A refresher course for school medical officers

PUBLIC HI~ALTtt, March, 1953

A REFRESHER

89

COURSE FOR SCHOOL MEDICAL

OFFICERS

The School Health Service Group of the Society organised a refresher course, mainly designed for junior o~qcers in the service, which was held at the London School of Itygiene and Tropical .~Iedicine from September 15th to 19th, 1952. We publish below a first instalment of the addresses given to the course which shouM be of general interest. SCHOOL MEDICAL OFFICERS IN RELATION TO THE N A T I O N A L H E A L T H SERVICE Dr. Andrew T o p p i n g , D e a n of the L o n d o n School of Hygiene and Tropical Medicine, in his introductory talk, briefly referred to the origin and development of the School Health Service and stressed the very great contribution which it had made and was making to the health of the people. H e was entirely satisfied that from the three angles of prevention of disease, early diagnosis and health education, the service had made a greater contribution in the past 40 years than had any other branch of medical activity. I n describing some of his own experiences, Dr. T o p p i n g emphasised that it was of the greatest importance that the team which undertook school medical work should also be in charge of infant welfare. I f this were not so contacts with and confidence of the parents were seriously affected. H e realised that it was in the welfare m o r e than in the school clinic that the doctor had an opportunity of tackling the problem of family control or s p a c i n g ; he agreed that this was a vexed question but insisted that it was one of the most important medical and social questions of the age. H e pointed out that m u c h of the work of the personal health services was made nugatory by ignorance and carelessness on the part of those in the lowest strata of society who were producing recklessly while those in better circumstances were limiting their families beyond o p t i m u m limits. H e stressed the value of co-operation from the teachers, and went so far as to say that, without this, the efficiency of the service was seriously affected. He gave several amusing instances from his own experience. Where the teachers were seized with the value of the work, and w h e n c o r d i a l relations existed bet-ween t h e m and the School Nurse, it was extremely rare f o r the child with occult or incipient disease or abnormality to be missed : there was something in one of the c o m m o n e r criticisms that too m u c h time was spent on the solemn ritual of the routine medical inspection. Dr. T o p p i n g ' s experience was that if you could rely on the teacher f r o m his or her daily observations and on the nurse for her findings on her interim visits there was no need to spend the length of time officially postulated for each school child, and energies thus spared should be devoted to the special cases and their parents, to health talks to the children and to continuous contact with interested teachers and to proselytising among the lukewarm. Dr. T o p p i n g then dealt with the relationship between the School Medical Officer and the Family Doctor, pointing out that the crux of the whole question was the extent of the personal relationship existing between them. He realised how difficult it was for a junior school medical officer with an income often less than half of that of the practitioners to meet socially on equal terms, but insisted nevertheless that personal friendship and contact were more than half the b a t t l e ; he instanced cases in which the family doctor had been entrusted with maternity and child welfare and school medical responsibilities w i t h - u n h a p p y results, but gave his opinion that these were due to the existing financial variations a n d that this did not i m p u g n the principle that t h e G.P. with the necessary extra training was eminently suitable to undertake m u c h of the work of the personal health s.ervices. Dr.-T6i~plng-Ttheft dealt with the relationship between t h e sCl-/0oI-medi.c~ilst~ff a n d the paediatrie d e p a r t m e n t ~ o f h6spit#ls .and universiti~S. :-Iri h i s opinlb-n jt w a s essential t h a t - t h e l a t t e r should descend f r o m their ivory towers and i n t e r e s t themselves in c h i l d health father t h a n in child

