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Family differentials in the habilitation of children with a brain injury McCallum, Mary Freda 1961

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FAMILY DIFFERENTIALS IN THE HABILITATION OF CHILDREN WITH A BRAIN INJURY by MARY FREDA McCALLUM T h e s i s Submitted i n P a r t i a l F u l f i l m e n t of the Requirements f o r the Degree o f MASTER OF SOCIAL WORK i n the School of S o c i a l Work Accepted as conforming t o t h e standard r e q u i r e d f o r t h e degree of Master o f S o c i a l Work School o f S o c i a l Work 1961 The U n i v e r s i t y o f B r i t i s h Columbia In presenting t h i s t h e s i s i n p a r t i a l f u l f i l m e n t of the requirements f o r an advanced degree at the U n i v e r s i t y of B r i t i s h Columbia, I agree th a t the L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e f o r reference and study. I f u r t h e r agree that permission f o r extensive copying of t h i s t h e s i s f o r s c h o l a r l y purposes may be granted by the Head of my Department or by h i s r e p r e s e n t a t i v e s . I t i s understood tha t copying or p u b l i c a t i o n of t h i s t h e s i s f o r f i n a n c i a l g a i n s h a l l not be allowed without my w r i t t e n permission. Department o f The U n i v e r s i t y of B r i t i s h Columbia, Vancouver $, Canada. Date i v ABSTRACT Western society has advanced in the provision of services for disabled children, but the i r complete acceptance \ and integration within the community has yet to be achieved. The development of interdiscipl inary team programs for diag-nosis and treatment, has nevertheless notably assisted this process. Social workers have an important contribution to make in this area, but there is s t i l l much to be done to standardize the information secured in the ir interviews with parents. An i n i t i a l project in this direction was carried out in Vancouver last year in a speech and hearing c l i n i c . y The present project explores adaptations of this with the cerebral palsied chi ld as representing one type of brain-injury. Two basic dimensions in the development of c r i t e r i a and rating scales are: 1) the health and socio-emotional circumstances of the ch i ld ; and 2) the family circumstances and home environment. The present study i n i t i a l l y gives particular atten-t ion to the la t ter , and considers some of the relationships between this and assessments of the progress of the chi ld in functional a b i l i t y . Since only limited sampling i s possible, measurement of the results i s not taken very far. There i s also evidence that this i s primarily a middle income group. Case i l lus t ra t ions and some comparisons of c r i t e r i a are used to supplement the conclusions. The qualitative characteristics of the c r i t e r i a and their significance for diagnostic assessment is subjected to careful view. In the present context they are considered in terms of the interrelatedness of culture, values, role and stress. The brain-injured chi ld may have a re la t ive ly mild or severe condition. While treatment may be complex, objec-t i v i t y i s essential in assessing habi l i tat ion potential . Differentials in family functioning as they pertain to parental relationships, emotional acceptance, understanding, and coopera-t ion are highly relevant to effective remedial or educational procedures, or casework. Indeed, the assessment of environmental circumstances in terms of social functioning may further the eventual integration of the disabled chi ld into the community. It i s reasonable to anticipate results from continued research of the present kind. V ACKNOWLEDGEMENTS I am singularly grateful to Miss Eleanor J. Bradley, Supervisor, Child Health Programme, University of B .C. , whose sustaining guidance has made this thesis a rea l i ty . Its direction and purpose was maintained through the invaluable assistance of Dr. Leonard Marsh, Director of Research, School of Social Work, University of B.C. Throughout the project, the interest shown by Dr. W.M. Gibson, Assistant Medical Director, G.F. Strong Rehabilitation Centre, has been a source of encouragement. The study of human relationships would not be possible without access to records. For this I am res-pectfully indebted to Dr. A.C. Pinkerton, Medical Director of the G.F. Strong Rehabilitation Centre and the Cerebral Palsy Association, and additionally, to the families represented. I wish to acknowledge further the patience, and congenial response of the Cerebral Palsy Association personnel. Their cooperation i s sincerely appreciated. i i TABLE OF CONTENTS Chapter 1. The Disabled Child and His Family Page Human needs of a l l children. Family dif ferentials . The development process. Physio-log ica l dif ferentials . The c l i n i c a l team. Setting of the study. Purpose, methods, and limitations 1. Chapter 2. Family Differentials - A Preliminary Analysis Differentials of socio-economic status. Differentials of family strengths. The chi ld ' s progress in physical function. Relationship of progress to physical and emotional environment 24. Chapter 3. A Framework to Assess Levels of Social Functioning Physiological, emotional, and soc ia l adap-tation of the ch i ld . Physiological, socio-economic, and socio-cultural adaptation of the family. A pro-posed revision of the schedule. Rating methods 3&. Chapter 4. The Social Work Contribution in a C l i n i c a l Setting Psychosocial diagnostic assessment and casework with the family. Agency and community responsibi l i t ies . Future research 56. Appendices: A. Two Schedules from a thesis by R. Varwig. B. A Medical Assessment Schedule. C. The Two Schedules Revised. D. Bibliography. i i i TABLES IN THE TEXT Page Table 1. Ratings of Family Differentials of the Brain-injured Child 26 Table 2. Comparative Family Scores for Two I l lustrat ive Cases 29. Table 3. Observed Progress in Functional Abi l i ty Over a Two Year Period 32. Table 4. Relative Progress in Functional Abi l i ty Over a Two Year Period 3 2 . Table 5. Comparative Ratings of Family Scores and Functional Progress of the Child 34-v i FAMILY DIFFERENTIALS IN THE HALT LITATION OF CHILDREN WITH A BRAIN INJURY CHAPTER I THE DISABLED CHILD AND HIS FAMILY Centuries ago, " c i v i l i z e d man" regarded physical de-formity in a human with fear and superstit ion. These prevailing attitudes demanded treatment in the form of punishment, avoidance, or complete physical rejection. Although Christianity taught differently, and although the bel ief in the inherent worth and dignity of man is based on this Hebraic heritage, modern man has only within relat ively recent decades made a conscious attempt to overcome the vestiges of such attitudes. The "study of man as a socia l being may be traced back to the philosophical specu-lations of the early Greeks . . . " ; 1 but the "study of man" needs s t i l l to develop an understanding of man as a social being. It i s easy to think, write, or speak about individuals within cate-gories of "the handicapped." It is not so easy to accept and respect them simply as people. Human Needs of a l l Children A l l children need to belong, to be part of a family, to be part of a community and of society. They have basic bio-logica l needs which must be sat is f ied in order to exist . Also, Simmons, Leo W., and Wolff, Harold G. , Social Science in  Medicine. Russell Sage Foundation, New York, 1954, p. 27. 2 most authorities agree that the child needs love, security, and sp i r i tua l nourishment in order to develop a healthy personality. Yet dependent on physiological, psychological and socio-cultural factors, the emphasis on the chi ld ' s obvious needs for food, clothing, shelter, learning and play opportunities w i l l vary. Thus a particular ch i ld of a particular age, and s imi lar ly , the chi ld with a d i sab i l i ty , w i l l have needs dif fering from those of any other. For example, the hearing-handicapped ch i ld and the brain-injured chi ld have the same basic needs, but their disa-b i l i t i e s represent individualized need which w i l l be further affected by their age and personality characteristics. Nevertheless, the ch i ld who appears physically or mentally "different" from the majority i s more frequently re-garded as an individual with a d i sab i l i ty than as an individual chi ld with thoughts, feelings, and often an inherent potential capacity as significant as that of any other ch i ld . Disabled children have no desire to be considered "different" and thus to be set apart. It i s society that sets them apart. While many organizations and programs have been de-veloped in the interest of such children with intent to ensure their optimum functioning, the remnants of fear, superstition, and revulsion have been sublimated in overprotection and segre-gation. Such attitudes are as characteristic of parents as they are of the community and society. As the primary nurturing units of society, a l l families within the community must assume the fundamental responsibil i ty for assuring the integration of the disabled ch i ld . The "family di f ferentia ls" which underlie 3 such responsibil i ty constitute the framework of the present study. Family Differentials Parents as well as children have differing needs which affect t h e i r interpersonal relationships. Parental management of a ch i ld w i l l therefore vary correspondingly i n individual respects. Moreover, " . . . t h e parent-child relationship develops and changes with the changes and needs of the growing c h i l d . " 1 Whatever action a person takes i n a given situation however, i s pre-determined by his inherent genetic and psychic capacity, by his perception of his role i n that particular situation, and by his singular value-system and cultural setting. "Role" for the sociologist refers to "the organization of habits and attitudes of the individual appropriate to a given position in a system of social re la t ionships . " 2 Values refer to the "system of ideas, attitudes, and beliefs which consciously and unconsciously bind together the members of a family in a common culture."3 In i t s broadest sense, "culture" refers to the geographic, economic, or national ist ic pattern or patterns of relationships, attitudes or experiences sustained by an • • ' •Little, Sherman, "Social and Emotional Handicaps of Children," Pediatric Cl inics of North America; Symposium on Handicaps and Their Prevention, ed. C C . Fischer, W.B. Saunders Co., Philadel-phia and London, August 1957, p. 734. 2Neiman, L . J . , and Hughes, J.W., "The Problem of the Concept of Role," Social Perspectives on Behavior, ed. H.D. Stein and R.A. Cloward, The Free Press, Glencoe, 1958, p. 17&\ ^Parad, H . J . , and Caplan, G. "A Framework for Studying Families in C r i s i s , " Social Work.(July 1960| p. 6. 4 i n d i v i d u a l . 1 This then includes cultural "groups" such as Americans, Indians, and Chinese, as well as cultural "sub-groups" such as upper and lower "socio-economic" class. It becomes obvious that roles , values and culture are intr icate ly interwoven in every individual ' s l i f e pattern, and consequently affect family relationships. For example, the roles of a middle-class American banker as the breadwinner, and father of two children, w i l l carry different responsibi l i t ies and values than those of a Swedish immigrant farmer who i s also father of two children, and the breadwinner of the family. Similarly, the mother's roles w i l l vary according to the cultural pattern. These nevertheless are not always well-defined; and changing cultural patterns and conditions frequently introduce uncertainties, confusion, or confl ict in the parents' perception or understanding of their respective roles. Anthropologists such as Malinowski have pointed out that " . . . inter-personal conflicts and stresses associated with parent-child relationships depend largely upon the kinds of pressures imposed upon the individual by the social structure and the family configuration, and . . . these may vary greatly from culture to cu l ture . " 2 Pathology induced by a stressful situation may be traceable to environmental conditions such as "hftfitrner, H . L . , and Kotinsky, R., ed. , Personality in the Making, The Fact-Finding Report of the Midcentury" White House Conference on Children and Youth, Harper and Brothers, New York, 1952, p. 165. 2Simmons, and Wolff, op. c i t . . p. 42. 5 overcrowded housing; to social conditions such as unemployment; or to differences in sub-cultural group values. Studies have shown for example that values attached to the individual ' s basic needs for food, shelter, sleep, l i ght , heat, and defense di f fer widely for each socio-economic class, and in addition reflect considerable influence on a chi ld ' s learning a b i l i t y . 1 For the lower classes, fear of starvation i s a strong motivation to over-eat at irregular times. Additionally, The conception that aggression and hos t i l i ty are neurotic or maladaptive symptoms of a chronically frustrated adolescent i s an ethnocentric view of middle-class psychiatrist(s) . In lower-class families, physical aggression i s as normal, social ly approved and socia l ly inculcated type of behavior as i t i s in frontier communities.2 Superiority in intelligence of children from the higher occupational groups was found in ten standard i n t e l l i -gence tests to be associated with the vocabulary used, and the greater motivation on the part of the higher occupational groups. When one controls the socio-economic cultural factors in a test , therefore, one finds sound s t a t i s t i ca l evidence that the average real in te l l ec-tual a b i l i t y i s in general at the same leve l for a l l socio-economic groups. 3 For many parents already under psychological, socia l , x Davis, A l l i son , "Socio-Economie Influences Upon Children's Learning," Paper delivered at the Midcentury White House Con-ference on Children and Youth, Washington, D . C , 1 9 5 0 , (mimeographed). 2 I b i d . , p. 4. 3 I b i d . . p. 6. 6 or economic stress, the presence of an abnormal child in the home may precipitate an emotional or marital problem, or be-havioural d i f f i cu l t i e s in the other chi ldren. In many cases, the chi ld himself w i l l precipitate the stress, yet the degree of pathology i s often increased because of other factors i n the to ta l family situation. A l l families experience stress to a certain extent. Many are able to adapt to these situations with l i t t l e d i f f i -culty. Prevention of intensif ied emotional stress involves knowledge of the degree of existing stress and the modes of adaptation. Prolonged uncertainty of diagnosis or prognosis of a chi ld ' s condition tends to heighten anxieties and increase tensions i n the home. By contrast, any situation becomes more manageable once the known replaces the unknown. Parents may be saved thi s type of emotional stress i f they are able to obtain an early diagnosis of their chi ld ' s d i s ab i l i ty . The parent of a handicapped chi ld adds: We need to look more closely for ways to prevent emotional breakdown within these families. A much better evaluation of parents, themselves, in the i n i t i a l stages of counselling, seems indicated. . . .Here we are delving into preventive socia l work....We need to educate the public that socia l workers don't work exclusively with the poor. . . .Any family can have a problem too big for them, and often parents need help in gaining insight to preserve or improve their mental health.1 The Development Process Current theories on the development of personality ^Patterson, L . L . , "The Role of the Parent," The Child with a  Handicap, ed. E .E . Martmer, C C . Thomas, Springfield, 1959, p. 18-19.' 7 substantiate the opinion that parental responses and attitudes are the primary environmental influence on the chi ld ' s early development. The mother-child relationship i s emphasized as being particularly significant in that the infant i s nurtured by, and i s primarily dependent on i t s mother. Growth necessi-tates nourishment. Healthy emotional growth necessitates healthy emotional nourishment. A warm, loving, and responsive relat ion-ship with the mother during the ch i ld ' s f i r s t year i s the emotion-a l nourishment that lays the basis for the f i r s t stage of the chi ld ' s ego development; namely, that of " t r u s t . " 1 As the ch i ld grows, his sense of trust i n himself and in his ever widening environment w i l l expand. Il lness or disa-b i l i t y i s a threat to this sense of trust , which may be temporary, or conceivably, of l i f e - long duration. As the chi ld develops, the conflict between dependency and his need for love on the one hand, and increasing parental demands for conformity to social and cultural standards on the other, often results in anxiety. Nonconformity may inci te anger on the part of the parent about which the chi ld may experience feelings of gu i l t , or which he might interpret as being a with-drawal of love. This plays a significant part i n the chi ld ' s learning process in accepting himself as a worthy individual . It i s during th i s period,referred to as the stage of "autonomy,"2 ^Erikson, E . H . , Childhood and Society. W.W. Norton and Co. Inc., New York, 1950, p. 219. 2 I b i d . , p. 222. 