with the Child  Guidance C l i n i c p o l i c y which does not request progress reports except as i n 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 t o t a l number of sample cases from both c l i n i c s . According to the above table, the percentage of patients showing s a t i s f a c t o r y adjustment  (3.8 per cent) was only h a l f as large as the per-  centage showing no improvement (7.7 per cent).  However, c l i n i c records  indicate that i n more than h a l f of the cases (51.5 per cent) varying degrees of improvement were noted.  133. CHAPTER  10.  FUTURE GOALS ome of the l i m i t a t i o n s of the c l i n i c services which have been i n d i -  s  cated i n cases described i n the preceding chapters have been remedied to a certain extent during the years under consideration 1948  and the current year.  as well as i n  I t 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 t h i s study, the  p s y c h i a t r i c examinations were made by p s y c h i a t r i s t s from the P r o v i n c i a l Mental Hospital.  There were s t a f f shortages at the Mental Hospital  during t h i s period and  too,  consequently there were l i m i t a t i o n s i n the time  which the p s y c h i a t r i s t s could spend at the Child Guidance C l i n i c . At the beginning of 194&, was  the c l i n i c d i r e c t o r , who,  2 p s y c h i a t r i s t s were appointed.  One  when not engaged i n the work of t r a v e l l i n g  c l i n i c s , acts as p s y c h i a t r i s t at the consultative  conferences i n which  s o c i a l and health agencies seek help i n understanding the p s y c h i a t r i c impl i c a t i o n s of the problems of some of t h e i r c l i e n t s . he T  examines a number of patients.  The  d i r e c t o r also  other p s y c h i a t r i s t wofcks f u l l time at  the Vancouver c l i n i c . There has a l s o been a gradual expansion i n the s o c i a l work s t a f f of the c l i n i c , was  during h a l f of 1945  the c l i n i c supervisor's time  divided between the c l i n i c and the s o c i a l service department of the  134. P r o v i n c i a l Mental H o s p i t a l .  L  a t e r i n the year, one s o c i a l worker was  em-  ployed f o r 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 s o c i a l workers (including the supervisor) on the c l i n i c s t a f f . One s o c i a l worker spends part time as a member of the t r a v e l l i n g  clinic  team. The number of c l i n i c a l psychologists has increased from 3 i n 1945,  to the present psychological s t a f f of 5.  gaged i n t r a v e l l i n g c l i n i c part of the time. been enlarged.  In 1945  there are 3 nurses.  there was  Two psychologists are enThe nursing s t a f f , too, has  one nurse at the c l i n i c j at present  More o f f i c e space and diagnostic equipment has also  been provided to keep paoe with s t a f f expansion. Through the f e d e r a l health grants, 4 members of the c l i n i c s t a f f (one from each profession of the c l i n i c team) have each completed  one  year's advanced u n i v e r s i t y t r a i n i n g . In the Mental Hygiene C l i n i c , too, there has been an enlargement of s t a f f .  An assistant mental hygienist was appointed  i n 1948,  facilit-  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 a l s o added,  to the Mental Hygiene D i v i s i o n , making possible the psychological examination 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 Vancouver.  The appointment of a p s y c h i a t r i c s o c i a l worker i s included i n  t h i s c l i n i c ' s proposed plans.  135. Turning now t o the 257 cases which are the subject of t h i s study, i t was noted e a r l i e r that they comprised only 13 per cent of the t o t a l 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 c h i l d of normal i n t e l l i g e n c e l i v i n g with parents or r e l a t i v e s .  Two reasons f o r t h i s  showing were revealed i n the course of the selection of cases which came within the l i m i t s 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 r e l a t i v e s had i n t e l l i g e n c e quotients below 80. ome of these were brought back to the c l i n i c , 2, 3 and even A times,  s  because the parents d i d not accept the f a c t that t h e i r children were mentally retarded.  Not only d i d 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 f o r emotionally disturbed children.  In some of these cases, the patients l i v e d at too great d i s -  tance from public school special classes to attend, although t h e i r i n t e l l i g e n c e was not too low f o r such classes. The early detection of mental deficiency i n Child Health Centres, and interpretation of t h i s to the mothers would be b e n e f i c i a l t o both children and parents.  With t h i s help, many mothers would be able to face  the situation, and plan accordingly. Too often, mothers t r y t o r e g i s t e r i n Grade 1, children with I.Q.'s below 50, who t o a l l except the parents are obviously d e f e c t i v e . Frequently family tensions are increased and s i b l i n g s become maladjusted when the community lacks resources f o r children whose i n t e l ^ P a t i e n t s up to 18 years of age.  136 l e c t u a l l i m i t a t i o n s are great.  The 2 c l i n i c s as w e l l as s o c i a l and health  agencies might furnish information as t o the extent which t h i s problem i s apparent i n t h e i r cases, which might i n turn give impetus t o more adequate planning f o r severely retarded children.  In Winnipeg, the Child Guidance  C l i n i c (1) was instrumental i n the forming of 3 "occupational" classes f o r feebleminded children with I.Q.'s of approximately  50 or below.  In Vancouver, S t . Christopher's School (under private auspices) i s a boarding school f o r boys of l i m i t e d i n t e l l i g e n c e .  