sickness : m a n y consultant paediatricians cold-shouldered the school or infant welfare medical officer--although the majority had held appointments in children's hospitals - - a n d instead of encouraging contact and co-operation, poured cold water on the value of their work. In his opinion, the average consultant paediatrician and his j u n i o r staff were inadequately equipped for their posts if they had no school medical or infant welfare clinic experience ; m a n y of t h e m had no knowledge of the healthy child or of the criteria on which this definition was based. T h e r e should, in Dr. T o p p i n g ' s opinion, be the closest co-operation between paediatric consultants and their units, and the personal m e d i c a l s e r v i c e - - e a c h had a lot to give to, and to learn from, the other ; there should be a two-way traffic between the two services with periodic secondment of staff and an immediate stoppage of the " old school tie " attitude of so m a n y paediatricians towards the officers of the local authority services : Newcastle and Great O r m o n d Street had shown the way. In conclusion, Dr. T o p p i n g deprecated the t e n d e n c y on the part of m a n y school medical officers to belittle their value and functions. N o b o d y could be doing m o r e valuable work than they were and there was no justification for any apologetic attitude. Finally, Dr. T o p p i n g referred to the title of his talk, " T h e School Medical Officer in Relation to the National Health Service," and regretted that he had not " stuck to his brief." Questions such as " W h e t h e r a family doctor should be asked to approve a child's reference to a hospital " or " \Vhether the School Medical Service was duplicating his work and filching his responsibility " were, in his oplnic n, academic. W h a t was needed if the Service was to be, as its name implied, a health service was mutual respect between its components, a realisation of the other person's function and point of view and a genuine desire to p r o m o t e individual and c o m m u n i t y health b y the best means possible.

PROBLEMS I N SPECIAL EDUCATION Dr. G. D. Pirrie, Senior Medical Officer, L o n d o n C o u n t y Council, gave a talk on the above subject. H e said that the development of special schools in this country preceded the formal beginning of the school medical service and has been marked by the great interest paid by school physicians. T h e 1944 Act placed on the education authority the responsibility of f o r m a l ascertainment, accepting or rejecting the recommendation of the school medical officer. In fact, this only emphasised the close tie between the physician and the teacher, a liaison that was always necessary to determine the needs of any child and which could give due weight to the educational, psychological and social as well as medical needs of each child. " De-ascertainment " had been left as the responsibility of the school physician, but if he were wise he would take the same care to consult the teachers concerned. Full consultation with family doctor and his consultant was needed in all eases of physical o r psychological defect if a good assessment of each child's need was to be made. T h e decision to send a child to a special school was a serious one and the parents were entitled to the assurance that it was based on t h e best o f available information -and judgment. It was necessary to gain t h e C0-operation of the parents to achieve su~es~. Reference was made to some special groups not covered by other lecturers : - -

PUBLIC HEALTH,

9o

March, ~953

Educationally Sub-Normal

THE SPASTIC CHILD AND ITS PROBLEMS

A b o u t 1.2% o~ the school p o p u l a t i o n n e e d e d education in special schools. A s c e r t a i n m e n t m u s t pay regard to e m o t i o n a l a n d physical h a n d i c a p s ; maladjustment and partial deafness were often difficult to detect. T h e r e was also t h e n e e d for social e d u c a t i o n a n d t r a i n i n g of coordination, e.g., s p e e c h - t h e r a p y a n d physical training.

Physician-Superintendent, Queen Mary's Hospital for Children, Carshalton

Maladjusted W h i l e it w o u l d take some t i m e before the M i n i s t r y of E d u c a t i o n C o m m i t t e e could be expected to report, there were several points t h a t could well be reiterated. (1) T h e co-operation of p a r e n t s was essential. (2) W i t h admission to a suitable school the work had only b e g u n ; t h e family m u s t b e p r e p a r e d for the child's e v e n t u a l r e t u r n a n d a psychiatric social worker was invaluable. Failing her, the p h y s i c i a n a n d school n u r s e / h e a l t h visitor m u s t be p r e p a r e d to try. (3) D a y classes for t h e maladjusted, as developed in Leicester, L o n d o n , a n d o t h e r towns, h a d a great, if limited, SUCCESS.