8 that the normal chi ld ' s neuromuscular s k i l l s develop, increasing his capacity for physical independence and self-rel iance. It i s thus reasonable to expect that the disabled chi ld ' s possible feelings of rejection and non-acceptance might be intensi f ied. His anxieties and fears therefore need to be understood and allayed. Every chi ld at th i s age needs parents who can not only allow him a degree of independence, but who can in certain s i tu-ations encourage his independence, while setting reasonable and consistent l imits within a warm and loving relationship. From three and a half years of age to five or six, the chi ld becomes more creative and imaginative. During this period he begins to learn habits and socia l roles by an identi f icat ion with the parent of the same sex. Here too, the normal chi ld ' s developing sense of "initiative"" 1" i s characterized by competition as he explores and finds opportunities to play with others his age. This again underlines the abnormal situation the disabled chi ld w i l l encounter unless he has the opportunity to participate in play ac t iv i t i e s with his peers. Where th i s becomes over-whelming to the chi ld less apt i n movement and expression than the normal ch i ld , he may develop a self-image of a weak and incapable being. He may then tend to withdraw, and become more dependent rather than incur fai lure by competing. Such a chi ld needs encouragement to experiment and learn tasks equal to his capacity. Ib id . , p. 224. 9 Conversely, the chi ld may fee l his l imitations excuse him from assuming re spons ib i l i ty . 1 This i s frequently an a t t i -tude encouraged by over-protecting parents, but prolonging the chi ld ' s dependency in this way only tends to s tu l t i fy the healthy growth of the ego. Overindulgence then, i s equally as detrimen-t a l to the chi ld ' s normal personality development as i s neglect or rejection. In order to develop as a social being, the chi ld has to learn the lessons of obedience, conformity, and recognition of the rights of others. He nevertheless needs to learn these within an atmosphere of love and understanding. Such an atmos-phere i s provided in the "democratic" home where authority i s expressed with affection, consistency, and ra t ional i ty . Considerable research has been carried out in recent years to test the influence of parental attitudes on the chi ld ' s personality development.2 Under the auspices of the Fels Research Institute, Baldwin et a l designed a rating technique for col lect-ing information about the home environment on the basis of home v i s i t s . 3 The profiles contain th i r ty variables within the following eight broad categories: Iwitmer, and Kotinsky, op. c i t . . p. 66. 2 Frankie l , Rita V . , A Review of Research on Parent Influences on Child Personality, F . S .A .A . , 1959. ^Baldwin, A . L . , Kalhorn, J . , and Breese, F . H . , "The Appraisal of Parent Behavior," Psychological Monographs, v. 63 (1949), No. 4 (Whole No. 299)-10 1. Home atmosphere 2. Contact of chi ld and mother 3. Control and influence of parent on chi ld 4. Babying and protectiveness 5. Cri t ic i sm and evaluation of child 6. Readiness of explanation 7. Emotional relationships between parent and chi ld &. Miscellaneous: these include understanding, emotionality, affectionateness, and rapport. Research based on this device found three key "clusters" as representative of dimensions of parent behaviour; namely, warmth, objectivity and parental control . Objectivity i s re-lated to two patterns: indulgence, and democracy which i s characterized by jus t i f icat ion, explanation and ab i l i ty to meet the chi ld at his own l e v e l . 1 A further study concluded that children experiencing a democratic atmosphere rate higher on socia l ly outgoing be-haviour, as well as on act iv i ty demanding intel l igence, curiosity, or ig inal i ty and constructiveness. Those experiencing indulgence were found to exhibit physical apprehensiveness and lack of s k i l l in muscular ac t iv i t i e s . Meng, Schilder, Bender, and others have studied the influence of d i sab i l i ty on behaviour and personality develop-ment.-^ Most theories developed are as yet speculative, although ^Frankiel, op. c i t . , p. 19-20. 2Baldwin, A . L . , "The Effect of Home Environment on Nursery School Behavior," Child Development. V. 20, (1949) , p. 57. ^Barker, Roger G. , Wright, B .A. , and Gonick, M.R., Adjustment  to Physical Handicap and Il lness; A Survey of the Social Psychology of Physique and Disabi l i ty , Social Science Research Council, New York, 1953 (copyright 1946) . 11 they o f f e r some ins i g h t i n t o the problems, and point with certainty to the fact that "both s i t u a t i o n a l and personality mechanisms are inv o l v e d . " 1 Environmental stress may vary from s i t u a t i o n to s i t u a t i o n , but adaptation to such stress i s de-pendent on the l e v e l of ego maturity of the c h i l d or parents. According to Meng, "even the most serious physical d i s a b i l i t y does not necessarily r e s u l t i n a dis t o r t e d p e r s o n a l i t y . " 2 Physiological D i f f e r e n t i a l s Because of the complexity of the condition, the brain-injured c h i l d exemplifies the philosophy that i t i s not the handicap, but the c h i l d which should receive f i r s t importance when considering " h a b i l i t a t i o n . " A brain-injured c h i l d i s one "who before, during, or a f t e r b i r t h has received an in j u r y to or suffered an i n f e c t i o n of the b r a i n . " 3 As the condition exists either at b i r t h or p r i o r to the f u l l development of the nervous system, the term " h a b i l i t a t i o n " here connotes f a c i l i t a t i o n of a chi l d ' s inherent p o t e n t i a l , rather than restoration of function as i s generally i m p l i c i t i n the term " r e h a b i l i t a t i o n . " Brain-injury i s often i n c o r r e c t l y equated exclusively with mental impairment. On the other hand, children with apparent emotional and behavioural disorders may have an unrecognized -'-Ibid., p. 93. 2 I b i d . , p. 86. 3 S t r a u s s , A.A., and Lehtinen, L.E., Psychopathology and  Education of the Brain-Injured Child, Grune and Stratton, New York, 1956 (copyright 1947), p. 4. 12 brain-injury when the primary impairment i s i n the area of per-ception. While the major defect may be either of the above, i t may alternatively involve primarily a neuromotor d i sab i l i ty , commonly termed cerebral palsy. Defects associated with this may include heart disease; conditions affecting speech; d i f f i -cult ies in auditory, visual , and tactual perception; or con-vulsive disorders. The subjects of this study are primarily brain-injured children with cerebral palsy; thus a br ief discussion of the causes and c lass i f icat ion of the d i sab i l i ty i s indicated. As evident in the l i terature , the data on cerebral palsy are ex-tremely involved, and there i s today no common agreement as to etiology, c lass i f icat ion or treatment. Moreover, there i s i n -creasing concern that "unless development i s taken into account, very few conclusions in the l i terature are v a l i d . " 1 What i s significant i s that " . . .growth and development may be disturbed in many ways. These...may be largely physiological or inte l lec-tua l , or due to unsuccessful management."2 Today, the American Academy of Cerebral Palsy defines cerebral palsy as any abnormal alteration of movement or motor function aris ing from defect, injury or diseases of the nervous tissues contained within the cranial vault. Such a condition may occur before, during, or after b i r t h . 3 Crothers, Bronson, and Paine, R.S., The Natural History of  Cerebral Palsy, Harvard University Press, Cambridge, 1959, p. 11. 2 I b i d . , p. 6 3Denhoff, E r i c , "The Child with Cerebral Palsy," The Child with  a Handicap, ed. E .E . Martmer, C C . Thomas, Springfield, 1959, p. 128. 1 3 The neuromotor d i sab i l i ty may be characterized by . . . spa s t i c i ty , weakness, incoordination, r i g i d i t y , tremors or involuntary motions, alone or in mixed variet ies . Dysfunction may be limited to a single limb or may involve the entire body. Dysfunction may vary i n degree of severity and may change from . time to time in relationship to the growth and develop-ment of the damaged nervous system. 1 The causes of cerebral palsy are complicated and frequently multiple. A sample of the respective et iological factors are l i s t ed within four broad categories or groupings: Genetic: including maternal constitutional factors. Prenatal: infections, i rradiat ion, maternal metabolic disorders. Paranatal: vascular injury, anoxia, trauma, prematurity, postmaturity. Postnatal: encephalitis, pneumonia, kernicterus due to RH incompatibility. It i s estimated that twenty to forty percent of the cases are of unknown cause. Perhaps the most commonly used terms typifying the condition are spasticity, r i g i d i t y , tremor, athetosis, and ataxia. The spastic group may also be c lass i f ied i n relat ion to the limbs affected. Studies of inte l lec tua l factors are d i f f i cu l t to validate due to the unre l iab i l i ty of standardized tests, however enough evidence has been accumulated to suggest that the incidence """Ibid. 2 I b i d . , p. 130. 14 of mental deficiency i s much higher than in the general popu-l a t i o n . 1 Thus, . . . there i s no characteristic course...and above a l l , the accurate description of the motor patterns may not give any insight into other important elements, such as in te l lec tua l and emotional d i f f i c u l t i e s . 2 More cerebral palsied children than normal children have hyperkinesis which i s characterized by loss of emotional control, hyperactivity, impulsiveness, poor attention span, d i s t r a c t i b i l i t y , l ist lessness and i r r i t a b i l i t y . . . . B e h a v i o r problems in children evidencing cerebral palsy are related both to organic factors and environmental confl icts with family and society.3 While cerebral palsy f a l l s within the c lass i f icat ion of "brain-injury," i t also comes within the group of neuro-muscular diseases which include poliomyelitis and the muscular dystrophies. However different their prognosis, they a l l "result in a disturbance of the neuromuscular apparatus which controls normal movement."^ This emphasizes that irrespective of the area of c lass i f icat ion, and however different the diagnosis, they a l l result i n a stressful situation for the c h i l d and his family. Viewed within his cultural environment, and dependent xCrothers, op. c i t . . p. 172. 2 I b i d . . p. 34. 3Denhoff, op. c i t . . p. 137-^Tobis, Jerome S., "The Child with Neuromuscular Disease," Management of the Handicapped Chi ld , ed. H. Michael-Smith, -Grune and Stratton, New York, 1957, p. 192. 15 on the severity of the "d i sab i l i ty " then, the "handicap" i t w i l l typify for the chi ld may be more soc ia l than physical, more emotional than in te l l ec tua l . The C l i n i c a l Team With increasing knowledge i n the psycho-social aspects of personality development, the concept of the "whole" chi ld to-day concerns not only his physical problem and what can be done for i t , but what can be done to enhance his and his family's socio-emotional environment. This has given impetus within c l i n i c a l settings particularly to the " interdiscipl inary team" approach in the management of the c h i l d with one or more dis-abling conditions. No one professional person has the s k i l l s to evaluate adequately the health needs of most handi-capped children. Teams, . . . t o be effective...must be variously constituted for each ch i ld ; they need not be formally and self-consciously organized; they must be capable., of deleting or adding members as the needs demand. Team orientation within a c l i n i c a l setting moreover not only demands a dynamic and progressive program, but requires recip-rocal recognition and respect for each d i sc ip l ine ' s specialized training and cultural ly determined roles and values. The inclusion of the parent on the team i s being suggested more and more by parents and professional people a l ike. Parents are faced with a phenomenal task in recognizing, accept-x M i l l e r , C .A . , "Health Needs of Children with Multiple Handi-caps," Prevention.and Management of Handicapping Conditions in  Infancy and Childhood, Institute sponsored by the University of Michigan School of Public Health, November, 1959, p. 67. 16 ing, understanding, treating, and interpreting their problem. For them i t i s largely a matter of emotional adjustment or adaptation which cannot be completely understood by others un-less experienced. Their participation in the treatment plan therefore i s dependent not only on economic resources, but on their attitudes toward the d i sab i l i ty which include the father's sympathetic and cooperative response, and the mother's emotional response to the developing personality of the chi ld . The d i f f i cu l ty of the parents often i s not the physical d i f f i cu l ty at a l l but any one of the apparently t r i v i a l complications which are inevi t-able when distortions of growth and development-interfere with adjustment at home or in school. Professional people therefore must be prepared to accept, and adjust to these problems as well as to their own respective roles in relation to the patient, his family, and the team interaction, in order to demonstrate a cooperative and integrated approach toward a common goal. In the management of the disabled ch i ld , the concept of "prevention" i s gaining wider recognition in both the medical and social work professions. This has implication, particularly in reference to early diagnosis of a disabling condition, from the aspect of prevention of social or emotional breakdown with-in families; and of prevention of pathology i n the ch i ld ' s physical and emotional development. In social work, the th i rd Crothers, op. c i t . , p. 29. 17 stage or " t e r t i a r y " 1 prevention may be conceived as the h a b i l i -tative aspect. This i s envisaged by offering help to people in the use of their inherent strength of character, and their socia l or community resources, thus f ac i l i t a t ing adaptation in face of stress. Setting of the Study The present study pertains to the treatment program of the Cerebral Palsy Association of Greater Vancouver. This i s a voluntary health agency or ig inal ly founded by a group of parents who had become aware of deficiencies in the services being provided for their children. The agency i s supported by private and public funds, with offices and f a c i l i t i e s located within the G.F. Strong Rehabilitation Centre. The program constitutes non-residential treatment f a c i l i t i e s and services for children with cerebral palsy, and for a l imited number of children with other disabling conditions such as poliomyelit is , traumatic brain injury, and muscular dys-trophy. There are no f inancial e l i g i b i l i t y requirements for those with cerebral palsy, and referrals of children of any age are accepted from within or without the Province of Br i t i sh Columbia on the recommendation of a medical practitioner. Parenthetically, i t may be noted that within the province, services for children with cerebral palsy are offered at the Beck, Bertram M. , Prevention and Treatment, based on the work of a Subcommittee, NASW National Commission on Social Work Practice (mimeographed), p. 8-9. 18 Children's Hospital in Vancouver; at the Health Centre for Children, Vancouver General Hospital; at the Royal Jubilee Hospital, Victor ia ; and a new program i s currently being de-veloped in Surrey. The medical personnel appointed to implement the program of the Cerebral Palsy Association of Greater Vancouver include two physiatrists and a pediatrician. Neurological, orthopedic, psychiatric, audiometric, orthoptic, dental, and psychological services are arranged on a consultative basis. Similarly, the services of the public health nurse are provided through the Metropolitan Health Committee. Other personnel comprise the professional disciplines of social work, physiotherapy, occupational therapy, speech and auditory therapy, and brace-making. Volunteers, and two staff aides assist in a l l departments. In addition to the above, there i s accommodation and staffing for a pre-school enrollment of th ir ty- f ive children; and an academic school enrollment of th i r ty , grades one to six inclusive. The lat ter i s a special service provided by the Vancouver School Board. Exclusive of these, an average of approximately f i f ty children attend monthly at various frequen-cies for therapy only. To enable the children to attend on a regular basis, transportation i s provided by one staff driver, and supplemented by drivers employed by the B.C. Crippled Children's Society. To date, the social worker has made a limited contri-19 bution i n the assessment of the chi ld and family i n terms of social functioning. Specif ical ly , this professional role i n -volves direct contact with parents, as well as l ia i son with the c l i n i c staff and the community. I n i t i a l l y in cooperation with the doctor, the social worker prepares the parents for the ch i ld ' s therapeutic assessment, and explains the scope of the program. In certain cases the social worker may be further requested to interpret the nature of the c h i l d ' s problem to the parents and give them support in his management. This may re-quire casework service on a short term or continuing basis in order to help these families reach a rea l i s t i c understanding of the ch i ld ' s d i s ab i l i ty , and plan for his future accordingly. On the basis of home and office v i s i t s , the social worker provides information to the other team members concerning the family circumstances. Information i s also exchanged in both formal and informal team discussions with regard to the family's and chi ld ' s attitudes to treatment and to the d i s ab i l i ty . As l ia i son between the family and the community, the social worker interprets the nature, extent, and implications of the problem to teachers, nurses, doctors, social workers, administrators, and other agency personnel in the community who are involved with the family. Purpose of the Study In socia l work practice, fact-finding i s a fundamental prerequisite to diagnostic assessment and treatment. Some re-search has already been undertaken within c l i n i c a l settings in 20 an endeavour to e l i c i t , c lar i fy , and record the facts pert i-nent to the case study. A tentative design was conceived for example in a loca l study of the hearing-handicapped c h i l d . 