There i s no such  school f o r g i r l s , but many parents have made i n q u i r i e s about such resourr ces.  x  h e only other i n s t i t u t i o n a v a i l a b l e f o r mentally defective children  i s the P r o v i n c i a l Training School i n New Westminster.  There are so many  demands f o r such an i n s t i t u t i o n that with the present f a c i l i t i e s of t h i s school i t i s sometimes necessary f o r children t o wait i n the P r o v i n c i a l Mental Hospital a t Essondale  for several months before entering i t .  Many  parents f i n d t h i s a d i f f i c u l t situation and some remove t h e i r children from the h o s p i t a l .  Anxiety during t h i s waiting period sometimes i n -  creases the family tensions rather than lessening them. Another reason f o r the small proportion of children i n the category surveyed i n t h i s study, i s that disturbed children are frequently not brought to the c l i n i c s f o r help unless the disturbance shows up i n the school s i t u a t i o n or family d i f f i c u l t i e s are s u f f i c i e n t l y acute that a s o c i a l agency i s called i n .  Parents' lack of awareness of the a v a i l a b i -  l i t y of c l i n i c services i s apparent i n many records.  ( l ^ T h i s c l i n i c i s j o i n t l y 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 s i g n i f i c a n t "I had been worried about Frank f o r over 3 years. I t r i e d everything I could think of, and j u s t about everything anyone suggested.  I was desperate.  been crying.  One day, my neighbour noticed that I had  She suggested that the C h i l d 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 a t a banquet  once."  Another mother, whose daughter had been involved i n small t h e f t s commented thus when she terminated her contact with the C h i l d Guidance Clinic: the  "More parents should know about t h i s c l i n i c .  I had noticed i n  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 i n court yet." Parents sometimes learn of the c l i n i c services through t h e i r friends.  Firm one c i t y block i n l e s s than one month came 3 severely d i s -  turbed children.  The f i r s t patient came to c l i n i c as a r e s u l t of r e f e r r a l  by the family doctor. the  Through h i s parents another boy's mother learned of  c l i n i c and referred her child f o r c l i n i c a l examination.  This mother,  i n turn, t o l d the parents of another c h i l d about the c l i n i c and a t h i r d patient was referred f o r 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 f o r mer patients who had f e l t that they had benefitted by contact with the clinic.  Recent newspaper p u b l i c i t y about the Crease C l i n i c as well as  one short a r t i c l e i n a c i t y paper about the Child Guidance C l i n i c have brought a deluge of requests f o r help with problems of long standing.  The  importance of early treatment f o r disturbed children, and of the value of  138 parents taking the i n i t i a l step i n seeking help for these children, i s recognized by the c l i n i c s .  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 advantageous. There are indications i n some of the Child Guidance Clinic records that some of the school principals, nurses and teachers lack information about the Child Guidance Clinic.  There appears to be some feeling  on the part of persons i n the schools, that i f a child i s a pupil he should be examined by the school c l i n i c .  X  he rights of parents to seek help for  their children from whichever clinic they choose i s 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 g i r l s are members of a family too and that parents may observe symptoms at home which are not apparent i n the school. Such attitudes may in part be attributable to a lack of close cooperation between the school and Child Guidance Clinic i n the past when staff shortages made frequent contacts with school personnel almost impossible.  These misunderstandings are not insurmountable, and may i n the  future be overcome to a certain extent by the more frequent conferences between school and c l i n i c personnel which staff expansions have made possible.  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 There ship  between t h e  meeting Child of  are i n d i c a t i o n s 2 clinics  between the  standings school  social  being  Supervisor  Guidance C l i n i c  several  is  that  a more s a t i s f a c t o r y sought.  of the  c l i n i c and s o c i a l  At this  meeting  between the  became  year,  is  Executive some o f  2 clinies  shown i n  concerned about her  a  the Directors  the  misunder-  and between  the  a n d some a g r e e m e n t s  An i l l u s t r a t i o n o f  occurred frequently  S a l l y whose p a r e n t s  and the  a g e n c i e s were d i s c u s s e d  overcoming t h e s e were r e a c h e d .  of t h i s  Metropolitan Health Nurses,  a g e n c i e s was h e l d .  standing which has  In February  D i r e c t o r and S u p e r v i s o r ,  regarding relationships  working r e l a t i o n -  about  one  type  of  misunder-  the  case  of  10 y e a r  temper  t a n t r u m s and  old  suicidal  threats. In July, at  Child  after  school  s c h o o l was history  parents  re-opened.  