Epileptics T h e r i g h t place for an epileptic child was in t h e o r d i n a r y school, b u t efficient t r e a t m e n t was needed. T e a c h e r s a n d p a r e n t s m u s t be e d u c a t e d in t h e needs of t h e epileptic child a n d t i m e m u s t b e s p e n t i n m a k i n g an assessment of the child's needs,

Physically Handicapped I n t h e past social a n d medical c o n d i t i o n s h a d m a d e

necessary a h i g h e r scale of provision t h a n w o u l d n o w b e t h o u g h t necessary. I n Switzerland, t h e provision was m i n i m a l because t h e o r d i n a r y school expected to take a p r o p o r t i o n of h a n d i c a p p e d children.

I n d i v i d u a l T u i t i o n in H o m e a n d Hospital T h o u g h p r o v i d e d u n d e r a different section of the E d u c a tion Act, p e r m i s s i v e n o t m a n d a t o r y , t h e t h e r a p e u t i c result of t h e provision of this tuition was m o s t i m p o r t a n t . I n addition, it could p r e v e n t the educational r e t a r d a t i o n t h a t was a n additional h a n d i c a p to c h i l d r e n already afflicted. I n t h e h o u s e it was i m p o r t a n t and, moreover, it gave the entrge to t h e school physician a n d the chance to develop good medico-social work.

After S c h o o l T h e r e c e n t M . R . C . r e p o r t o n t h e e m p l o y m e n t of c h i l d r e n leaving special schools in G l a s g o w was m o s t illuminating. T h e work of t h e physician c o n t i n u e d after t h e child h a d left school. N o one else was in a b e t t e r position to help the Y o u t h E m p l o y m e n t Officer, b u t to do so t h e physicia n m u s t k n o w s o m e t h i n g of the processes in local industries. T h e local a u t h o r i t y ' s welfare s c h e m e for t h e care of h a n d i c a p p e d persons was of i m p o r t a n c e to the school physician a n d he s h o u l d k n o w of its scope and be ready to advise t h e Welfare Officer o n the n e e d s of particular children.

N a t i o n a l Organisatlons T h e r e were several organisations t h a t were c o n c e r n e d w i t h t h e care of h a n d i c a p p e d c h i l d r e n , for instance, the S h a f t e s b u r y Society, N a t i o n a l Association for M e n t a l H e a l t h , British Epilepsy Association, N a t i o n a l Council for t h e Welfare of Spastics. O f t e n these organisations could help w h e r e a local a u t h o r i t y was u n a b l e to act. Finally, t h e r e was n o aspect of school health work t h a t f u r t h e r e d so i m m e d i a t e an e m o t i o n a l satisfaction, b u t n o n e t h e l e s s this was truly p r e v e n t i v e work, T h e importan~ t h i n g always to r e m e m b e r was t h a t this essentially was n o t a n organisational p r o b l e m b u t was the individual p r o b l e m of a child a n d his relationship w i t h his family, his school, a n d his c o m m u n i V ' . E a c h h a n d i c a p p e d child p r e s e n t e d a specific p r o b l e m t h a t h a d to b e faced and solved.