1 The design consisted of two rating schedules, one for the ch i ld , and one for the family. In addition, the study evaluated the chi ld ' s response to treatment (see Appendix A). Profiting from the Varwig project, the present explora-tory study proposes to determine: a. to what extent data about the chi ld with cerebral palsy have been sought in the strategic areas set out in the Varwig schedules, and how the information has been recorded. The study further proposes thereby to explore the relationship bet-ween the chi ld ' s physical and emotional environment, and his progress in functional capacity. b. what specific additional or modified information i s necessary to assess the soc ia l functioning of the to ta l family when the problem centres on the management of the ch i ld with brain-injury known as cerebral palsy. c. how far methods for compiling data can and should be systematized. d. how the data might then be used i n making a diag-nostic assessment on which to structure the medical-social treatment plan. It i s clear that good recording methods contribute not Varwig, Renate, Family Contributions in Pre-school Treatment  of the Hearing-Handicapped Child, Master of Social Work thesis, University of Brit i sh Columbia, I 9 6 0 . 21 only toward the understanding of intra-faraily relationships, but also to further sc ient i f ic research. It follows that a ra-t ing technique may eventually be developed from systematically compiled material, and subsequently standardized as a predictive instrument in evaluation of the casework process. Method Data for the study were obtained from the medical and social case records, then supplemented by staff interviews. Forty-one case records of children between the ages of four and six were reviewed. From these, twenty-five children were selec-ted as having reached the age of four by January, 1954, or having terminated their sixth year in December, 1956. Each chi ld was known to the agency for a period of not less than twenty-four months, and was l i v i n g at home with both parents within the Greater Vancouver area. The s imilar i ty of type, or frequency of treatment were not regarded as necessary determinants in the se-lection of cases. The c r i t e r i a set out in the two Varwig schedules were reviewed, however, only the family schedule was used in compiling the data for tabulation in this study. In recognition of the perceptual problems of the brain-injured ch i ld , rating of the children on the data as outlined was not considered pract ical . The twenty-five families were subsequently rated there-fore on the l ines of one set of the Varwig c r i t e r i a (see Schedule 2, Appendix A). In addition, the children were rated by the c r i t e r i a in Appendix B pertaining to t h e i r progress in physical 22 function over a two year period. The group was later divided according to the severity of the ch i ld ' s condition. The results of the rated material are tabulated and discussed in Chapter II . As the study progressed, the need for a concise me-thod of col lect ing and recording information pertinent to the so-c i a l casework process in the c l i n i c a l setting became more appa-rent. Using the c r i t e r i a as explored in the earl ier study (Schedules 1 and 2, Appendix A) the s ignif icant areas of social functioning were examined. Thereafter a revised and extended profi le was developed. This i s proposed in Chapter III as a framework for assessing levels of socia l functioning for the disabled chi ld (in this case the brain-injured chi ld with cere-bral palsy), and his family. Suggestions are considered in Chapter IV for the application of this instrument i n future. Limitations This project involves only a small group of cases se-lected for the purpose of exploring the extent to which specific information has been recorded. The limitations of the tabulated material must therefore be recognized at the outset. The sample case records actually proved inadequate i n both consistency and uniformity of recording judged by the c r i t e r i a set out in the schedules i n Appendix A. Frequently th i s material was documented in a general form, and occasionally was omitted ent ire ly . More-over, the repetitious content of the descriptive material in the schedules presented d i f f i cu l ty in interpretation. The children within the small sample also represent 23 different d i sab i l i ty types, further complicated by a varied range of intell igence levels . Additionally, the functional progress ratings were determined on a purely subjective assess-ment of the ch i ld ' s progress over a two year period. The revised schedules have not been subjected to systematic application and are therefore presented as a specu-lat ive profi le only. CHAPTER II FAMILY DIFFERENTIALS - A PRELIMINARY ANALYSIS The significance of stable parent-child relationships in the c h i l d ' s development i s now generally accepted. The chi ld ' s emotional environment i s composed primarily of his pa-rents in the early years of l i f e . Their insight of the needs of the ch i ld , their responsiveness and consistency, are condi-t ional to giving the chi ld a feeling of security and acceptance. As stated earl ier however, the aspects of the c h i l d ' s physical environment are also of import. It has been noted that while the economic status of the home must be taken into account, the values and standards attached to high and low income classes must also be recognized. The ways in which the chi ld ' s emotional and physical environment affect his adaptation to a d i sab i l i ty , therefore, can only be measured and evaluated i f there i s some means of rating and standardizing relevant c r i t e r i a . The significance of parental attitudes toward the chi ld for example, can only be studied and tested i f there i s a systematic assessment of the family circumstances of each ch i ld . This might then be compared with the degree of the ch i ld ' s d i sab i l i ty and the general expec-tation of progress. The following sample selection of cases and situations may contribute to emphasize the poss ib i l i t ie s inherent 25 in combined medical-social research within a c l i n i c a l setting. Differentials of Socio-economic Status The results of the ratings of family differentials on the lines of the Varwig c r i t e r i a are presented in Table 1. The percentage figures give additional significance to the differen-t i a l s . It i s important to note at the outset that there i s a high percentage of cases within the higher income groups. (The Varwig study of hard-of-hearing children,carried out in an out-patient hospital c l i n i c , showed large percentages in the lower income groups). This leads one to question whether lower income families are restr icted in obtaining referrals from family doctors due to the ir inab i l i ty to pay his fee. It might also indicate a lack of interest , or a lack of awareness on the part of lower income families that a service i s available. There i s of course another alternative, namely, that these families receive service elsewhere. S t i l l following the argument, the earl ier study included families drawn from the whole province. A l l these points must nevertheless be borne in mind for future studies. In spite of the high income group, there are not correspondingly high ratings in the figures i l lu s t ra t ive of so-cio-economic status. This might be indicative of the fact that high income does not necessarily correlate with high status, or alternatively, the cr i ter ion was not accurately stated or i n -terpreted for the purpose intended. The representative percentages showing the parents' 26 Table 1. Ratings of Family Differentials of the Brain-injured Child (Percentage Distribution) FACTOR " Good Fair Poor Economic Status 1. Income 52 40 2. Employment 63 28 4 3. Housing 64 36 -4. Education 1 (mother) 15 40 45 (father) 20 25 55 5. Socio-economic status 23 40 32 Family Strengths 6. Marital Relations 52 40 8 7. Financial Management 6S 28 4 S. Social handicaps 60 32 a 9. Family s tab i l i ty 76 24 -10. Mother-child relationship 64 36 -11. Father-child relationship 68 24 4 12. Acceptance of handicap (mother) 48 52 (father) 36* 62 -13. Insight into chi ld ' s needs 72 28 -14. Handling of chi ld 56 44 -15. Cooperation with c l in i c 60 36 4 16. Understanding of treatment goals 52 48 -Percentage of known cases (20). 27 levels of education are more consistent with the socio-economic status figures than with those representing income levels . A cross-check was made of the apparent equality in ratings between income level and marital status on the one hand (items one and s ix) , and employment and financial management on the other (items two and seven). This identif ied forty percent of the tota l cases as consistent in the two ratings in the former instance while seventy-six percent were consistent in the l a t ter . This tends to confirm the obvious inference that a positive relationship exists between employment and f inancial management. This i s at least true in this study on the basis of the c r i t e r i a set. Differentials of Family Strengths The findings show relat ively high scores in the areas of family strengths with the exception of the item "acceptance of handicap". The percentages i l lu s t r a t ing father-child re-lationships are not necessarily as s ignif icant as apparent in the table. The data in the records in this area were documented in f a i r ly general terms in a number of cases, necessitating subjective interpretation for rating. In these families, the social handicaps other than marital problems; namely, unemployment, alcoholism, j a i l terms, poor physical and emotional health, absence of parent, and preg-nancy at time of marriage; are not as apparent or gross as those in the previous study. Exploration of the data compiled re-vealed that marital d i f f i cu l ty as described in the schedules i s 28 evident in twelve (forty-eight percent) families, and f inancial d i f f i cu l ty in eight families (thirty-two percent). This infor-mation must be considered with reservation in view of the lack of evidence to the contrary in the records. The item "acceptance of handicap" i l lus tra tes in a graphic sense the whole significance of the study. Regardless of the apparent levels of family strengths determined on the basis of the c r i t e r i a set, there i s not a correspondingly high level of acceptance of the ch i ld ' s d i sab i l i ty . While i t might be argued these factors are dependent on the subjective inter-pretation of the researcher, i t does not negate their s i gn i f i -cance. It rather supports the importance of accuracy in re-cording data. The previous study does not give a clear indication of the manner in which the data were assembled to reach an over-a l l score for each family. It i s assumed this was done on the basis of the average score; that i s , according to the leve l having the largest concentration of ratings for the sixteen items. The family having a preponderance of " f a i r " ratings would then receive an average score of " f a i r " . Such a rating device can however be misleading and deserves i l lu s t r a t ion here. The two sample cases selected for this purpose, Roy's family and Chris ' family, are presented in Table 2. Scores were given each family for the respective c r i t e r i a as outlined. On the basis of an average score for the tota l l i s t , Chris ' family rating i s "good", and Roy's family " f a i r " . At 29 Table 2. Comparative Family Scores for Two I l lustrat ive Cases Rating: G - Good; F - Fair ; P - Poor. Criterion FAMILY Roy Chris Economic Status 1. Inc ome F G 2. Employment F G 3. Housing F G k. Education (mother) P P (father) P F 5. Socio-economic status P G Family Strengths 6. Marital relations F F 7. Financial management F G 8. Social handicaps G G 9. Family s t ab i l i ty G G 10. Mother-child relationship G G 11. Father-child relationship G G 12. Acceptance of handicap F F 13. Insight into chi ld ' s needs G G 14. Handling of chi ld G G 15. Cooperation with c l i n i c F G 16. Understanding of treatment goals F G Average Score: Items 1-16 F G Items 1-5 F-P G Items 6-16 G G 30 sight these scores would infer that Chris ' family i s better adapted to the problem of a disabled chi ld in the home than Roy's. On closer examination however, the areas showing greatest dis-agreement between the two families are those within the f i r s t five items. These include income, employment, housing, educa-t iona l l eve l , and socio-economic status. The inclusion of these for an average assessment tends therefore to place the balance of selected c r i te r i a in doubt. Were Roy's family to be given a rating of "good" in three of these areas for example, i t would change his average score to "good". Items one to five then are not indicative of the family's.attitudes to the chi ld and his d i s ab i l i ty . The items most indicative of th i s and of other family strengths number six to sixteen inclusive. An average score on these items alone thus changes Roy's family rating to "good". The average family scores tabulated later in this chap-ter are therefore based on these eleven items alone. The Child 's Progress in Physical Function The foregoing has i l lus t ra ted one means by which to turn recorded material into a rating device. It i s now relevant to examine whether environmental factors exemplified in the to ta l family score bear any relationship to the chi ld ' s progress in functional capacity. Taking account of the physician's diag-nostic knowledge of the twenty-five children over a two year period, an assessment of each was made (see Appendix B). This was done on the l ines of the ear l ier study by rating the chi ld ' s observed progress as good, satisfactory, slow, or poor. The children were i n addition rated i n accordance with the following 31 levels of relative progress in functional a b i l i t y : AA - As anticipated or better. BB - Some improvement, but not to the level expected. CC - No improvement; or deterioration. The diagnostic problems represented include three children with athetosis, nine with spastic quadriplegia, five with spastic hemiplegia, and eight with spastic paraplegia. The results of these medical assessments are tabula-ted by degree of d i sab i l i ty and are presented in Tables 3 and 4. While the numbers are small, the implication of the data in Table 3 suggests that the children progressed i n ratio to the degree of d i s a b i l i t y . That i s , the children with a mild disabi-l i t y made on the average more satisfactory progress than those with a moderate or severe d i sab i l i ty . None of the children with a mild condition f e l l within the lowest category. Con-versely none of the moderate or severe group f e l l within the highest category. Further, while i t i s a smaller representative group, the rat io of the figures in the severe category indicate lower relat ive scores than those in the moderate or mild groups. The figures i l lu s t ra t ing the chi ld ' s relat ive progress (Table 4) indicate that while the chi ld with a mild d i sabi l i ty makes pro-gress as anticipated, those with moderate and severe d i sab i l i ty in f a i r ly equal ratio show relat ively less improvement than ex-pected. This i s again on the basis of the c r i t e r i a set. That i s , there i s a higher weighting of scores in the "AA" category for the mild group than for the moderate and severe. These findings tend to bear out the importance of recognizing the sig-nificance of normal growth and development factors when anti-32 Progress i n Functional Ability- over a two year period Table 3. Observed Progress Rating: A - Good B - Sati s f a c t o r y C - Slow D - Poor Degree of d i s a b i l i t y Rating Total A B ' C D Mild 1 5 1 - 7 Moderate - 5 5 2 12 Severe - 2 2 2 6 Total 1 12 S 4 25 Table 4. Relative Progress Rating: AA - As anticipated BB - Not to l e v e l expected CC - No change Degree of d i s a b i l i t y Rating Total AA BB ' CG Mild 7 - - 7 Moderate 5 5 2 12 Severe 3 3 - 6 Total 15 S 2 25 33 cipating change in the child*s functional progress. Relationship of Progress to Physical and Emotional Environment A more comprehensive analysis of the findings discussed is now pertinent. The findings relative to the chi ld ' s physical progress, and the family's ratings are presented in Table 5. The discussion w i l l refer to the factor depicting relat ive pro-gress in the chi ld . The factor of observed progress i s included in the table as additional interpretation. Of the twenty-five families, fifteen received an average score within the "good" category and are l i s ted in Group I. Ten families scored within the " f a i r " category and are l i s ted in Group II . None received an average score of "poor". Within Group I six children have mild d i s a b i l i t i e s . A l l have good fa-mily ratings and good progress ratings. There are only two c h i l -dren i n this group with a severe d i sab i l i ty . Conversely, there are four children in Group II with a severe d i sab i l i ty . Peter and Sammy i l lu s t ra te children for whom the c r i t e r i a fa i led to e l i c i t the true parental s ituation. While both c h i l -dren receive warmth and love, in both situations overprotection i s prevalent. This i s more a matter of pampering in Peter's case than as an expressed fear for his safety. He has average i n -telligence and only a mild d i sab i l i ty , yet he tends to be emo-t ional ly dependent and controll ing i n his behaviour. Therefore while his functional progress i s in l ine with that anticipated, there are situational factors which undoubtedly impinge on his emotional maturity. This point bears out the reference to 34 Table 5 . Comparative Ratings of Family Scores and  Functional Progress of the Child Family rating: Functional rating: Group I - Good Relative progress - RP Group II - Fair Observed progress - OP Disabi l i ty Child Functional Progress Type2 Degree OP RP GROUP I SP Mild Dick A AA SQ Moderate Brenda B AA SP Mild Diane B AA SQ Moderate Sammy B AA SP M i d Nick B AA SQ Mild Peter B AA SP Mild Chris B AA SQ Severe Ken B AA AQ Mild Neil C AA SH Moderate Gordon D AA SH Severe Ruth B BB SQ Moderate Doug C BB SH Moderat e Shirley C BB SP Moderate Roy c BB AQ Moderate Bobbie D CC GROUP II SP Moderate Lynn B AA SP Mild Louise B AA SH Moderate Don B AA SQ Severe John D AA SQ Severe June D AA SQ Moderate Phi l ip B BB AQ Severe El len C BB SQ Severe Alan C BB SH Moderate Ian C BB SP Moderate B i l l C CC 'See Appendix B. Disabi l i ty types: SP - spastic paraplegia SQ - spastic quadriplegia SH - spastic hemiplegia AQ - athetoid quadriplegia. 