closed  but the  including  at  S a l l y was  the  time  there when  about  school,  education  was d i s c u s s i o n school  her  person,  school  know t h a t  to  Clinic. so  It  was  concerned  maladjustment concealed disturbed  obvious  to  about her  that  child,  t o S3e  she  mother  the  social  low,  social cards  talked  very  she  about  history,  why s h e  examined  at  d i d n o t want  child's  worker's  teachers  extremely  Child  worker t h a t the  em-  and  seeing S a l l y ' s t e n s e and  the  Guidance  the  mother  Sally's problem  explanation  gave v e r b a l a c c e p t a n c e , later  about  the  can do f o r h e r a t  school,  the  report  I n f o r m a t i o n was  a very  to keep  To the  days The  that  c o u l d d o much t o w a r d h e l p i n g a n u n h a p p y  over  how much we  extremely  this  social  The examining p s y c h i a t r i s t ,  e s t e e m was  Sally's  own c o n t r i b u t i o n t o w a r d  wanted  school.  talk i t  with the  of  mother  the  a few  preparation of  gave numerous r e a s o n s  from the  "We'll  any c o n t a c t  b e g i n G r a d e 5.  complaint being that  of  S a l l y had been  place  Sally herself  The m o t h e r ,  an u n d e r s t a n d i n g t e a c h e r added  to  A l l of  with the  examination  take  the  only  section  re-opened.  talkative  like  of  Sally's  to  mother had saved a l l  "no g o o d i n a r i t h m e t i c " .  bodied i n the  was  arranged f o r  those from k i n d e r g a r t e n .  favourably was  the  G u i d a n c e C l i n i c w h i c h was  aware  suggested t o  and t h a t  i n the  but  school,  immediately  but f i r s t  I'd  home." of  the  mother's  feeling  about  that  Sally's  self-  school,  and the  oom  both parents home,  the  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 a f t e r S a l l y had returned to school, the mother mentioned that the l i t t l e g i r l l i k e d her new teacher. After discussing with the s o c i a l worker the value of a r t lessons for S a l l y , the mother said that she intended to go t o the school soon to inquire about Saturday morning a r t classes. S a l l y had asked her to do t h i s . A few days l a t e r , before the s o c i a l worker had seen the mother again, the supervisor of nurses i n the area i n which S a l l y l i v e d , phoned the worker. She said that the school nurse had learned that S a l l y had been examined at Child Guidance C l 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 preparat i o n of the s o c i a l h i s t o r y . She went on to say that the school had been very concerned about S a l l y , and that she thought that i t was most unfortunate that the Child Guidance C l i n i c had not been more cooperative. The s o c i a l worker commented that evidently the parents had been even more concerned than the school. Her explanation that the s o c i a l h i s t o r y was prepared during school holidays, but that the c h i l d ' s report cards were taken i n t o 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 p r i n c i p a l . The worker then explained that S a l l y ' s mother had as yet been unw i l l i n g to bring the teacher or school nurse i n t o the plan of treatment. However, the C l i n i c saw the need f o r t h i s and was working toward helping the mother recognize t h i s . The whole idea of "accepting the c l i e n t where she i s " , and of parents' r i g h t s to seek p s y c h i a t r i c advice where they choose, seemed completely foreign to the supervisor of nurses. The s o c i a l worker agreed to v i s i t the parents soon, and t o bring to t h e i r attention the school's concern about S a l l y and i t s desire to learn about the findings and recommendations of the C l i n i c . The s o c i a l worker asked how the school nurse had learned about S a l l y ' s examination at Child Guidance C l i n i c , saying that mother would need an explanation of t h i s . Had the school nurse learned through S o c i a l Service Index? •'•he supervisor d i d not know. Had she learned through S a l l y h e r s e l f ? Again the supervisor did not know. The telphone conversation ended on a somewhat happier note when the worker agreed t o contact the school after the next i n terview with the mother, and said that she would l e t the p r i n c i p a l  141. know i f the parents s t i l l refused permission; i f , on the other hand, the parents agreed the s o c i a l worker would arrange t o see the p r i n c i p a l , nurse and teacher. Sally's mother welcomed the s o c i a l worker's suggestion of a v i s i t to the home, saying "I have something good t o t e l l you". The mystery of how the school nurse had learned of the examination was solved when the mother t o l d the "something good" at the beginning of the interview. She r e l a t e d the story of having gone t o the school t o l a l k t o the teacher about S a l l y ' s a r t c l a s s . 'I hadn't intended t o mention Child Guidance C l i n i c that day, but the teacher was so nice that I just up and t o l d her everything. She was very interested. I hope you w i l l go t o the school and t a l k with them about S a l l y . " The pooling of information and the j o i n t approach t o helping S a l l y , which evolved from the s o c i a l worker's v i s i t t o the school had encouraging r e s u l t s . Sally's mother was l a t e r b l e to say how much better she and her husband f e l t about t h e i r r o l e of parenthood. " I t ' s a b i g job, and i t has i t s ups and downs, but we don't have t o grope along alone when we're puzzled about how our children are developing." a  It i s u n l i k e l y that t h i s mother would have learned a new approach to her c h i l d 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 s o c i a l work profession had been included i n the Mental Hygiene C l i n i c personnel.  In 1939, the  future plans of t h i s c l i n i c included the addition of. a s o c i a l worker to the c l i n i c team.  Ten years l a t e r , the proposed plan appears nearer to  f u l f i l m e n t , a grant having been made f o r the salary of a p s y c h i a t r i c s o c i a l worker. A recent s u r v e y ^ ) of the r o l e of the school s o c i a l worker, demonstrated by means of an experimental  study i n one elementary school,  (l)Thompson, Mary A. The S o c i a l Worker i n the School U n i v e r s i t y of B r i t i s h Columbia t h e s i s 1948.  