By C. D. S. ACASSlZ, M.C., M.D., F.R.C.P., D.P.tt.,

T o appreciate o u r p r o b l e m s in dealing w i t h the cerebral palsied child, a n d the p r o b l e m s t h a t c o n f r o n t the child, we s h o u l d have a clear idea as to w h a t we m e a n b y the t e r m cerebral palsy. I p r e f e r this t e r m to the t e r m spastic, as t h e spastic child is o n e w h o is suffering f r o m only one f o r m of cerebral palsy, namely, spasticity. T h e sense in w h i c h I a m c o n s i d e r i n g this p a r t i c u l a r affection is confined to t h a t c o n d i t i o n in w h i c h the child's b r a i n receives damage e i t h e r before, d u r i n g or a f t e r b i r t h as a c o n s e q u e n c e of w h i c h the child has a disability of m o v e m e n t w h i c h is usually general b u t m a y be of v a r y i n g degree a n d not c o n f i n e d to one particular p a r t of t h e b o d y as, for example, a h e m i p l e g i a resulting f r o m cerebral haemorrhage. W h e n t h e r e is this b r a i n damage, t h e r e is a consequential interference w i t h n e r v o u s control of the muscles d e p e n d i n g on the p o r t i o n of b r a i n affected a n d t h e type of disability varies w i t h the site of t h e lesion in t h e b r a i n : (i) I n t h e case of cortical lesion we find spasticity. (ii) A lesion in the basal .ganglia p r o d u c e s athetosis. (iii) A lesion in t h e sub-cortical areas p r o d u c e s rigidity w h i c h is often m i s t a k e n for spacticity. (iv) A lesion in t h e c e r e b e l l u m p r o d u c e s ataxia. (v) I n certain types of lesion one finds tremors. T h e r e are t h u s , broadly, these five types of cerebral palsy a n d the m e t h o d of h a n d l i n g each type is different a n d in each case the m e t h o d of dealing w i t h t h e child is individual. I n order to get successful results, therefore, we m u s t always bear in m i n d t h e s e t h r e e essential points : - (1) T h a t the lesion is a neurological one a n d not o r t h o paedic, t h o u g h d i s t u r b a n c e s of m o v e m e n t result f r o m the neurological lesion. T h e muscles a n d joints are n o r m a l a n d therefore it is useless to p r e s c r i b e massage, electrical t r e a t m e n t or p h y s i o t h e r a p y as a r o u t i n e unless you have a clear idea of w h a t you are p r e s c r i b i n g it for a n d why. (2) A n d , secondly, t h a t every case varies a n d t h e t r e a t m e n t p r e s c r i b e d m u s t b e individual. N o set s c h e m e of exercises or p h y s i o t h e r a p y can therefore be set out. T h e case of cerebral palsy m a y b e slight or severe a n d obviously t h e slight case is n o t g o i n g to require t h e same s u p e r v i s i o n or s c h e m e of t r a i n i n g as t h e severe case, n o r is the s c h e m e o f t r e a t m e n t at t h e b e g i n n i n g t h e same as t h a t r e q u i r e d w h e n the child has progressed. (3) A n d , ~hirdly, one has to b e a r in m i n d t h a t w h e r e t h e r e is a cerebral lesion it m a y be slight or severe and, w h e r e it is severe, t h e r e is m o r e likely to he damage to the intellectual faculties. I n m a n y of these cases, therefore, t h e r e m a y be p r o d u c e d variations in m e n t a l power apart f r o m t h a t r e t a r d a t i o n of m e n t a l activity t h a t always results w h e r e t h e r e is limitation of m o v e m e n t . T o get satisfactory results the child m u s t be m e n t a l l y n o r m a l or potentially n o r m a l a n d the assessment of this m e n t a l power is one of o u r m o s t difficult p r o b l e m s . I n order, therefore, to have a clear c o n c e p t i o n of w h a t f o r m s our t r e a t m e n t of these c h i l d r e n s h o u l d take we m u s t constantly bear in m i n d w h a t is t h e d e v e l o p m e n t of a n o r m a l b a b y . At b i r t h a n d for some t i m e afterwards all m o v e m e n t is i n v o l u n t a r y or leflex. As the child's n e r v o u s s y s t e m grows a n d the n e r v e s b e c o m e m y e l i n a t e d the b a b y b e g i n s to show v o l u n t a r y m o v e m e n t a n d his p o w e r of m o v e m e n t and m e n t a l pictures of m o v e m e n t s develop f r o m the s t i m u l i he receives f r o m outside a n d within. H e c o m m e n c e s to lift his head, to lift his arms, to be attracted b y b r i g h t o h j e c t s a n d to try to grasp t h e m a n d so on until he reaches t h e stage of t r y i n g to s t a n d a n d walk. A t first his m o v e m e n t s are f u m b l i n g a n d irregular a n d incoordinated, b u t slowly t h e y improve. W h e n t h e r e is damage to t h e b r a i n so as to interfere w i t h the d e v e l o p m e n t of the n e r v o u s control, t h e child is u n a b l e to lift his h e a d or take m u c h i n t e r e s t in his s u r r o u n d i n g s a n d as a c o n s e q u e n c e t h e