35 emotional factors ear l ier in the study. Sammy's overprotection may in part be accounted for by the cultural heritage of his family where the i l l are expec-ted to be helpless and cared for. There were indications in the record that this tendency was lessening as the parents were helped to reach an understanding of the need for the child to develop self-confidence and independence. The language barrier furthermore posed some d i f f i cu l t i e s for the staff in working with this family. Ruth's average family score i s good, yet when further analysed, f a i r scores only were prevalent in the areas of "acceptance of handicap" and "cooperation with c l i n i c " . The ch i ld ' s d i s ab i l i ty i s severe, yet she has average intel l igence. There are both cultural and socio-economic factors to be taken into consideration in her family. Her parents are of different rac ia l origin and they place emphasis on f inancial gain somewhat to the exclusion of concern for the c h i l d . Of the children in Group II , Alan's family situation i l lus trates other significant stressful environmental conditions. His parents are European and have had considerable d i f f icul ty re-establishing their home in this country. His father has never maintained steady employment since their a r r iva l in Canada. While there i s warmth i n the family relationships, there i s also evidence of over-solicitude on the part of the mother as ex-pressed in unnecessary anxiety and concern over the chi ld ' s health, and hesitancy in encouraging his independence. Corres-ponding hesitation and fearfulness i s evident in the chi ld ' s 36 attitudes to people. The chi ld ' s slow progress may relate to these environmental stresses or alternatively to the degree of d i s ab i l i ty , or to both. Another chi ld i n this group, Phi l ip , has a moderate d i sab i l i ty . He i s an adopted ch i ld , and there i s evidence of conflict between parental attitudes toward and acceptance of his d i s ab i l i ty . Occupational pressures and economic stress have further aggravated the marital discord. These situational factors may conceivably therefore have affected the ch i ld ' s response to therapy. Ian has only a moderate d i s ab i l i ty , and average i n -tel l igence, yet here again, there are confl ict ing attitudes on the part of the parents in the management of the c h i l d . One parent in particular has had d i f f i cu l ty in accepting the ch i ld ' s d i sab i l i ty . There i s notable socio-economic stress within the home as wel l . B i l l y , the last chi ld in this group, has average i n -telligence and a moderate d i sab i l i ty . His parents both have a poor educational leve l , and rate within the lowest socio-economic group. The father i s frequently unemployed and finan-c i a l management within the home in general i s poor. The pa-rents also have d i f f i cu l ty accepting the ch i ld ' s d i s ab i l i ty . Thus, while he has an average inte l lec tua l capacity his phy-s i c a l progress appears to have been retarded, and may reflect his home environmental atmosphere. 37 One study of parents by Murstein 1 i s i l lu s t ra t ive of the atmosphere in B i l l y ' s family, and lends insight to the need for further exploration in future projects of the present kind. Murstein concluded that emotional adjustment was related to the variables of education, inte l lectual understanding and occupa-t ion . Furthermore, "democratic attitudes" were found more fre-quently amongst parents with a high educational l eve l . Those with a lower level exhibited passive-neglectful or actively hos-t i l e attitudes toward the children. While the foregoing analysis has e l i c i t ed results of some apparent significance in that a relationship exists between the chi ld ' s progress i n functional capacity and home environment, i t cannot be accepted with complete va l id i ty in view of the limitations previously outlined. It i s apparent in this study nevertheless, that regardless of the high income group repre-sented there i s a relationship between the ch i ld ' s progress in functional a b i l i t y , and the emotional home environment. Murstein, Bernard I . , "The Effect of Long-term Illness of Children on the Emotional Adjustment of Parents," Child Develop-ment, vo l . 31 (March I960), pp. 157-171. CHAPTER III A FRAMEWORK TO ASSESS LEVELS OF SOCIAL FUNCTIONING The dist inct ive feature of the family situation which concerns the medically oriented soc ia l worker i s the effect an i l lness or d i sab i l i ty has on the dynamics of parent-child re-lationships. In addition to the generic knowledge and s k i l l s which are basic to the profession, the c l i n i c a l social worker has a specif ic contribution to make in providing factual infor-mation about the family circumstances and the interaction of family members. Additionally, the socia l worker may use the data to provide interpretation of the characteristic meaning a d i sab i l i ty has for the parents and ch i ld . This necessitates the seeking of data which w i l l be both relevant and useful not only for the soc ia l worker, but also for the interdiscipl inary team. It must be understood however that not a l l the data can be ob-tained in one or two interviews; in some cases i t may require a f a i r l y lengthy period of contact with the family, dependent on the degree of parental anxiety. Home v i s i t s , particularly in the i n i t i a l stage of contact are considered essential to under-stand the f u l l implications of the family situation. There are specific areas of knowledge which are con-sidered essential to the understanding of family relationships. In the Varwig schedule (see Appendix A, Schedule 1), the follow-ing are included in the chi ld ' s evaluation: 39 1. Physical Development S. Relationship with Mother 2. General Intelligence 9. Relationship with Siblings 3. Mental Alertness 10. A b i l i t y to r e l a t e to other 4. Emotional Development Children 5. Self-Assurance 11. A b i l i t y to r e l a t e to Strangers 6. S e l f Control 12. Response to Social Stimulation 7. Happiness 13. Cooperation ( C l i n i c ) 14. Willingness to learn (New experiences) In the present context these areas of knowledge are i d e n t i f i e d as pertaining to l e v e l s of s o c i a l functioning. "Social functioning" r e f e r s to the i n d i v i d u a l ' s pat-terns of behaviour which can be observed and d i f f e r e n t i a t e d i n terms of adaptation to s t r e s s f u l and non-stressful environmental si t u a t i o n s . Presumably, the l e s s stress i n a s i t u a t i o n , the more l i k e l i h o o d of adequate s o c i a l functioning and s a t i s f a c t i o n f o r the person involved. In compiling the data necessary to evaluate the cause and degree of stress, and i t s meaning f o r the i n d i v i d u a l c h i l d or family i n any environmental s i t u a t i o n , the t o t a l i t y of physio-l o g i c a l , psychological, s o c i o l o g i c a l , and c u l t u r a l factors must be taken into consideration. For the c h i l d , these may be divided into three primary c l a s s i f i c a t i o n s of a d a p t a b i l i t y : (a) physio-l o g i c a l , i n c l u d i n g physical and mental; (b) emotional; and (c) s o c i a l . Physiological Adaptability The data pertinent to physiological a d a p t a b i l i t y i n -clude general health, physical development, and general i n t e l l i -gence. The l a t t e r e l i c i t s further data relevant to learning a d a p t a b i l i t y which include learning capacity, task performance, 40 and response to new experience. From the physiological aspect, one of the most baffl ing diagnostic and developmental elements affecting the management of the brain-injured ch i ld , including the chi ld with cerebral palsy, i s that of perception. Sensory and motor impairments have in the past received more attention than disturbances in the mental processes which might also be attributed to the injury. The mental processes of perception, conceptual formation, language, and emotional behaviour may be thereby affected. It follows that "disturbances i n one of these areas may influence detrimentally the functioning and development of-the others . " 1 This i s true whether or not the injury involves a neuromotor d i sab i l i ty . While rea l i ty demands are frequently a source of con-f l i c t and anxiety for the normal child during his maturational process, the intensi f icat ion of these for the brain-injured chi ld may result in some impairment of in te l lec t and/or mature beha-viour, actual or apparent. The distortion of stimuli received through v i sua l , auditory, t ac t i l e or kinesthetic sources results in the ch i ld comprehending only a part of the whole which the chi ld with normal perception takes for granted. Thus exaggera-ted behaviour patterns of stubbornness, ly ing , fantasy, hyperac-t i v i t y , inconsistency, and di s t ractabi l i ty frequently typify the Lewis, Richard S., Strauss, A . A . , and Lehtinen, L . E . , The  Other Child; the Brain-Injured Chi ld , a Book for Parents and Laymen, Grune and Stratton, New York, 1951, p. 26. 41 brain-injured ch i ld . Added to th i s , " . . . t h e makeup of the chi ld not only contributes to the way he reacts to his parents and to the world, but also in some measure influences how parents and the world react to h i m . " 1 Thus physiological adaptability concerns both the physical health and the development of the c h i l d . I f either of these i s poor or subject to stress there i s l ikelihood of socia l functioning being impaired. Mental a b i l i t y i s also a physiolo-gica l ly determined adaptation. While i t i s d i f f i cu l t to assess with accuracy the intelligence of some children with a d i s a b i l i -ty , i t i s also recognized that others perform at a lower level than the potential indicated by psychometric test ing. This under-lines the need to consider both mental and physical function when assessing learning adaptability or capacity. A chi ld for example may have good intell igence, yet due to a perceptual d i f f i cu l ty or other brain pathology, w i l l be easily distracted and unable to concentrate on a physical task, or give attention to a mental exercise except for periods of short duration. This may apply in socia l learning generally, or adaptation to new experiences. Emotional Adaptability Data referring to emotional adaptability comprise emo-t iona l development, sel f-control , and attitude to d i s ab i l i ty . The stages of personality development relevant to ego function L i t t l e , Sherman, "Social and Emotional Handicaps of Children," Pediatric Cl in ics of-North America: Symposium on Handicaps and Their Prevention, ed. C C . Fischer, W.B. Saunders Co., Philadel-phia and London, August, 1957, p. 733. 42 provide the basis on which to assess the ch i ld ' s level of emo-t iona l adaptability or maturity at any given age. Maturity moreover achieves some c lar i ty i f considered i n terms of depend-ency. The anxious chi ld i s for some reason afraid to give up his dependency entirely, feeling insecure in himself and in his relationships with others. This in turn shows up in his be-haviour. The secure chi ld i s by contrast able to control his own desires within reasonable l imi t s . The frequent demands and attention-seeking reactions of the hurt or anxious chi ld may be his way of gaining retribution from his apparently restr ict ive environment. The child who views his d i sab i l i ty as such a res-t r i c t i o n or control, or as a "punishment", may also respond in this negative way. Social Adaptability Items indicative of socia l adaptability embrace a range of areas of social relationships involving the mother, father, s ibl ings , neighbourhood children and adults, and familiar c l in ic staff. Sibl ing relationships are complicated by the to ta l parent-chi ld interaction; but they may on occasion highlight or give identi f icat ion to the existence of pathology in the parent-child situation. The chi ld ' s relationships to other children and adults, both familiar and strange, are more subtle. His rela-tionship to other children may differ depending on whether or not there are environmental controls in operation. Thus, an un-happy chi ld may strike out at other children i f he finds him-se l f in a position where adult restrict ions are absent. 43 The chi ld who experiences the r i g i d control of his parents may be fearful of exhibiting a negative reaction toward them. He may unconsciously however feel safe i n giving vent to these feelings when with other adults. A cooperative chi ld trusts the people in his environment. A lack of cooperation may be in part a demonstration of fear or mistrust. These are the particular areas of concern i n assessing a chi ld ' s levels of social functioning. While the chi ld ' s socio-emotional environment i s comprised primarily of parental in f lu-ences and attitudes, the inherent meaning of his situation can only be understood i f the wider family-community cultural en-vironment i s taken into account. In effect, by emphasizing the concept of the "whole c h i l d " , the concept of the "whole family" achieves greater significance. Adaptation of the Family In the family schedule (see Appendix A, Schedule 2), the Varwig c r i t e r i a include the following items: 1. Income 9. Family Stabi l i ty 2. Employment 10. Mother-child Relationship 3. Housing 11. Father-child Relationship 4. Education 12. Acceptance of Handicap 5. Socio-Economic Status 13. Insight into Child 's Needs 6. Marital Relations 14. Handling of Child (discipline) 7. Financial Management 15. Cooperation with Cl in ic 8. Social Handicaps 16. Understanding of Treatment goals. Within the present context, in addition to the possi-b i l i t y of physiological stress or i l l health, data pertaining to the family's adaptation to stress may be divided into two broad areas; namely, those relat ing to socio-economic status and socio-cultural standards. 44 Physiological Stress The physical and emotional health of parents; their degree of maturity and s tab i l i ty , or ego strength; and their intell igence determines the i r adaptability to their socio-economic and socio-cultural environment. I l l health may represent a threat to family s tab i l i ty and create pressure on the roles of individual family members. In addition, . . . the effects of i l lness on an individual , his family, and his close associates can have as many different meanings as there are possible combina-tions of such factors as personality development, social conditions, environmental pressures, ways of becoming i l l or handicapped, methods of treat-ment and possible results . Poor health of the father, i f the primary wage-earner, and requiring his absence from work for a prolonged period, w i l l affect the economic and f inancia l s tabi l i ty of the home. Poor health of the mother i f severe or chronic w i l l throw greater responsibil ity on either the father or the elder children in the household management. Socio-economic Status Within North American society, cultural meaning has significance particularly in the class structure and i n related value systems. The occupational structure i s perhaps the fun-damental cr i ter ion upon which the class concept i s based. ^Elledge, Caroline, "The Medical Social Worker," The Handi-capped and Their Rehabilitation, ed. Harry A. Pattison, C C . Thomas, Springfield, 1 1 1 . , 1 9 5 7 , p. 4 1 6 . 45 Closely related to t h i s i s i n d i v i d u a l socio-economic status: .. . c h i l d - r e a r i n g e f f o r t s are greatly f a c i l i t a t e d i f parents f e e l that they are sure of t h e i r place i n society. The economic arrangements of the so-c i e t y play a large part i n the promotion of such feel i n g s i n parents. Economic arrangements must therefore sustain the be-l i e f that the i n d i v i d u a l matters and that l i f e has dignity and meaning i n order t o maintain health of personality i n both c h i l d -hood and adulthood. The value attached to achievement moreover may a f f e c t emotional well-being i n r a t i o to the degree that i n -come s a t i s f i e s the ambitions and expectations of family members. Some studies have shown a r e l a t i o n s h i p between economic status and incidence of physical disease. Furthermore, anthropologists can give "evidence that low income and low s o c i a l status go to-gether and that children from the lowest l e v e l of American so-c i e t y are looked down upon and discriminated against." 