1 4 2 .  that the " i n c l u s i o n o f 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 d e s i r a b l e next step" i n Vancouver Schools.  I n the present  study,, the complexity o f i n t r a f a m i l i a l r e l a t i o n s h i p s and s o c i a l problems i n c l i n i c cases, i n d i c a t e s the need f o r the use o f the p r i n c i p l e s and techniques o f s o c i a l work along with those o f 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 a l s o b e t t e r follow-up might be expected i f s o c i a l workers were included i n the mental health program f o r schools. The value o f the m u l t i - d i s c i p l i n e team i n the study o f emotiona l l y disturbed p a t i e n t s i s described by one n e u r o p s y c h i a t r i s t ( l ) as follows: "Modern diagnosis and therapy i s not best accomplished by an i n d i v i d u a l p s y c h i a t r i s t . A l l p a t i e n t s need c a r e f u l s o c i a l s e r ' v i c e s and psychological work-up and follow-up A skilled 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 t o 1 0 times as many p a t i e n t s as he can alone. He can not only care f o r more but the q u a l i t y o f care i s markedly enhanced." This leads t o a consideration o f the f u n c t i o n a l s t r u c t u r e 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 t o the maximum the c o n t r i b u t i o n s of members of the m u l t i - d i s c i p l i n e team.  I n many c l i n i c s the team c o n t r i -  butes t o the study o f the " c h i l d as a whole" both i n diagnosis and i n t r e a t ment.  The d i a g n o s t i c s t a f f conference i s the formal meeting o f the t o t a l  p r o f e s s i o n a l s t a f f o f 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 a t a d e c i s i o n as t o the nature of the c h i l d ' s problem, as w e l l as the need f o r and f e a s i b i l i t y o f treatment.  ( ^ B l a i n , Daniel, "Some E s s e n t i a l s o f Mental Health Planning" B u l l e t i n o f the Menninger Clinic„ Nov. 194-6. p. 184.  143. In the course of treatment i t i s often necessary f o r the team members to formally confer together.  Such a meeting i s a treatment confer-  ence c a l l e d f o r the purpose of evaluating the o v e r - a l l d i r e c t i o n of the work on the case, f o r the making of new plans i f necessary, or f o r c l a r i fying the current s i t u a t i o n .  This conference may be c a l l e d by any member  of the team involved i n the treatment of the c h i l d .  Other community per-  sons also active i n the s i t u a t i o n may also be i n v i t e d .  The o v e r - a l l de-  c i s i o n f o r the termination of treatment of a patient i s also j o i n t l y arrived a t through a conference of the entire s t a f f i n such c l i n i c s . At present, the structure referred to above as i t concerns diagnostic and treatment conferences has not been possible i n the Vancouver C h i l d Guidance C l i n i c .  The diagnostic conference has been used both f o r  diagnosis and formulation of treatment plans and community persons have been i n v i t e d to attend.  No f a c i l i t i e s f o r treatment conferences of the  entire team have been afforded.  However, i n treatment cases the s o c i a l  worker or psychologist consults with the p s y c h i a t r i s t during the l i m i t e d time he has available between h i s d a i l y duty of 4 physical and p s y c h i a t r i c examinations o f patients and the 4 conferences which follow.  Because of  the d i v i s i o n of treatment between p s y c h i a t r i s t s , s o c i a l workers and psychologists the lack of time f o r conferences around patient's progress i n treatment i s a serious handicap and places heavy r e s p o n s i b i l i t y on the d i s c i p l i n e within the team d i r e c t l y involved with treatment.  The addition  of another p s y c h i a t r i s t to the C h i l d Guidance C l i n i c s t a f f would help i n remedying t h i s d i f f i c u l t y . . Under e x i s t i n g circumstances, more c a r e f u l s e l e c t i o n of cases on  144. the part of s o c i a l and health agencies would conserve the p s y c h i a t r i s t ' s time and make him more available f o r d i r e c t i o n of treatment of emotionally disturbed children. Again when s o c i a l 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 r e f e r r i n g agency an unwillingness to r e l i n q u i s h the patients f o r treatment by the Child. Guidance C l i n i c team. This may be attributed i n part to a lack of recognition by workers i n s o c i a l and health agencies of the specialized s k i l l of the d i s c i p l i n e s which go to make up the c l i n i c team. The C h i l d Guidance C l i n i c has offered a cooperative service i n an attempt to meet the agencies' need of treatment services f o r t h e i r c l i e n t s . Lately the demand on the part of agencies f o r t h i s service has grown, but so have the demands of parents and general p r a c t i t i o n e r s .  So that onee  again Child Guidance C l i n i c i s faced by the l i m i t a t i o n s of the time the p s y c h i a t r i s t has available f o r d i r e c t i o n o f treatment. The high incidence of poor group adjustment found i n the cases i n t h i s study as well as the frequency of recommendations regarding t h i s symptom, 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 o f such relationships i f recognized, does not appear to have been put to p r a c t i c a l use to any extent.  Too frequently, c l i n i c r e -  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 f o r the c l i n i c s and s o c i a l agencies to divulge such i n -  U 5 .  formation might have been expected i n many cases, i f through c a r e f u l case work the v a l i d i t y of such action had been interpreted to the parents. S o c i a l group workers as well as case workers through t h e i r t r a i n ing have some understanding o f the dynamics of human behaviour.  Group work  agencies should therefore be one source of r e f e r r a l s to the c l i n i c s .  In  the past, maladjusted children have been referred by group work agencies to s o c i a l or health agencies which i n turn sometimes seek the help of the clinics.  The p o s s i b i l i t y o f d i r e c t r e f e r r a l s from group work agencies i n  some cases should be investigated.  Such action would necessitate increased  knowledge o f c l i n i c a l services on the part of group workers and v i c e 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 r e -  sources i n the community and has r e s p o n s i b i l i t y f o r helping to carry out the recommendations regarding group adjustment.  The addition of a group  worker to the Child Guidance C l i n i c team appears to be a l o g i c a l future development which would enhance services t o children i n t h i s c i t y where the growth i n community centres i s marked.  Such an addition to the Mental  Hygiene C l i n i c also might be considered a f t e r s o c i a l case work services i n the schools i s established. One of the most apparent and urgent needs i n t h i s community i s a treatment and observation centre f o r emotionally disturbed children.  Such  an i n s t i t u t i o n , 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. f i r s t and to date, the only one of i t s kind i n Canada.  This centre was the I t operated under  146. the auspices of a private organization, the Alexandra Children's Home Society, which had o r i g i n a l l y been founded for the care of dependent or neglected children. Admissions to the centre were made through the Child Guidance C l i n i c .  The supervision of the centre were made through the Child  Guidance C l i n i c .  The supervision of the centre was a t 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 c h i l d 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 i n s t i t u t i o n had been demonstrated but that "such an organization 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 C l i n i c 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 i n s t i t u t i o n 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 B r i t i s h Columbia thesis, 1946. pp. 45-4-8. ( ) i b i d , pp. 109-110. 2  H7. Vancouver Health League,  The continued e f f o r t s of a l l person interested i n  a centre o f t h i s kind may be required i n order to obtain governmental support. Numerous inadequacies i n the s o c i a l h i s t o r i e s were noted i n t h i s study.  In many instances these occurred i n the h i s t o r i e s prepared f o r the  c l i n i c s by workers i n other agencies r e f e r r i n g c h i l d r e n f o r examinations. In many c l i n i c s a l l h i s t o r i e s are prepared by c l i n i c a l p s y c h i a t r i c s o c i a l workers.  This has not been the case i n the Vancouver Child Guidance C l i n i c  except i n private cases.  In the early stages of t h i s c l i n i c ' s development,  lack o f c l i n i c personnel necessitated the delegation o f t h i s r e s p o n s i b i l i t y to workers i n r e f e r r i n g agencies.  Consideration of the educational value  to agency workers of history taking also played a part i n t h i s development. I t i s understandable that the p s y c h i a t r i c s o c i a l worker by the nature of her work i n the c l i n i c should be able to prepare the kind o f s o c i a l h i s t o r y which would best serve a l l members of the c l i n i c a l team® the c l i n i c , the s o c i a l worker acts as integrator of the team.  In  This i n t e -  gration involves judgment on whether a request f o r service f a l l s within the c l i n i c ' s function of diagnosis and treatment.  I t also involves a r r -  angements f o r the appointments of the c h i l d with various members of the teaan as well as the i n t e r p r e t a t i o n to the parent of the function, purpose and findings o f each member of the team, including the s o c i a l worker. I f the C h i l d Guidance C l i n i c continues to. delegate r e s p o n s i b i l i t y for history taking to workers i n health and s o c i a l agencies (and t h i s 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 r e s p o n s i b i l i t y i n showing these workers what i t considers e s s e n t i a l i n s o c i a l h i s t o r i e s . This might be done to some extent by means of i n d i v i d u a l 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, will in the future as well as in the past be largely dependent 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 e x i s t i n g mental health c l i n i c s i n Canada several are under the auspices of p r o v i n c i a l Departments of Health, or as i n B r i t i s h Columbia. (1) the Department of Health and Welfare. These p r o v i n c i a l 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, B r o c k v i l l e , 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. C l i n i c s have been held p e r i o d i c a l l y at 11 other centres i n Alberta. A c l i n i c was established i n V i c t o r i a i n 1934, and t r a v e l l i n g c l i n i c s have v i s i t e d 12 other centres i n B r i t i s h Columbia. In the province of Quebec, the only mental health c l i n i c i s the Mental Hygiene I n s t i t u t e i n Montreal which i s financed e n t i r e l y by the Welfare Federation. In Nova Scotia, an out-patient p s y c h i a t r i c c l i n i c operated by the Medical School of Dalhousie University, was opened i n H a l i f a x 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 i n the order of the dates of establishment. The Mental Hygiene Service of the Toronto P u b l i c Schools was organized and maintained by the Municipal Department of Public Health i n 1919. The Toronto Juvenile Court Psychiatric C l i n i c was opened i n 1921. The C l i n i c f o r Psychological Medicine which i s part of the Out-Patient Department i n the Toronto Hosp i t a l f o r Sick Children was organized i n 1925. In Vancouver the Mental Hygiene C l i n i c f o r P u b l i c Schools opened i n 1936 under the auspices of a d i v i s i o n of the Metropolitan Health Committee. The Winnipeg C h i l d Guidance C l i n i c was organized i n 1941 by the C i t y Health Department.  