3 Educa-t i o n , employment, income, housing and r e s i d e n t i a l area are a l l c r i t e r i a i n d i c a t i v e of socio-economic status, and are at the same time c l o s e l y i n t e r r e l a t e d . Socio-cultural Standards S i g n i f i c a n t areas re l a t e d primarily to the socio- c u l -t u r a l value concept but which may be i n d i r e c t l y affected by so-c i a l class concepts are parental authority; health, and attitudes -LWitmer, H.L., and Kotinsky, R., ed., Personality i n the Making, The Fact-Finding Report of the Midcentury White House Conference on Children and Youth, Harper and Brothers, New York, 1952, p. 104. 2 I b i d . 3Ibid., p. 119. 4 6 to disease or d i sab i l i ty ; religious beliefs ; and attitudes to the professions. Generally speaking, in the upper middle class family today, parental authority i s mutually recognized and shared. S t i l l , there are families within any social class group where authority may be exercised primarily or unquestionably by one or other spouse. When there i s conflict or uncertainty of the parental roles, the resulting disharmony inevitably w i l l affect the children. Role relationships moreover provide an indication of consistency in or deviation from normative beha-viour, as well as making evident the individual ' s attitudes and values. "Roles" then are more or less inherent in a l l areas of social functioning. It i s recognized that i l lne s s , stress, and grief, as threats to ego-integration, may cause regressive or defensive behaviour patterns. Parental attitudes of rejection and over-protection have been suggested as being detrimental to a ch i ld ' s emotional development, and can become greatly intensif ied i f the chi ld has a d i sab i l i ty . One writer mentions excessive demands, minimizing accomplishments, and overstressing a mild handicap as those typica l of the rejecting parent. Exaggerated demonstra-tions of affection, expressed fears of injury, and forbidding of independent act iv i ty are those indicative of overprotection. 1 Inconsistency, permissiveness and anxiety also tend to e l i c i t responses from the child symptomatic of behaviour disorder. Cooper, W., M.D., "The Emotional Problems of the Physically Handicapped C h i l d , " Emotional Problems of Childhood, ed. Liebman, S., J.B. Lippincott Co., 1958, p. 162. 47 While many of these attitudes are reinforced by social pressures, or the responses of relatives and friends, i t i s expedient none-theless to enquire why they prevai l . It i s not easy for parents to distinguish between acceptance of the i r child and acceptance of his d i s ab i l i ty . Due to society's emphasis on competition and achievement however, "the capacity to produce unimpaired offspring i s psychologically and cultural ly important for the parent's sense of personal adequacy." 1 Disabi l i ty in a chi ld then, severely tests their a b i l i t y to maintain their emotional balance and consequently appropriate soc ia l functioning. It may for some parents be a constant reminder of their fa i lure to produce a normal chi ld , which i s disturbing in turn to the i r own self-image and ego. The ch i ld becomes overprotected in part as a protective defense to retain their own ego-identity. In a sense then this i s also a form of rejection. Such basically anxious and frightened pa-rents need reassurance, and exoneration from blame. While not refuting t h i s , a r ea l i s t i c recognition of the ch i ld ' s l imita-tions i s indicative of a healthy attitude. Commonly, parents of disabled children are too dis-turbed or defensive in their relationships to the chi ld to con-sider future real i ty ; others plan unrea l i s t i ca l ly . In consi-deration of the whole family, a rea l i s t i c appraisal must involve both positive and negative attributes in the s ituation. . . •"•Kozier, Ada, "Casework with Parents of Children Born with Severe Brain Defects," Social Casework. Vol . 38 (Apri l 1957), p. 134. 48" Planned ins t i tut ional care for certain children may prove to the ir own as well as to their family's benefit in terms of fu-ture happiness. Occasionally, individuals experience confl icts related to the i r religious values and beliefs in the ir recognition and acceptance of an i l lness or d i s ab i l i ty . The la t ter may be con-sidered a "punishment", and attitudes of denial or non-inter-ference may represent an obstacle to appropriate treatment. Primitive superstitions and tradi t ional folklore s t i l l prevail to varying degrees precipitating confl ict with modern sc ient i f i c medical practice. A person's ethical or religious values may be a crucial factor influencing attitudes to the medical profession, or a medically oriented agency, but i t i s one too seldom appre-ciated. These personal beliefs are in addition, intr icate ly re-lated to the individual ' s adaptive behaviour and as such are fundamental to inclusion in c r i t e r i a indicative of social func-t ioning. Further to th i s , Charlotte Towle has commented that: Through the influence of re l ig ion the purpose of human l i f e i s better understood and a sense of ethical values achieved. With that understanding comes keener appreciation of the individual ' s re-lationship to his fellow man, his community, and his Nat ion. 1 A cr i ter ion reflecting social interests and act iv i t ies provides a measure of the parent's concerns beyond their imme-diate circumstances. It i s recognized nevertheless that one or Towle, Charlotte, Common Human Needs, American Association of Social Workers, New York, 1 9 5 3 , p. 8 49 other parent can develop and participate i n these act iv i t ie s to the exclusion of the primary family-centered interest. L i t t l e enough attention has been given the actual i n -fluence of community attitudes toward the family and their dis-abled chi ld ; or toward their l i v i n g and ethnic standards and values. It i s only by systematic recording of these as expe-rienced and verbalized by the family that a degree of va l id i ty may be given to assumed ideas. In l ight of physiological, economic, social and cul-tura l stress, the family's levels of socia l functioning may thus be conceived as a dichotomy of adaptation with reference to social class structure and socio-cultural standards or values. A Proposed Revision of the Schedules On the basis of the material discussed, the schedules in Appendix C were developed as a re-interpretation of the Var-wig data supplemented by additional c r i t e r i a . The descriptive ratings are presented i n terms of levels of socia l functioning, or adaptation to stress. Specific sub-groups are suggested within some of the descriptive categories i n view of the com-plexity and var iab i l i ty of human adaptation. In the chi ld ' s schedule, the category "physical de-velopment" required more definit ive meaning than that e l i c i ted in the or ig inal schedule, thus the category "general health" was added. The previous grouping of general intell igence levels was disproportionate to the problems of the children being stu-died. Consideration must be given those children whose a b i l i -t i e s could not be accurately tested. 50 The category "learning capacity" combines two items of the earl ier schedule, namely, "mental alertness" and "wi l l ing-ness to learn" . The category "task performance", as differen-tiated from learning ab i l i ty was developed as a separate item, being conceived as more than an aspect of "self-assurance" as inferred in the earl ier c r i t e r i a . Items twelve and fourteen of the Varwig c r i t e r i a were combined to form item six in the revised l i s t . As " socia l stimulation" i s inherent in a l l socia l relationships, the ex-planatory divis ion, of this cr i ter ion in the or ig inal schedule was fe l t to be more accurately stated in terms of adaptability to new experience. The revised item of "emotional development" combines descriptions previously under the three headings of self-assu-rance, sel f-control , and happiness. It now precludes factors such as d i s t rac tab i l i ty and short concentration span as being indicative of emotional imbalance per se. These factors rather, are incorporated in the explanatory material within the areas of academic and experiental learning, and of task performance, thereby becoming clues to identify perceptual d i f f i cu l ty . The item "sel f-control" i s revised as primarily re-f lect ing the a b i l i t y to accept l imits and d i sc ip l ine . The or ig inal c r i t e r i a fa i led to include the attitude of the chi ld to his father and to his d i sab i l i ty . Also the disabled chi ld frequently experiences the overprotecbion of an elder s ibl ing as much as of the parents. These factors are taken into account i n the revised schedule. 51 The chi ld ' s relationship to other children may differ depending on whether or not ac t iv i ty occurs within a controlled environment. The suggestion i s made in the schedule that the setting be designated. Relationships to adults are divided to include familiar and unfamiliar situations. In the family's schedule, the category of employment i s extended to form two separate items in order to e l i c i t i n -formation pertaining to the occupational group as well as to the employment record. Discipline and consistency are inseparable from parent-chi ld relationships, therefore some of the descriptive material of items thirteen and fourteen i n the original schedule was com-bined and i s included in the revised items of parent-child re-lationships. The revised item "attitude to d i s ab i l i ty " was changed from "acceptance of handicap" to indicate essentially the parent's recognition of the limitations presented by the d i sab i l i ty . The additional data proposed in this schedule include the following: health, residential d i s t r i c t , socio-economic c l i -mate, role perception, assessment of the chi ld ' s future, ethical values, community ac t iv i ty , and socio-cultural community a t t i -tudes. The health of parents may be a primary factor influen-cing parent-child relationships as has been pointed out, and thereby warrants inclusion separate from "social handicaps" as inferred in the earl ier c r i t e r i a . The item socio-economic climate i s devised to e l i c i t 52 parental expectations and feelings with respect to their socio-economic situation. Rating Methods The formulation of c r i t e r i a according to levels of social functioning is needed i n a l l branches of social work. The f i r s t successful family profi le developed along these l ines was that of the family-centered project of St. P a u l . 1 Culmina-t ing ten years of research with multi-problem families, the c r i -ter ia are divided on a rating scale "adequate-marginal-inade-quate", according to family behaviour being in l ine with communi-ty expectations. The family schedule of the present study, while dif fer-ing in emphasis, covers the same general areas of knowledge of intra-family relationships, with the possible exception of de-t a i l in role-performance. Within this context however the grading of data A-C i s not concerned with the fact that the fa-mily's behaviour i s a threat to the community. It i s concerned with intra-family conflict affecting the family sol idar i ty and well-being. Moreover, in this c l i n i c a l setting, the assumption i s that the stress precipitating confl ict i s primarily centered in a specific factor; namely, a disabled chi ld in the family. Thus in grading the data A-C according to levels of adaptability to stress, the area of socio-cultural adaptation w i l l in the main -•-Geismar, L .L . and Ayres, B. , "Patterns of Change i n Problem Families ," Family Centered Project, Greater St. Paul Community Chest and Councils, Inc. , St. Paul, (July 1959), pp. 30-3$. 53 reflect the existence of this conf l ic t . Within this group only-then the rating may be conceived along the l ines of the study cited in the following manner: A - adaptation conducive to the family's well-being B - adaptation a potential threat to the family's well-being C - adaptation constituting a concern to the well-being of the family and secondarily to the community. The level of adaptation in the physiological and socio-economic areas may or may not have relevancy to the conflict and hence does not warrant rating in these terms. Similarly, for the brain-injured ch i ld , the levels of adaptability w i l l reflect functioning pathology primarily in the emotional-social areas. Rating in these groups only might be conceived as adequate-inadequate in so far as the adaptation i s conducive to, or a threat to the chi ld ' s well-being. Again, physiological adaptation may serve to highlight or give ident i-f icat ion to pathology evident i n the foregoing areas. I f in addition, or alternatively, i t i s desirable to make an overall assessment of the family's adaptability to en-vironmental stress on the basis of the average score, the c r i -t e r i a indicative of socio-cultural standards only, items eight to twenty, should be rated. The c r i t e r i a indicative of socio-eco-nomic status, items two to seven, along with item one, reflect adaptability i n face of economic, soc ia l , cultural and physio-log ica l stress. Items twelve to seventeen indicate adaptability to the stress of a disabled chi ld i n the home, but are also a ref lection of socio-cultural standards. 54 Item twenty-one, "family s t a b i l i t y " , may serve as the c r i t e r i o n against which to measure the average assessment of items eight to twenty, and i f desirable, items twelve to seventeen. Scores may then be further correlated with items one to seven respectively. In recognition of the brain-injured chi l d ' s enhanced s u s c e p t i b i l i t y to environmental stress, the o v e r a l l assessment of s o c i a l functioning by an average score r a t i n g must allow f o r a d a p t a b i l i t y to physiological conditions of health, physical de-velopment and i n t e l l i g e n c e . The average score r a t i n g of emotion-a l adaptation based on items seven to nine might thus be corre-lated with the average score of items one to three, and with that average score of learning adaptation, items four to s i x . S o c i a l adaptation may be rated s i m i l a r l y , both exclusive and i n -clusive of the home environment, and correlated respectively with the foregoing areas of adaptation. It should be pointed out that a diagnostic assessment f o r an i n d i v i d u a l family i s not encumbent on the data being cor-related i n accordance with the above ra t i n g scheme. Neverthe-l e s s , such a device may prove useful f o r subsequent exploratory research. The schedules may i n addition serve as an evaluative instrument to measure progress i n casework treatment. A s i m i l a r approach to that of the Hunt-Kogan study might be undertaken. This was a pioneering research project i n the evaluation of case-work services f o r the i n d i v i d u a l c l i e n t . The schedules were divided according to "adaptive e f f i c i e n c y , d i s a b l i n g habits and 55 conditions, verbalized attitudes and understanding, and environ-mental circumstances." 1 They were used in the i n i t i a l evalua-t ion , and reviewed at three month intervals to assess progress or regression in the case. It i s only by means of systematic application of a prof i le that i t s va l id i ty in diagnosis, treatment and evaluation can be established. The proposed design nevertheless affords a comprehensive method of recording data significant to the family-centered casework process in the c l i n i c a l setting. As such i t constitutes the framework for a diagnostic assessment upon which to structure the medical-social treatment plan. That i s , the areas contributing to maladaptation might be ident i f ied , and subject to the ir re la t iv i ty to the to ta l pattern, subsequently indicate areas appropriate to treatment. Chapin, F .S . , review of a study by J. McV. Hunt and Leonard S. Kogan: "Measuring Results in Social Casework: A Manual on Judging Movement," Social Work Journal, v o l . 