Win  B r i t i s h Columbia, C h i l d Guidance C l i n i c s are i n part under the j u r i s d i c t i o n of the Department of the P r o v i n c i a l Secretary. o  iix B (1) FORMS IN USE BY THE CHILD GUIDANCE CLINIC  SOCIAL HISTORY OUTLINE P S Y C H I A T R I C H I S T O R Y O U T L I N E for use both i n H O S P I T A L and C L I N I C C A S E S . Name: Address:  City:  Telephone: Date of coming to Canada—Scheme—Voluntary. Steamship and r a i l w a y 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-. Reliability and the impression of informant: The way in' which information was given — whether spontaneously, unw i l l i n g l y , i n response to direct questioning, or w i t h much display of emotion. Development of Present Problem.—Secure careful picture w i t h 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). N a t u r a l - or instrumental birth, difficult labour and length of labour— b i r t h injuries; weight at b i r t h ; breast or bottle fed; age weaned and difficulties of weaning; age teething, walking, and t a l k i n g (single words and sentence formation) ; was development apparently normal, both physically and mentally? Health.—What illnesses has the subject had, at what .age, w i t h what sequelae? H o w has he reacted to these illnesses? A g e of puberty, any accompanying emotional or physical disturbances. Subject's attitude to health and his estimate as to his habitual degree of health, overconcern and overcompensation.  B (1) FORMS IN USE BY THE CHILD GUIDANCE CLINIC  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 leaving, grade obtained, character of work, grades i n 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 i n behaviour or attainments? Work.—Positions held, earnings, promotions; frequent changes, i f so, why? If discharged, why? I f resigned, why? H a s 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. Attitude to responsibility at work and satisfaction from it. The economic status—debts, responsibilities, habits of saving. I f on relief, how long, work relief. Interest and Recreation. — The subject's interest i n 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 i n 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 i n 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 statement of others. Subject's personality previous to the development of the present problem. W h a t 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 impractical, desultory. Outgoing, friendly, good mixer or seclusive, shy and withdrawing, over-sensitive, cries easily, cheerful,  composed or emotionally labile, irritable, obstinate, t i m i d , sulking, petulant, whining, tantrums or temper explosions, suggestible, holds grudges, affectionate, co-operative, ability to get along with others, dependable, honest, mutually respectful, tolerant, personal appearance—cleanly, courteous, punctual, ability 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 H o m e . — F o r each of the following persons give: age, education, health, outstanding personality traits, social behaviour, 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, w a r record, efficiency, habits, personality traits, any nervous or mental illness! Mother.—Maiden name i n full, 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 i n the child's life, describe circumstances. Siblings.—Give names and ages in order of b i r t h ; birth date, including still-births; and cause of death of a l l dead children. F o r l i v i n g 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 i n m a k i n g a social plan? W h a t special help, financial, employment, or recreational, is available? H o w f a r 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? Patient's Name: APPEARANCE: HEAD: EYES: EARS: NOSE: THROAT: MOUTH: NECK:  Date of Examination: Bate o f B i r t h :  Shape Vision Hearing Septum Tonsils Tongue Teeth Thyroid Glands  RESPIRATORY SYSTEM:  Inspection Palpation Percussion Auscultation  CIRCULATORY SYSTEM:  Inspection Palpation Percussion Auscultation Pulse Rate  ABDOMEN:  PRELIMINARY NERVOUS SYMSTEM:  Hair Size Pupils Canals Turbinates Enlarged Protrudes Enamel Enlarged Enlarged  F i l e No Height: Weight: Eyes  Injuries Fundi Drums Discharge Diseased Gums URINALYSIS  eoi.  Reaction Alb. Sug. S.Go  V.  R.  T.  B.p.  Arteries  Inspection Tenderness  Hernia Rigidity  Masses  Speech Motor Co-ordination Reflexes Babinski  Nerves Sensory  Tremors  Superficial Oppenheim  Deep 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 c h i l d , age and sex. Time of a r r i v a l , departure^ and absences from playroom.  2.  Names, sex and r e l a t i o n s h i p of adults accompanying the c h i l d . Age, sex and r e l a t i o n s h i p 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 s t a r t 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 c h i l d and the c h i l d towards parents. The conversation of parent to c h i l d and the others waiting i n playroom regarding the c h i l d .  SPECIFIC: 1.  Energy - Over or under-active?  2.  S o c i a l Habits - How does he get along with children? With Adults? Is he. shy? Polite? Seclusive? Need urging? Bold? Boisterous? S e l f i s h ? Show Off? Does he make a play f o r attention? Does he seem to prefer older or younger children, etc.?  3.  Emotional Habits - Any evidence of i n s t a b i l i t y ? E a s i l y moved to tears? Anger? Temper tantrums? Feelings e a s i l y hurt? Jealousy, etc.?  4.  Work and Play Habits - Short span of i n t e r e s t and attention? Slovenly? Awkward? Neat? Dexterous? How does he react to suggestion and guidance, etc.  5.  Physical Condition: Appear w e l l , handicapped, etc. does he compensate any physical handicaps, etc.  6.  Other notes to s u i t peculiar s i t u a t i o n .  Impulsive?  Mischievous?  In what, manner  154. Appendix B  (4) PSYCHOLOGIST'S REPORT  Name;  . . . . . .  . . •  Date . .  Address . . . . .  .  School  Birthdate . . . .  .  Grade  Birthplace  Stanford Binet Form .  . . . . .  Sex  Problem  .  Appearance:  Attitude to Examiner and Test:  Co-ordination:  Mode o f Reaction:  Play-room Observation:  Handedness  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 I I  2.  Stanford-Binet Forms L and M  3.  C a t t e l l 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 f o r Young Deaf Children  8.  Chicago Non-Verbal Examination  9.  Wechsler Memory Scale (sample)  10. II  C a t t e l l Culture - free t e s t Personality t e s t s  1.  C a l i f o r n i a 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  4..  Bernreuter Personality Inventory  5.  B e l l Adjustment Inventory Student Form Adult Form  6.  Minnesota Multiphasic Personality Inventory  Test - High School - College  - 17-adult.  157 7.  Brown Personality Inventory f o r Children - 9-14  8.  Rogers Test of Personality Adjustment - 10 years.  9.  Vineland S o c i a l Maturity Scale.  10.  The Personal Audit - Sr. High School - adult  11.  Problem Check L i s t  years.  III Vocational Tests INTEREST TESTS 1.  Strong Vocational Interest Blank  2.  California  3.  Kuder Preference Record - highschool - adult  4-.  Primary Business Interests - highschool - adult  5.  Brainard Occupational Preference Inventory (sample) Highschool - adult  6.  Interest questionnaire f o r High School  7.  Personal Test - Wonderlie (sample)  8.  Hoppock Check L i s t for Self-Guidance  9.  Hoppock Check L i s t f o r Occupations  10.  Occupational Interest Inventory  Woman's Personnel C l a s s i f i c a t i o n •  APTITUDE AND  C l e r i c a l and  Students  (sample)  (sample)  Test  ABILITY TESTS  Stenographic  1.  D e t r o i t C l e r i c a l Aptitude Test  2.  Minnesota C l e r i c a l Test  3.  N.I.IoP. C l e r i c a l 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 f o r Mechanical  4-.  Stanford S c i e n t i f i c Aptitude Tests  • 5.  Revised Minnesota Paper Form Board  Ability  Miscellaneous Test of special aptitudes such as nursing, teaching, a r t judgment, e t c . IV  Achievement Tests  American School Achievement Tests 1.  Form IA - Gr.  1  2.  Form IIA - Gr. 2 and  3.  Form IntA - Gr.  4.  Detroit General Aptitudes Examination  5.  Wide Range Achievement Tests  3  4-6  Arithmetic 1.  Stanford Arithmetic Test Primary - grades 2 and 3 Intermediate - grades 4-6 Advanced - grades 7-9  Reading and 1.  Vocabulary  dominion Achievement Tests i n S i l e n t Reading Word Recognition Phrase and Sentence Reading Paragraph Reading  159. 2.  Grays Standardized O r a l Reading  3.  Haggerty Reading Examination - Gr. 1-3, Gr. 6-12  4.  Monroe. Reading Form 1 t e s t s 1 and 2 Form 2 Test 1  160 Appendix C  (1) FORMS IN USE BY MENTAL HYGIENE CLINIC METROPOLITAN HEALTH COMMITTEE  H  78 MLH S o c i a l and Family History 194-  Date  Name  ,  Religion  Address  . . . . . .  School  R a c i a l Origin  Telephone Previous Addresses  .  . . . . . . . . . . .  .  S o c i a l Status (ChM, marital status, etc.) S o c i a l Service Exchange Record. .  Family Physician.  Referred by Sources o f information Problem  . -, Family  Birth Date  Birth Place I  . ...  Children  s  1 ••••!  School Grade Reached  Age of Leaving  Occupation and notes  Home Conditions; o c i a l standards, type of neighbourhood, others i n home. Relationships among members of family s  Economic Security  Developmental History  Medical History  Training Methods  Attitude towards Authority  S o c i a l Adjustments  Present d i f f i c u l t i e s from family point o f view  Information from School Medical card  Signature^ Nurse  162. Appendix C (2) H 81 M  METROPOLITAN HEALTH COMMITTEE SCHOOL HISTORY School  Name (Surname) Date o f B i r t h  Date of F i r s t Attendance (At any school). . . . .  Schools previously attended;  Present Grade Grades repeated  Grades skipped Absences: Extent of . Reasons f o r  Academic Achievement:  Special A b i l i t i e s :  Special D i s a b i l i t i e s :  (Standing t h i s term with comments about achievement i n e a r l i e r grades.)  DESCRIPTION OF CHILD'S PERSONALITY AND BEHAVIOUR  Attitude towards Authority  P a r t i c i p a t i o n i n A c t i v i t i e s o f 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 o f view  Signature  Title  164. Appendix C (3) METROPOLITAN HEALTH COMMITTEE Mental Hygiene D i v i s i o n C l i n i c No (For Central O f f i c e ) PROGRESS REPORT Name  Unit  School . . . .  . . . .  ^hange i n Address ( I f any)  O r i g i n a l 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:  Addresses  C l i n i c No:  Bates o f examinations  1.  1.  2.  2.  3.  3.  A.  A.  Date o f B i r t h :  Age:  Schools Attended:  Birthplace: Sex: National Extraction:  Started:  Grades  Age:  S o c i a l Status:  Reached:  Grade:  Age:  S. M. W. D, Sep.  