32 (January 1951), p. 3#. CHAPTER I V THE SOCIAL WORK CONTRIBUTION I N A C L I N I C A L SETTING S o c i a l work i n a m e d i c a l l y - o r i e n t e d c l i n i c a l s e t t i n g r e q u i r e s a s p e c i a l i z e d a p p l i c a t i o n o f g e n e r i c " p r o b l e m - s o l v i n g p r i n c i p l e s . " The c o n t r i b u t i o n o f t h e s o c i a l w o r k e r as a member o f t h e t r e a t m e n t team i s t o p r o v i d e c a s e w o r k s e r v i c e s t o f a m i -l i e s t o h e l p i m p r o v e o r r e s t o r e t h e s o c i a l f u n c t i o n i n g o f t h e i r members. I n t h e management o f t h e d i s a b l e d o r b r a i n - i n j u r e d c h i l d , t h e s o c i a l w o r k e r ' s c o n t r i b u t i o n a l s o i n v o l v e s i n t e r p r e -t a t i o n a b o u t t h e d i s a b i l i t y , ways o f c o p i n g w i t h i t , and n e e d e d r e s o u r c e s , b o t h w i t h i n t h e a g e n c y a n d t h e community. The e f f e c t i v e n e s s o f t h e s e r v i c e however, i s d e p e n d e n t on a c o m p r e h e n s i v e d i a g n o s t i c a s s e s s m e n t . I n a c l i n i c , t h e d i a g n o s i s on w h i c h m e d i c a l - s o c i a l s e r v i c e s a r e b a s e d i s depen-d e n t on an e v a l u a t i o n o f t h e m e d i c a l - s o c i a l p r o b l e m . The s c h e -d u l e s a s d e v e l o p e d i n t h i s s t u d y p r o p o s e c r i t e r i a a l l o f w h i c h a r e o f d i a g n o s t i c i m p o r t . A f a m i l y a s s e s s m e n t b a s e d on t h e s e w i l l g i v e b e t t e r f o c u s t o t h e management o f t h e b r a i n - i n j u r e d c h i l d . E . W a l k i n s has d e f i n e d p s y c h o s o c i a l d i a g n o s i s a s . . . t h e s t u d y and e v a l u a t i o n o f t h e i n n e r and o u t e r f o r c e s a f f e c t i n g t h e c h i l d and h i s f a m i l y . T h i s w o u l d i n c l u d e n o t o n l y a knowledge o f t h e p h y s i c a l i n v o l v e m e n t o f t h e h a n d i c a p , b u t t h e m e a n i n g t h e h a n d i c a p h a s f o r t h e p a t i e n t and h i s f a m i l y . I t i n c l u d e s a s t u d y o f t h e s o c i a l s t r e s s e s w h i c h may be a f f e c t i n g t h i s f a m i l y , a s w e l l a s t h e r o l e p l a y e d 57 by c u l t u r a l values and economic f a c t o r s . 1 B.K. Simon suggests three further elements relevant to a psychosocial study: a. The current, s p e c i f i c adaptive operations that the patient i s using to handle the s t r e s s . b. The current, s p e c i f i c indications of the patient's p o t e n t i a l f o r r e l a t i o n s h i p . c. Current resources within the patient and his en-vironment that may be c a l l e d upon to contribute to the solution of his problems. 2 The s o c i a l worker's preliminary diagnosis moreover i s not a s t a t i c or f i n a l formulation. It must be expanded and revised as a d d i t i o n a l data are received. The c l i n i c s o c i a l worker, using the casework method, endeavours to help restore parents' adaptive mechanisms by enabling them to discuss t h e i r f e e l i n g s of disappointment, f r u s t r a t i o n , and g u i l t , as well as those of pride, and s a t i s -f a c t i o n . Of f i r s t importance i n t h i s process i s that the worker ascertain the degree of understanding the parents have with re-gard t o the reason f o r the r e f e r r a l , how i t was made, what part they took i n i t , and what t h e i r expectations are i n respect to the t o t a l program and the worker's r o l e i n i t . This i s par-t i c u l a r l y relevant i n c l i n i c a l settings where the focus i s on the c h i l d i n the r e f e r r a l , but where the main d i f f i c u l t y may yet l i e i n the family's attitude and understanding. Parents, more-over, need opportunities to express t h e i r f e e l i n g s concerning 1Walkins, Elizabeth L., "Community Programs f o r Children with Multiple Handicaps: The Contribution of the S o c i a l Worker," Prevention and Management of Handicapping Conditions i n Infancy  and Childhood, I n s t i t u t e sponsored by the University of Michigan School of Public Health (November 1959), p. $4. 2Simon, Bernece K.,"Relationship Between Theory and Practice i n S o c i a l Casework," So c i a l Work Practice i n Medical Careand Re-h a b i l i t a t i o n Settings, Monograph IV, National Association of S o c i a l Workers, New York, I960, p. 16. 58 previous experiences related to the ch i ld ' s problem. Their contacts with other team members during the i n i t i a l phase gives them a broader understanding on which to base t h e i r own con-clusions. During this process, the socia l worker i s able to determine how the parents have adapted to situations in the past, and in l ight of their present levels of social function-ing gain insight into their capacity to respond to structured treatment. Miss Simon's comments in this connection apply equally to parents or patient: The patient's real i ty-test ing capacity, his judgement, and his inte l lec tua l ab i l i ty are ob-served and assessed from both the substance and the manner of his presentation. We assess these personality functions and characteristics by the apparent relevance, coherence, and logic i n the patient's presentation. The social worker's reciprocal response i n acknowled-ging and accepting the parents' degree of stress, i s a decisive factor in determining the establishment of a sound relationship. S t i l l following Miss Simon's exposition, The diagnostic and therapeutic problem for the worker i s the ident i f icat ion, establishment, and sustaining of the kind of relationship that the patient needs and can use for the solution of his problems.2 The worker furthermore aids parents to identify and differen-t iate this relationship from other helping relationships. The treatment plan proposed by the social worker must Ib id . , p. 17. 2 I b i d . , p. 39. 59 focus on a specific goal or termination point. While this goal may be f lexible , i t nevertheless plays an important part in judging the effectiveness of the service. It must also be understood by the client that treatment may be resumed at a later period should the situation warrant. During the treat-ment period, by encouraging parents of a disabled chi ld to par-t ic ipate in planning, they are helped to reach a firm under-standing of the ch i ld ' s needs relative to his condition. Where attitudes impede appropriate planning, they may be guided to recognize and accept their fai lures as well as the ir successes, to substitute new patterns of adaptive response, and to set rea l i s t i c goals. This level of service i s a demanding one in terms of casework s k i l l ; the degree of efficiency must to some extent be measured against the size of caseloads, and the number of social work staff i n relation to agency time. Additionally, the arrange-ment of staffing w i l l vary depending on the orientation of the agency in the recognition of the primary factors impinging upon the ch i ld ' s satisfactory habi l i ta t ion. These may be perceived as soc ia l , emotional, developmental, or physical. Of course when there are several members of a team, the primary therapeutic relationship with parents or chi ld i s not necessarily assumed by the soc ia l worker. For that matter, not a l l families w i l l require the same range, or degree of treatment. However, i t i s essential to gain an understanding of the problem as soon as possible in the i n i t i a l period. The worker's s k i l l in diagnostic assessment thereby becomes 60 indispensable not only i n determining the needs of c h i l d and parent, but i n helping to perceive which i s the most approp-r i a t e team member to assume the main r e s p o n s i b i l i t y f o r therapy. In the words of W.T. H a l l , ...the s o c i a l worker must, through h i s own s e n s i t i v i t y to the needs, desires, and moti-vations of t h i s patient and family, and through hi s knowledge of the environmental stresses which may be operating i n a p a r t i c u l a r s i t u a -t i o n , help each team member to understand, and to r e a l i z e the importance of understanding, why t h i s i n d i v i d u a l and t h i s p a r t i c u l a r parent are behaving the way they do. 1 This then i s relevant whether or not the s o c i a l worker undertakes to treat the c h i l d or family. Dependent on the i n d i v i d u a l s i t u a t i o n , the p r i o r i t y s e l e c t i o n of a given t r e a t -ment procedure at any one time may be determined by the area of urgency, whether physical, s o c i a l , or emotional. In many cases, admittedly, these are of equal concern; nonetheless, i t i s here that f l e x i b i l i t y and c l a r i t y of role i n team organiza-t i o n i s e s s e n t i a l . Furthermore, when circumstances warrant, modification i n the o r i g i n a l treatment structure must be under-taken. The s o c i a l worker should be i n a position to evaluate factors which w i l l help or hinder i t s adoption. The most important member of the team, i t must be remembered, i s the c h i l d . Whether he has a brain i n j u r y or other d i s a b i l i t y , h is emotional p a r t i c i p a t i o n i s of f i r s t H a l l , Wm. T., "The So c i a l Worker i n a Community Hearing Pro-gram," Prevention and Management of Handicapping Conditions i n Infancy and Childhood, I n s t i t u t e sponsored by the University of Michigan School of Public Health (November 1959), p. 123. 61 importance i f his functional or inte l lectua l participation i s to be assured. In a diagnostic formulation based on the pro-posed schedules, the socia l worker should be able to identify-some of the symptoms contributing to the ch i ld ' s social dys-functioning. The resolution of such maladaptation does not necessarily concern parental attitudes. It may require modi-f icat ion of attitudes on the part of any adult occupying a sig-nificant position in the chi ld ' s environment. Direct treatment of the ch i ld may in addition involve soc ia l stimulation within a peer group; or the opportunity to express anxieties and feel-ings within a casework or play therapy situation. It i s t radi t ional and s t i l l very common to think in terms of the disabled ch i ld ' s physical treatment, yet his socio-emotional treatment needs equal consideration. Medical specia-l i s t s repeatedly infer this in their writings, and in addition corroborate the significance of environmental attitudes. An orthopedic surgeon has observed some of the social and emotional symptoms creating obstacles to functional improvement of the disabled chi ld ; namely, those of anxiety, overprotection, re-jection, and social privation. He comments, . . . there i s no real speci f ic i ty between the cause of the handicap and the nature of the emotional de fec t . . . . I t i s more a question of the degree and quality of the handicap and the nature of the , environment or the atmosphere that surrounds i t . It may furthermore be stated that regardless of the Cooper, W., M.D., "The Emotional Problems of the Physically Handicapped C h i l d , " Emotional Problems of Childhood, ed. Liebman, S., J.B. Lippincott Co., 1958, p. 150. 62 level of proficiency in functional ab i l i ty , a dis i l lusioned or demanding chi ld may become an embittered or soc ia l ly rejected adult. According to another source, . . . the extent to which a ch i ld i s handicapped depends more on his feelings than on the nature or degree of the handicap i t s e l f , and that the most important single factor determining the attitude of a chi ld toward his handicap i s the attitude of his parents. This statement carries greater impact than i s at f i r s t apparent. As already suggested, the attitude of parents i s often a mirror of the socio-cultural attitude. This in turn then i s no less profoundly shaped by the attitudes of the people representing the professional discipl ines closely involved in the problem. Thus, whether or not parents are included consciously as an integral part of the "team", professional people have a responsibil ity to acknowledge the parents' problem and to offer honest, candid, and constructive guidance and support. They also have a responsibil ity to reappraise the services they pro-vide. Practice does not axiomatically infer competence. In-deed, the real handicap of multiple disabled children, i t has been said, "may be our ignorance of what i s wrong with them and 2 what to do about i t . " It has been furthermore observed that: The success of management i s assured only when the chi ld arrives at maturity with confidence and maximal a b i l i t y to compete. This, we believe depends upon the emotional s tab i l i ty of the parents Services for Handicapped Children, Prepared by the Committee on Child Health of the American Public Health Association, American Public Health Association Inc. , New York, 1955, p. 49 . 2 M i l l e r , C .A . , "Health Needs of Children with Multiple Handi-caps," Prevention and Management of Handicapping Conditions in  Infancy and Childhood, Institute sponsored by the University of Michigan School of Public Health (November 1959) , p. 70. 63 and the c h i l d f u l l y as much as i t does on motor competence. Agency and Community R e s p o n s i b i l i t i e s The objective toward which the Cerebral Palsy program aspires f o r each c h i l d i s that he gain physical and emotional independence, and thereby achieve early integration within h i s peer groups i n the community. There are here however three i n t e r r e l a t e d facets to consider: the socio-emotional, the physi-c a l , and the i n t e l l e c t u a l . With regard t o the f i r s t , the impor-tance of a psychosocial diagnosis i n t h i s s e t t i n g must now be • evident. Such an assessment based on the proposed schedules i n Appendix C, together with an understanding of the diagnostic and prognostic implications of the brain-injured c h i l d ' s physical condition, w i l l e stablish a framework f o r planning and treatment. From the physical aspect, some children may reach a stage of independence early; others w i l l remain dependent for l i f e ; s t i l l others w i l l gain only p a r t i a l independence. It i s i n t h i s respect that a r e a l i s t i c outlook on the part of the treatment s t a f f i s imperative i f the c h i l d i s to gain emotional independence, and i f the parents are to be helped to recognize the c h i l d ' s l i m i t a t i o n s as w e l l as the l i m i t a t i o n s i n the s o c i a l structure of the community. The appropriate integration of the i n t e l l i g e n t c h i l d with a severe physical d i s a b i l i t y i s a car-d i n a l point here. This i s an area where community planning i s as yet inadequate to the need. For those children who do reach a l e v e l of independence, Crothers, Bronson, and Paine, R.S., The Natural History of  Cerebral Palsy, Harvard University Press, Cambridge, 1959, p. 285. 64 their integration within the socia l structure necessitates interpretation to the community. Many inte l lectua l ly bright children with physical d i sabi l i ty are, primarily due to ignorance, regarded inte l lec tua l ly as less than normal, or as objects of p i ty . Fear for the ch i ld ' s safety i s expressed again and again, particularly by teachers, who are generally the f i r s t people in the community with whom the child has a sustained relationship. Many teachers have exhibited sensitive understanding, but many others need to gain a more enlightened attitude toward these c h i l -dren. The disabled chi ld needs encouragement to participate in ac t iv i t i e s , yet he needs at the same time to develop an awareness of his own l imitations. This conversely involves a recognition by the teacher of his l imited capacities. It however does not imply that he should receive preferential d i sc ip l ine . This agency furthermore, i s concerned with the whole family, wherever marital, f inancia l , or social problems are sus-pected as being intr icate ly related to the ch i ld ' s condition. The extent of this relationship can only be identif ied by a care-fu l diagnostic assessment by the soc ia l worker, which again can be formulated according to the suggested levels of adaptation to environmental stress. A social diagnosis moreover, i s tantamount to effective interpretation and referral to other community agen-cies. The latter would apply when family d i f f i cu l t i e s either do not have direct bearing on the chi ld ' s problem, or when they may be more appropriately treated in a different setting. No habi l i tat ive program, can be carried out effectively without an awareness and u t i l i za t ion of community resources. 65 This necessitates a reciprocal understanding of the nature of the services provided by any one agency. Interpretation must thereby involve the social worker in the role of consultant both within and external to the agency. According to the National Association of Social Workers, Consultation contributes the expert knowledge and judgement of the medical social worker regarding the psychosocial factors which influence needs and treatment of individual patients to the medical and paramedical personnel giving the service on the program, to the administrative staff, and to staff of other agencies participating in the provision of services to i t s patients.1 Consultant service then applies to the immediate intra-agency community as well as to the province-wide community. The fact must not be overlooked that there are many rura l , and other urban communities where no special treatment f a c i l i t i e s are available for the chi ld with brain injury or cerebral palsy. This in some respects places an even greater degree of respon-s i b i l i t y on the community. Dependent on the individual circum-stances, the loca l public health department, public or private social agency, or the family doctor may be approached to assume the primary relationship with the family. As the goal of habi l i tat ion i s to fac i l i ta te the ch i ld ' s and family's social functioning and independence, i t i s only by a recognition and acceptance of this responsibil ity that they can be assured of Report of a Conference Sponsored by the Medical Social Division of the National Foundation for Infantile Paralysis, Medical Social Work Preparation and Performance, New York, March 3-7, 1957, p. 49. 66 integration within their own environment. This nevertheless poses the question of leadership in the whole area of habi l i ta t ion and rehabil i tat ion of disabled children. In the community where a health agency such as that under discussion i s established, an interdiscipl inary consul-tative service should be provided on a province-wide basis, and support assured medical and social agencies when the needs de-mand. In this respect then, the program carries a further res-ponsibi l i ty to in i t i a te planning for more effective services when these become inadequate to meet the demand. Dr. Wishik states s ignif icantly , Two common and unfortunate tendencies in the development of new services are f i r s t , to establish a completely new service apart from any existing ones, and second, to set up a specialized service for one or another diagnostic group or condition. . . . Individuals and organizations should focus on the needs of children as a to ta l group rather than on one or another specific condition handicapping some c h i l d r e n . 1 Another writer comments: In great part, the snobbishness that the parents of a handicapped chi ld may feel concerning one handicap versus another has grown out of the professional attitude of the trained personnel connected with the various agencies. 2 . . .Without a feeling of pride in their chi ld or hope of pro-mise they become disorganized, and often misunder-stood and misdirected.3> Dr. Deaver, s a t i r i c a l l y at f i r s t , sums up the discussion: -•-Wishik, Samuel M. , M.D., "The Role of the Physician," The  Child with a Handicap, ed. E .E . Martmer, C C . Thomas, Spring-f i e l d , 1959, P. 9. 2 Hood, Oreste E . , Your Child or Mine, Harper and Bros., New York, 1957, p. 42. 3 I b i d . , p. 171. 6 7 Pity the youngster with a d i sab i l i ty for which no organization has yet been founded 1 If we consider rather their common d i sab i l i t i e s , i t i s evident that they can a l l be handled to-gether to great advantage.1 In consideration of the family's adequacy of social functioning, the social worker has a primary responsibil ity to define the need and participate in the i n i t i a t i o n and develop-2 ment of resources appropriate to this need. This refers to "program consultation", a professional function described as that which ...makes available the expert knowledge and s k i l l of the medical social worker to social workers, members of other professions and discipl ines or appropriate community persons, groups, or organi-zations, in their assessment of the need for, or the development, reorganization,•or maintenance of, various programs in which the medical-social needs of patients or potential patients are an important f a c t o r .3 The writer thus firmly believes that in order to avoid the poss ib i l i ty of additional, segmented services developing, the Cerebral Palsy Association treatment program presently estab-lished within a rehabil i tat ion centre should be consciously and purposefully expanded to include a l l physically disabled children, inclusive of the brain-injured chi ld whether or not a physical d i sab i l i ty i s apparent. -•-Bluestone, S.S., M.D., and Deaver, G.G., M.D., "Rehabilitation of the Handicapped C h i l d , " Pediatrics.(May 1 9 5 5 ) , p. 6 3 4 . 2 Cocker i l l , E . , and Gossett, H . , The Medical Social Worker as  Mental Health Worker, National Association of Social Workers, New York, 1 9 5 9 , p. 1 1 . 3Report of a Conference Sponsored by the Medical Social Division of the National Foundation for Infantile Paralysis, Medical Social Work Preparation and Performance, New York, March 3 - 7 , 1 9 5 7 , p. 5 1 . 68 Community resources for the mentally disabled are expanding, nevertheless reciprocal treatment and consultative services should be available because of the frequent combina-t ion of physical and mental problems. This applies particu-l a r l y when apparent mental retardation of a physically normal chi ld i s considered attributable to a perceptual problem as a result of a brain-injury. In addition, the community must be given a clear interpretation of the range of the program. Furthermore, th i s agency should provide leadership in the area of services for disabled children by participation in the c o l -laborative development of existing related services. Future Research In comparison with other s o c i a l and medical sciences, social work research i s largely experimental. Dr. L .L . Geismar puts the point this way: Social work research has not attained the stage where i t can build i t s theory on the basis of comparing results among related and converging f i e l d studies. In order to make experiment possible, however, data must be made available. In order to gain knowledge about family and social functioning, new methods of recording and appraisal must be sought and applied. Only in this way too can results of case-work be evaluated, and the service subsequently improved. Again, Dr. Geismar comments: Geismar, L .L . and Ayres, B., -'Patterns of Change in Problem  Families, Family Centered Project, Greater St. Paul Community Chest and Councils, Inc., St. Paul (July 1959), p. 28. 69 A fundamental question to be asked about any program of cure, therapy, rehabi l i tat ion, etc. is whether i t had a lasting effect . Any re-habi l i ta t ive program which serves only as a temporary prop has not f u l f i l l e d i t s overall purpose.1 The r e l i a b i l i t y and usefulness of the revised sche-dules as presented in this study can only be tested by systema-t i c application associated with concise and accurate recording. The aim of the St. Paul research project for example followed two steps: ...1) the development of a rel iable method for appraising the behavior of multi-problem families; and 2) the application of this method to a group of cases, so that the results obtained from 2 family centered treatment could be evaluated. It i s recommended therefore that the suggested profi le be adopted as a tool in the assessment and treatment process with-in the agency to which the study pertains. It i s evident more-over that this may be used profitably in other agencies serving disabled children. The selection of a limited group of cases for the purpose of testing r e l i a b i l i t y of the proposed design would not overtax the present caseload commitments. An ensuing research project might entai l a more ob-jective selection of cases according to age, diagnosis, and intelligence of the chi ld ; and frequency or consistency and nature of treatment of both chi ld and parents. It would be of further value to e l i c i t verbal responses of parents and children in a controlled study of their attitudes and feelings. They •'-Ibid. , p. 17. 2 I b i d . , p. 1. 70 might then be compared with the recorded material indicative of levels of soc ia l functioning. Not every c l i n i c a l setting has to ta l ly accepted social work as having a contribution to make. It more urgently there-fore behooves the social worker within such a setting to demon-strate in a practical yet purposeful way what can be offered in aiding diagnosis and treatment, drawing from the areas of person-a l i t y di f ferentials , family dif ferentials , and community re-sources generally. In consideration of the findings in this and other studies, i t is apparent that the chi ld ' s adaptation to his d i sab i l i ty i s dependent on the family's understanding and accept-ance of the problem. The importance of the social worker's contribution i s therefore clear. The St. Paul study confirms that research i n social work can be re l iable provided the method i s sound. Nevertheless, Dr. Geismar has pertinently observed that The soc ia l and psychological sciences are s t i l l in a state of relative infancy when i t comes to pro-viding a complete and coherent picture of the behavior of man and the changes in his behavior. The supporting social sciences s t i l l therefore have a long way to go, but as long as the socia l work contribution i s qualitative, i t w i l l s ignif icantly affect the understanding of the behaviour of man. ^Ibid. , p. 7. 71 Appendix A Schedule 1. Suggested Cr i ter ia for Evaluation of Emotional and Social Adjustment Cr i ter ia Explanation of Ratings Good Fair Poor 1. Physical Development Healthy,normally Healthy ch i ld . Slow physical de-developing ch i ld . Normal develop- velopment due to No serious i l l - ment once inter- frequent i l lnes s , ness. rupted by serious or several i n c i -i l lness ;or ,phys i - dents of severe cal development i l lness ;or , im-s l ight ly retarded, pairing disabi-l i t y other than hearing loss. 2. General Intelligence (a) (superior) (average) (dull normal,or s l ight ly re-tarded) . 3. Mental Alertness Bright,active, Alert child,but Dull,slow in re-quick,understand- easily frustra- sponse and under-ing .Abi l i ty to ted;or somewhat standing;or,with-adjust easily to slow in adjust- drawn and day-new situation. ing to new dreaming. situations. 4. Emotional Development Well balanced, Easi ly frustra- Very immature;or, contented and ted,regresses when shows symptoms relaxed. Acts faced with new and of emotional his age. d i f f i c u l t exper- disturbance. ience,short con-centration span. 5. Self-Assurance Independent,se- Easi ly frustrat- Overly dependent cure i n relation- ed,demanding and and clinging, ships,trusting. attention seeking, Extremely shy Persistent and whiny;or,shy and and anxiousjdis-goal directed self-conscious. t rust ful and when trying to fearful in re-perform set task. lationships. (a) Determined on the basis of tests administered by the Metropolitan Health Committee. 72 Schedule 1. continued Cr i ter ia Explanation of Ratings Good Fair Poor 6. Self Control Relaxed and se-cure in relation-ships,able to postpone immediate wish fulfil lment; able to accept l imi t s . Temper tantrums when frustrated, but does not pre-sent serious be-haviour problem; or,too controlled due to fear. Severe temper tantrums on slightest occa-sion; completely uncontrolled and uncontrollable; destructive; or, r i g id self con-t r o l , severe withdrawal. 7. Happiness Happy,friendly, outgoing and trusting ch i ld . Changing moods; often whiny and dissat i s f ied,or stubborn and defiant. Negativistic and hosti le ;or ,ex-tremely with-drawn and un-responsive.  £ . Relation-ship with Mother Warm and relaxed. Feels loved and wanted;responds with love and affection. Shows not too much spontaneity in relationship with mother;or, demanding;con-stantly attention seeking. Negativistic and resentful toward mother,or with-drawn . C omplet e lack of communi-cation, warmth, and understand-ing between mo-ther and ch i ld . 9. Relation-ship with Siblings Mutual acceptance and affection; feeling of be-longing together. Ambivalence ex-pressed by either reaction forma-t ion , or by resent-ment alternating with acceptance and tolerance. Extreme s ibl ing rivalry.Jealous and deeply re-sentful. Constant-ly competing for parents' atten-t ion . 10. Ab i l i ty to relate to other Children Outgoing and friendly with children;relates easily.Coopera-: t ive in play and sharing.Assumes leadership role , but able to accept leader-ship of others. Quarrelsome,does not l ike to share; or,shy,slow in making friend-ships, only able to relate to small group of children. Hostile,aggres-sive, and disturb-ing in play with other children. Likes to attack younger children; or,unable to es-tabl ish rapport with children; fearful.withdrawn 73 Schedule 1. continued Cr i ter ia Explanation of Ratings Good Fair Poor 11. Ab i l i ty to relate to Strangers Trusting,out- Shy and inhibited, Negativistic going child, fr iend-or resentful,but and hostile to-ly ,ea s i ly re- able to relate ward strangers; lat ing to gradually i f or,withdrawn in strangers. shown continuing presence of friendliness and strangers. interest . 12. Response to Social Stimulation Outgoing and Shy,but interest Remains negati-fr iendly;relates and attention can v i s t i c and with-quickly to new en- be aroused. drawn,unable to vironment and new relate to his experiences. environment. 13. Coopera-t ion (Clinic) Very cooperative, I n i t i a l resent- Extremely un-eager to please, ment or shyness; cooperative,re-trusting, cooperates f a i r l y sentful and well after be- host i le ;or with-coming familiar drawn. with c l in i c and c l i n i c staff. 14. Wi l l ing-ness to learr (New Exper-iences ) Eager to learn; Slow or inconsis- Completely un-to explore; tent i n response responsive;no curious and to learning ex- motivation to inquis i t ive . perience;easily gain new distracted or experiences. frustrated. Appendix A 74 Schedule 2. Suggested Cr i ter ia for Assessment of the Family Cr i ter ia Explanation of Ratings Good Fair Poor 1. Income $4800. - or more, steady income. $2400. to |4800. Less than $2400., in receipt of Social Assist-ance, or Unem-ployment Insu-rance. Living on marginal income. 2. Employ-ment Good work record. Permanent employ-ment with possi-b i l i t i e s for advancement. Employed, but employment sub-ject to change, depending on general employ-ment situation. Unemployed;sea-sonal employment only;poor work record. 3 . Housing Comfortable, spacious home. Adequate from hygienic,although not from aesthetic point of view.Does not allow for too much privacy.  Crowded and inadequate l i v ing quarters. 4. Education College - or university education. High school graduate. Part ia l high school education or less. 5. Socio-economic Status High standard of l iving,recog-nized socia l position. Living i n f a i r l y Low-status occu-comfortable c i r - pation,low i n -cumstances.White come,limited col lar occupation, poss ib i l i t ie s for advancement. 6. Marital Relations Harmonious,happy marriage,mutual affection and respect,sharing of interests, goals,and responsibi l i t ies . Some evidence of marital conf l ict , spouses do not always pursue same goals,or share responsibi l i t ies equally. Gross disharmony between spouses, serious lack of c ommuni c at i on and understand-ing; constant quarrels or com-plete indi f -ferenc e. Schedule 2. continued 75 Cri ter i a Explanation of Ratings Good Fair Poor 7. Financial Management Both partners plan and manage wisely within given bud-get, without being compulsive or ex-cessively worried about f inancial af fa irs . Inconsistent hand-l i n g of money;fair amount of debts; or, too r i g i d and preoccupied with f inancia l matters. Heavy debts, chaotic house-hold manage-ment, unable to plan within l imits of given income. £ . Social Handicaps No social prob-lems .Harmonious, sound, stable family. Social problems in one or more areas of l i v i n g , but these are re-cognized and t r i ed to over-come. Gross social pathology in one or more areas of l iving.Limited insight. 9. Family Stabi l i ty Closely knit , warm family unit, Family able to maintain s t ab i l i ty , but tends to ,or may, break down under severe stress;or sta-b i l i t y only main-tained through conscious effort of one marital partner.  A multitude of problems aris ing as a result of family instabi-l i t y ; lack of cooperation bet-ween members. 10. Mother-Child Relationship Warm and close, chi ld receives s tab i l i ty and security, i s loved and wanted. Ambivalent fee l- Poor.Lack of ings toward chi ld ; warmth and under-inconsistent standing.Child handling. regarded as a burden. 11. Father-Child Relationship Warm and close, chi ld receives s t ab i l i ty and se-curity, i s loved and wanted. Ambivalent feel- Poor. Lack of ings toward chi ld ; warmth and under-inconsistent standing. Child handling. regarded as a burden. 76 Schedule 2. continued Cr i ter ia Explanation of Ratings Good Fair Poor 12. Accept-ance of Handicap Complete accept-ance of chi ld and his handicap. Handicap regarded as a challenge. Ambivalence,ex-pressed by denial of handicap;ex-cessive demands on child;over-c r i t i c a l a t t i -tude; over-protection.  Actual and overt rejection,neglect or,obscessional, smothering over-solicitude. 13. Insight into Child 's Needs Child regarded as " c h i l d " f irst ,and needs met with love and under-standing. Inconsistency in meeting chi ld ' s needs. Not too clear understand-ing of parental role . Physical or emo-t ional neglect, rejection;or, maltreatment;or, grossly over-protective.  14. Handling of Child (Discipline) Sound and loving, consistency in setting l imi t s . Inconsistent and erratic a l t e rna t -ing between harsh disc ipl ine and overpermissive-ness. Overly harsh } punitive attitude smothering and domineering over-solicitude; or complete i n -difference. 15. Coopera-t ion with Cl in ic Eager and wi l l ing to use and accept help;conscious effort to follow suggestions; keeps appoint-ments even under d i f f i cu l t phy-s i ca l conditions. Active par t i c i -pation; Disagrees easi ly, unable to tolerate inconveniences when attending c l i n i c , needs constant reassu-rance and support. Rejects help offered;makes no effort to follow suggesti ons;with-draws chi ld from treatment;or uses c l i n i c to satisfy own needs. 16. Under-standing of Treatment goals F u l l understand-ing and apprecia-t ion of treatment goa l s .Al l help i s used in a con-structive way. Has d i f f i cu l t i e s inte l lec tua l ly to grasp treatment objectives,but t r ie s to follow a l l suggestions; or,feels ambiva-lent about treat-ment goals.  Intellectually and emotionally unable to compre-hend goals; or does not see necessity for treatment. 77 Appendix B Medical Assessment Cr i ter ia Schedule Cr i ter ia Description 1. Observed Progress (past two years) A. Good B. Satisfactory C. Slow D. Poor 2. Relative Progress in Functional A b i l i t y (past two years) AA. As anticipated or better. BB. Some improvement, but not to level expected. CC. No improvement; or deterioration. 