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: P h y s i c a l C l a s s i f i c a t i o n : Psychiatric Classification: Psychological C l a s s i f i c a t i o n : Treatment: ( l ) T h i s 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 r e f e r r a l . Reason f o r r e f e r r a l . Examining c l i n i c . Patient's Name Sex  Age  Intelligence Length o f residence i n B r i t i s h Colubmia Ordinal p o s i t i o n i n the family Parents' Racial Extraction Marital status (married, divorced, separated, common-law, widowed) Religion Number o f children Presence of factors contributing to patient's maladjustment Absence o f father while serving i n the Armed Forces Inadequate housing (poor or crowded) Interference of grandparents or other r e l a t i v e s l i v i n g i n the home *Patient School report Group adjustment Health Developmental history: b i r t h to end of second year, t h i r d to sixth year, and l a t e r Age at time of f i r s t appearance of symptoms Interests and recreation Siblings - t h e i r adjustment, attitude toward patient Findings o f c l i n i c a l examination Parents Age, education, occupation, marital adjustment, health, i n t e r e s t s , general adjustment Attitude of each parent toward patient Family background Economic security Home conditions  4 This part of the schedule was used f o r the 20 per cent to the sample (52 cases) only. Previous section o f schedule was used f o r 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 A l l e n , Frederick H., Psychotherapy with Children, W.W. Norton & Co. Inc. New York, 1942. Bowley, Agatha H., The Psychology o f the Unwanted C h i l d . E. and S. Livingstone L t d . , 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. E n g l i s h , 0., and Pearson, G.H., Common Neuroses o f C h i l d r e n and Adults, W.W. Norton and Co., New York, 1937. E n g l i s h , 0., and Pearson, G.H., Emotional Problems o f L i 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 o f C h i l d Guidance, C h i l d Care P u b l i c a t i o n s , New York, 1947. Kanner, Leo, C h i l d P s y c h i a t r y , Charles C. Thomas, S p r i n g f i e l d , 111.,  1946.  Lewis, Nolan D. and P a c e l l a , Bernard L., e d i t o r s , Modern Trends i n C h i l d P s y c h i a t r y , I n t e r n a t i o n a l U n i v e r s i t y 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 o f I n f a n t s , Columbia U n i v e r s i t y Press, New York, 1943. Strecker, Edward A., Beyond the C l i n i c a l F r o n t i e r s , W.W. Norton and Co., Inc. 1940. T r u i t t , Ralph p., The C h i l d Guidance C l i n i c and the Community, The Commonwealth Fund, New York, 1928. Witmer, Helen L., ed. P s y c h i a t r i c Interviews with C h i l d r e n, 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 o f P u b l i c Health, J u l y , 1947. L o u t t i t , CM., "The School as a Mental Hygiene Factor" Mental Hygiene V o l . 31. January, 1947. Ryther C h i l d Centre, Monograph on Organization and Operation, S e a t t l e ,  1946.  U.S. Children's Bureau Helping C h i l d r e n i n Trouble P u b l i c a t i o n  1947.  320,  169. SPECIFIC REFERENCES Books Bowley, Agatha H., The Problems o f Family L i f e , E. and S. Livingstone L t d . , Edinburgh, 194-6. French, L o i s M., P s y c h i a t r i c S o c i a l Work, The Commonwealth Fund, New York, 1940. H a l l , M u r i e l B,, The P s y c h i a t r i c Examination o f the School C h i l d , Edward Arnold and Co., London, 1947. Hamilton, Gordon, Psychotherapy i n C h i l d Guidance', Columbia U n i v e r s i t y Press, New York, 1947. Jewish Board o f Guardians, The Caseworker i n Psychotherapy, Jewish Board o f Guardians, New York, 194-9. Lowrey, Lawson G., Psychiatry f o r S o c i a l Workers, Columbia U n i v e r s i t y Press, New York, 1946. Menninger, W i l l i a m C , Psychiatry: I t s Evolution and Present Status, C o r n e l l U n i v e r s i t y Press, Ithaca, New York, 1948. Rogers, C a r l , The C l i n i c a l Treatment o f the Problem C h i l d S w i f t , Sarah H., T r a i n i n g i n P s y c h i a t r i c S o c i a l Work, The Commonwealth Fund, New York, 1934. Towle, Charlotte, S o c i a l Case Records From P s y c h i a t r i c C l i n i c s , U n i v e r s i t y o f Columbia Press, Chicago, 1941. Witmer, Helen L., P s y c h i a t r i c C l i n i c s f o r 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 , B r i a n , "Mental Health i n Canada" The Canadian Forum, May, 1947. B l a i n , Daniel, "Some E s s e n t i a l s i n National Mental Health Planning" B u l l e t i n o f the Menninger C l i n i c , Nov. 1946. I l l i n o i s Children's Home and A i d Society, Plans f o r an I n s t i t u t i o n f o r the Treatment o f Emotionally Disturbed C h i l d r e n , Chicago,  1946.  Laabs, Alma, "Development o f S o c i a l Work i n Education", The Compass, March 1945. Laabs, Alma, "When the School C h i l d i s i n Trouble", The C h i l d , Dec.  1947.  Lowrey, lawson G., "Psychiatry f o r Children" American J o u r n a l o f P s y c h i a t r y, Nov, 1944. P r i c e , Morrish H. and Feldman, Yonata, L., "A Study o f Re-opened Cases". The Family, June 1942. Reports "Annual Report of the S o c i a l Welfare Branch of the Province o f B r i t i s h Columbia f o r the year 194-7-48". Gundry, C.H., "Annual Report to the Metropolitan Health Committee o f Vancouver" 1946, 1947 and 194-8. Report o f Winnipeg C h i l d Guidance C l i n i c , 1948.  170. Other Studies Thompson, Mary A., The S o c i a l Worker i n the School U n i v e r s i t y of B r i t i s h Columbia t h e s i s , 194-8. Munro, Marjory H., A General Survey and Evaluation of an I n s t i t u t i o n f o r the Observation and Treatment of Problem Children, U n i v e r s i t y B r i t i s h Columbia t h e s i s , 1946.  

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