78 Appendix G Schedule 1 . A Proposed Schedule for Rating Social Functioning of a Disabled Child J-Cri ter ia A B L. General iealth Healthy chi ld . a. health below par; a.General health b. frequent colds; poor; cone serious i l l - b.frequent i l l -ness in past year, ness.  2. Physical development Within normal l imi t s . S l ightly abnormal: a. under-weight or height, or b. over-weight. Poor develop-ment: grossly a. under-weight or height,or b. over-weight. •P •rl rH •H Xi C6 -P ed "C o •H faO O rH O •H CQ >> xi 3 . General i n t e l l i -gence Average or better. High to low borderline. a. Defective: moderate to severe retar-dation; or b. unable to determine. !f. Learning capacity Alert and quick in understand-ing. Eager to learn, explore. Good attention span. a. Slow or incon-sistent in,un-derstanding and/ or in response to learning situation; b. functions below tested ab i l i ty ; c. distractable, short attention span.  a. Dull,unrespon-sive; b. lacks motiva-tion or under-standing in learning; c. inattentive. 5. Task per-formance Purposeful,goal-directed, persis-tent; good con-centration span, a. Uncertainty of goal or purpose; b. distractable, short concen-trat ion span. a. Purposeless; b. lacks persist-ence, inab i l i ty to concen-trate. 6 . Response to new ex-perience Adjusts well to new experience or change in routine or pro-gram.  a. Slow to adjust; b. excitable. a. Regresses when faced with new experience; b. extreme ex-c i t a b i l i t y . For rating method see Chapter III . 7 9 Schedule 1. continued Cr i ter ia B H -P •r l r-i • H , 0 cd -P P-cd << rH cd C O •rl +3 O 7 . Emotional development (maturity) Emotionally i n -dependent and secure; confident; contented. a. Anxi ous,needs reassurance; b. demanding and attention-seeking; c. shy and self-conscious; d. discontented. Emotionally dependent and insecure: a. lacks confi-dence; b. extremely shy or anxious; c. indifferent. 8. Self-control (response to discipl ine) Relaxed;able to postpone wish-fulfilment ; able to accept l imi t s . a. Sullen,crying, or mild temper tantrums when frustrated or l imits set; b. changing moods. Unable to accept l imi t s : a. destructive,or severe temper tantrums; b. r i g i d self-control. 9 . Attitude to d i sab i l i ty Expresses and demonstrates awareness and acceptance. Anxiety and/or frustration expressed. a. Lacks awareness b. rejects disa-b i l i t y . 10. Relation-ship with mother Warm and relaxed; Ambivalence: responds with loving and fear-love and affec- ing,or defying, t i on . a. Negativistic and resentful; or b. withdrawn,lack of communi-cation and warmth. +3 • r l 11. Relation-ship with father (as above) •r l X> cd +3 cd TJ ^ . R e l a t i o n -ship with siblings Mutual accept-ance and affec-t ion; independ-ence encouraged. i—i cd • r l O O CO Ambivalence ex-pressed by pro-tection or tolerance, and resentment. a. Extreme r i v a l -ry, or jealousy; b. overprotection. 13. Relation-ship with other children a. Friendly,re-lates easily; b. cooperative in play and shar-ing; c a b l e to accept leadership or assume leader-ship role . a. Shy,slow in a.Hostile,aggres-making friends; sive; b. quarrelsome; b.unable to es-c o n l y able to re- tablish rapport late to small with children; group of chi ld- c . fearful , ren; withdrawn, d.may assume lead-ership, unable to tolerate that of others. 80 Schedule 1. continued Cr i ter ia A B C Social Adaptability 14. Relation-ship to fa-mil iar adults in neighbour-hood Friendly, a.Shy and i n - a.Negativistic; trusting. hibited; b.withdrawn; b.attention- c .distrustful or seeking and fearful . errat ic . Social Adaptability L5. Relation-ship to adult strangers Relates easily, (as above) (as above) fr iendly. Social Adaptability L6. Relation-ship to familiar c l i n i c staff Cooperative, Cooperates Extremely un-eager to please, gradually: cooperative: a. maintains re- a.resentful and sentment or host i le ; shyness; b.withdrawn. b. erratic and attention-seeking. 1 81 Appendix C Schedule 2. A Proposed Schedule for Rating Social Functioning of the Family of a Disabled Child Cr i ter ia A B C Socio-economic Status 1. Health Both parents a.One parent poor a.Both parents healthy. general health; poor general b.constant con- health; cern over b.one or both health. serious i l lness in past year. Socio-economic Status 2. Education (mother and father) University, a.High school; a .Part ia l high college, or pro- b.vocational school; fessional t ra in- tra ining. b.grade 1-8. ing. Socio-economic Status 3. Nature of employment (occupation) (mother and father) a. Professional; a .Ski l led ; a.Semi-skilled; b. managerial; b . c l e r i c a l ; b.unskilled; c. semi-profes- c.sales. c.domestic s ional . service. Socio-economic Status 4 . Employment record (father;mother mother-desig-nate i f breadwinner) Regular Employed, but a.Unemployed; employment. a.subject to b.spasmodic change,st r i ke s; employment. b.seasonal. Socio-economic Status 5. Income $4800.or more, a.$2400.-$4800; a.Under $2400; steady income. b.variable i n - b.Unemployment come. Insurance; c .Social Assist-ance. Socio-economic Status 6. Housing a. Family comfort- a.Some crowding; a.Inadequate ably accommo- b.some repairs, functionally dated,house in f a c i l i t i e s and physically good repair; needed; (overcrowded. b. good play space.c.restricted play in disrepair); space. b.poor,or no play space. Socio-economic Status 7. Residen-t i a l d i s t r i c t a. New develop- a.Moderate-cost a.Generally "run-ment area; homes; down" area; b. high-cost homes;b."older" b.shared units; good f a c i l i t i e s , neighbourhood; poor f a c i l i -moderate-good t ies , f a c i l i t i e s ; c.apartment area. 1 — . , — " - I 8 2 Schedule 2 . continued Cr i ter ia A B C Socio-Cultural Standards 8 . Socio-economic climate of home Both parents con- One or both One or both i n -tent ;progres- parents dissa- different or dis-s ive , rea l i s t i c t i s f ied,but contented;un-planning. efforts to rea l i s t i c change. planning. Socio-Cultural Standards 9 . Financial management Wise planning a.Planning im- a.Poor f inancial within given bud- paired due to management-no get,without medical budgeting; being compul- expenses; b.heavy debts. s ive,or unduly b.inconsistent worried. handling of money; c. f a i r amount of debts; d. pre-occupied with f inancial matters. Socio-Cultural Standards 1 0 . Marital relations Harmonious,happy Some evidence of .Communication marriage;mutual conflict ,but not impaired: affection and gross. a.lack of under-respect. standing; b. constant quarrels; c. complete indi f -ference. Socio-Cultural Standards 1 1 . Role perception Both parents ex- a.One parent a.Both parents press leadership accepted leader lack leadership; in clearly de- in most areas; b.one authori-fined or mutually b.some role tarian to determined roles. conf l ic t . extreme; c.considerable role conf l ic t . Socio-Cultural Standards 1 2 . Mother-chi ld relationship Warm and close; a.Anxious feel- a.Lack of warmth, chi ld ' s needs met ings about understanding; with love,under- ch i ld ; b.punitive; standing and b.inconsistency c. indifferent; consistency. in meeting d.grossly over-needs; protective. c. unrealist ic demands; d. overprotection. Socio-Cultural Standards 1 3 . Father-chi ld relationship (as above) 83 Schedule 2. continued Cri ter ia B 11+. Attitude to d i sab i l i ty (mother and father) Realist ic recognition of l imitations. Di f f icu l t ie s in recognition of l imitations. a. Rejection; b. conscious or unconscious physical or emotional neglect.  fl • H -P fl O O CO Ti U cO Ti fl CO* •P CO rH cO M +3 H O I o • H O o CO 15. Assessment of ch i ld ' s future. Parents plan rea l i s t i c goals. a. Over-anxious No planning for improvement; or goals. b. unrealist ic goals; c. disagree on goals.  16. Parent participation in treatment (mother and father) Cooperative,good relationship to s ta f f ;wi l l ing to use and accept help; conscious effort to follow suggestions; keeps appoint-ments. a. Needs constant reassurance and support; b. disagrees easi ly; c. d i f f i cu l ty tolerating i n -conveniences. a. Rejects help b. makes no effort to follow suggestions; placing f u l l responsibil ity on staff; c. uses c l in i c to satisfy own needs; d. l i t t l e or no interest. L7. Under-standing of treatment goals Understands and appreciates aims of treatment. a.Has d i f f i c u l -t ies in grasping aims or objectives. a. Withdraws child from treatment; b. does not see necessity for treatment. L8. Ethical values (mother and father) Derived from be-l i e f in and ad-herence to a particular ortho-dox religious syst em. Derived from ad- No adherence to herence to par-t i cu la r system of ethics, or from unorthodox religious sys-tem. or respect for any particular value system. 34 Schedule 2. continued Cr i ter ia B X! CD ti CS •H +3 O o CQ -d U ct5 x) ti ctJ CO H CO-SH ti •P rH ti O I o •H O O CO 19. Community-social act iv i ty Both parents "healthy" par-t ic ipat ion in church,club, school,recrea-t iona l , or other interest. Hesitancy,or restricted oppor-tunity for one or both to par-t ic ipate due to a. finances; b. transportation; c. family t i e s . One or both parents: a. disinterested or intolerant of act iv i ty outside im-mediate family; b. participation in outside ac-t i v i t y to ex-clusion of family's interests. 20. Socio-cultural community attitudes Congenial neigh-bourhood; accept-able l i v i n g and ethnic or sub-cultural stan-dards as reflec-ted in mutual respect. Experience frus-trat ion due to: a. income or l i v -ing standards; b. ethnic or cul-tura l dif fer-ence; c. presence and/or management of disabled ch i ld . Experience dis-crimination due to a . , b . , c . 21. Family s tab i l i ty Closely knit , warm family unit ; a b i l i t y to handle stress: moves, death,inter-ference of re la-t ives , and others. a. Stabi l i ty main-tained through effort of one partner; b. socio-economic problems may persist,but not damaging. a. Family breaks down under stress; b. multitude of socio-economic problems caus-ing i n s t a b i l i -ty .  35 Appendix D. BIBLIOGRAPHY  Books Barker, Roger G. , Wright, B.A. , and Gonick, M.R. Adjustment  to Physical Handicap and I l lness : A Survey of the Social Psychology of Physique and Disab i l i ty . Social Science Research Council, New York, 1953 (copyright 1946). Bartlett , Harriett M. Some Aspects of Social Casework in a  Medical Setting. Prepared for the Committee on Functions, American Association of Social Workers, G. Banta, Chicago, 1940. Bowley, Agatha. The Young Handicapped Child. E. and S. Livingstone L td . , Edinburgh and London, 1957. Crothers, Bronson, and Paine, R.S. The Natural History of Cerebral Palsy. Harvard University Press, Cambridge, 1959. Erikson, E.H. Childhood and Society. W.W. Norton and Co. Inc., New York, ±9~W. Fischer, C . C . , ed. Pediatric Cl inics of North America: Symposium on Handicaps and Their Prevention. W.B. Saunders Co., Philadelphia and London, August, 1957. French, David G. Measuring Results in Social Work. Columbia University Press, New York, 1952. Hood, Oreste E. Your Child or Mine. Harper and Brothers, New York, 1957^ Lewis, Richard S., Strauss, A . A . , and Lehtinen, L .E . The Other  Child; the Brain-Injured Child, a Book for Parents and Laymen. Grune and Stratton, New York, 1951. Lord, Elizabeth Evans. Children Handicapped by Cerebral Palsy. H. Milford, Oxford University Press, London, 1937. Martmer, E . E . , ed. The Child with a Handicap. C C . Thomas, Springfield, 195^ Michael-Smith, H . , ed. Management of the Handicapped Child. Grune and Stratton, New York, 1957. Prevention and Management of Handicapping Conditions i n Infancy  and Childhood. Institute sponsored by the University of Michigan School of Public Health, November 1959. Simmons, Leo W., and Wolff, Harold G. Social Science in Medicine. Russell Sage Foundation, New York, 1954. 86 Strauss, A . A . , and Lehtinen, L .E . Psychopathology and Education  of the Brain-In.jured Child. Grune and Stratton, New York, 195F: Witraer, H . L . , and Kotinsky, R., ed. Personality in the Making. The Fact-Finding Report of the Midcentury White House Con-ference on Children and Youth, Harper and Brothers, New York, 1952 . Pamphlets Cocker i l l , E . , and Gossett, H. The Medical Social Worker as  Mental Health Worker. National Association of Social Workers, New York, 1959. Frankiel, Rita V. A Review of Research on Parent Influences  on Child Personality. Family Service Association of America, 1959. Geismar, L . L . and Ayres, B. Patterns of Change in Problem  Families. Family Centered Project, Greater St. Paul Community Chest and Councils, Inc. , St. Paul, July, 1959. Josselyn, Irene M. , M.D. Psychosocial Development of Children. Family Service Association of America, New York, I960, (copyright 1948). K r o l l , Frances. Children with Juvenile Rheumatoid Ar thr i t i s ; Social and Developmental Problems. Arthr i t i s and Rheumatism Foundation, New York, 1958. Medical Social Work Preparation and Performance. Report of a Conference Sponsored by the Medical Social Division of the National Foundation for Infantile Paralysis. Harriman, New York, March 3-7, 1957. Services for Children with Cerebral Palsy, a Guide for Public Health Personnel, Prepared Jointly by the Committee on Child Health of "the American Public Health Association and the American Academy for Cerebral Palsy, New York, 1955. Services for Handicapped Children. Prepared by the Committee on Child Health of the American Public Health Association, American Public Health Association Inc. , New York, 1955. Social Work Practice in Medical Care and Rehabilitation Settings, Monograph II . "Teamwork: Philosophy and Pr inc ip les . " National Association of Social Workers, Washington, July 1955. Social Work Practice in Medical Care and Rehabilitation Settings, Monograph IV. "Relationship Between Theory and Practice in Social Casework," National Association of Social Workers, New York, I960. 8 7 Social Work Practice in Medical Care and Rehabilitation Settings, Monograph V. "Perception of Culture: Implications for Social Caseworkers in Medical Settings," National Association of Social Workers, New York, I960. Towle, Charlotte. Common Human Needs. American Association of Social Workers. New York, 1953. Articles Baldwin, A . L . , Kalhorn, J . , and Breese, F .H. "The Appraisal of Parent Behavior." Psychological Monographs, v o l . 63 (1949), No. 4 (Whole No. 29T). Baldwin, A .L . "The Effect of Home Environment on Nursery School Behavior." Child Development, vo l . 20 (1949), pp. 49-61. Bluestone, S.S., M.D., and Deaver, G.G. , M.D. "Rehabilitation of the Handicapped C h i l d . " Pediatrics, v o l . 15 (May 1955), pp. 631-641. Chapin, F.S. Review of a study by J. McV. Hunt and Leonard S. Kogan: "Measuring Results in Social Casework: A Manual on Judging - Movement." Social Work Journal, v o l . 32 (January 1951), pp. 38-40. Cocker i l l , Eleanor. "The Interdependence of the Professions in Helping People." Social Casework, vo l . 34 (November 1953), pp. 371-378. Cooper, W., M.D. "The Emotional Problems of the Physically Handicapped C h i l d . " Emotional Problems of Childhood, ed. Liebman, S., J.B. Lippincott Co. 1958, pp. 149-164. Elledge, Caroline. "The Medical Social Worker." The Handicapped  and Their Rehabilitation, ed. Harry A. Pattison, C C . Thomas, Springfield, 111., 1957, pp. 414-426. Kozier, Ada. "Casework with Parents of Children Born with Severe Brain Defects." Social Casework, v o l . 38 (April 1957), pp. 183-189. Krupp, George R., M.D., and Schwartzberg, B. "The Brain-Injured Child: A Challenge to Social Workers." Social  Casework, v o l . 41 (February I960), pp. 63-69. Lesser, Walter. "The Team Concept - A Dynamic Factor in Treat-ment." Reprint from Journal of Psychiatric Social Work, vo l . 24 (January 1955), pp. 119-126. McCormick, Mary J . , Ph.D. "The Role of Values in Social Functioning." Social Casework, vo l . 42 (February 1961), pp. 70-78. 88 McGuire, Elizabeth T. "The.Social Adaptation of Multiple Sclerosis Patients." Smith College Studies i n Social Work, v o l . 29 (June 1959), pp. 204-239. Murstein, Bernard I. "The E f f e c t of Long-term I l l n e s s of Children on the Emotional Adjustment of Parents." Child  Development. v o l . 3 1 (March I960), pp. 157-171. Neiman, L.J., and Hughes, J.W. "The Problem of the Concept of Role." S o c i a l Perspectives on Behavior, ed. H.D. Stein and R.A. Cloward, The Free Press, Glencoe, 1958, pp. 178-185. Parad, H.J., and Caplan, G. "A Framework f o r Studying Families i n Crisis.',' S o c i a l Work, v o l . 5 (July I960), pp. 3-15-Perutz, Lotte. "Treatment Teams at the James Jackson Putnam Children's Center." Smith College Studies i n Social Work, v o l . 28 (October 1957), pp. 1-31. Schein, Edgar H. "Interpersonal Communication, Group S o l i d a r i t y • and Social Influence." Sociometry, v o l . 23 (June I960), pp. 148-161. Steiner, Ivan D. "Human Interaction and Interpersonal Perception." Sociometry, v o l . 22 (September 1959), pp. 230-235. Wallace, Helen M., M.D. "The Role of the Social Worker i n the Reh a b i l i t a t i o n of the Handicapped." So c i a l Casework, v o l . 38 (January 1957), pp. 15-22. Weisman, I., and Chwast, Jacob, Ph.D. "Control and Values i n Social Work Treatment." Social Casework, v o l . 41 (November I960), pp. 451-456": Miscellaneous Sources Ayres, Beverly. The Family Centered Project of St. Paul, A Series of Three Seminars on a Demonstration Project with Multi-Problem Families. Community Chest and Councils of the Greater Vancouver Area, Vancouver ( A p r i l I960), (mimeographed). Beck, Bertram M. Prevention and Treatment. Based on the work of a Subcommittee, National Association of S o c i a l Workers National Commission on Social Work Practice, I960 (mimeographed). Davis, A l l i s o n . Socio-Economic Influences Upon Children's  Learning. Paper delivered at the Midcentury White House Conference on Children and Youth, Washington, D.C, 1950 (mimeographed). Varwig, Renate. Family Contributions i n Pre-school Treatment  of the Hearing-Handicapped Child. Master of Social Work thesis, University of B r i t i s h Columbia, I960. 

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