- Email: [email protected]
Child Guidance
836
visible particles in fact the agent for ? Certainly their absence from oancer-free strains makes them worth pursuit, and the Leeds team is proposing to ascertain whether they can be found in the tissues of strains which lack the agent though they have similar hereditary characters. It is of great interest to hear that the particles are absent also from mammary tumours induced by chemical carcinogens, which suggests either that they are not extractable from, or that they are not present in, the original tumours. The next step is to discover whether they are viable and capable of producing tumours when reinjected into suitable mice : instead of being the agent itself they might be a product of its presence. Inquiries into these problems will not be complete for some months, and even then a negative result will not be final, since the process of extraction might itself destroy tumour-producing potency. Meanwhile PASSEY and his colleagues may be encouraged by the similarity between the appearance of their small particles and that of the larger known animal viruses-a similarity which so experienced an observer as Dr. MERVYN GORDON considers significant. This work is referred to in the 24th annual report of the British Empire Cancer Campaign,3 from which it is clear that many long-standing problems have been solved or are nearing solution. For example, a source of naturally occurring carcinogens has long been sought. It was thought at one time that these might be formed in, the liver, since extracts could be made of this organ, whether cancerous or not, that produced sarcomas on injection into animals. It now seems. from Dr. I. HIEGER,’s work that cholesterolrich fractions of the unsaponifiable part of various tissues contain the responsible agent. Commercial cholesterol,. which is impure, is sometimes carcinogeaiic. Purer cholesterol has been prepared, and is next to be tested to determine whether it is itself carcinogenic. The same end is being pursued by Prof. F. DICKENS, F.R.s., from another angle, in the formation of aromatic-ring structures by intact living cells. The inhibition of growth by carcinogenic growth-promoting chemicals has been shown by Dr. L. A. ELSON to depend on the nutrition of the animal. A diet sufficiently high in protein reduces or neutralises the inhibitory action. Since radiotherapy was first introduced a controversy has been carried on as to the mode of action of the rays. Some fifteen years ago it was hotly denied by many that indirect action caused the death of either normal or malignant cells under proper conditions of irradiation. The present report acknowledges in many places an indirect action on the tumour bed, as the vascular connective-tissue is now familiarly but inaccurately called. In welldevised Dr. I. LASNITZKI has computed that at the surface of tumour tissue the direct effect accounts for about one-third and the indirect effect .(ascribed to vascular damage) for two-thirds of the total lethal effect. The attention shown by various authors to radionecrosis, to necrosis in normal brain irradiated in the process of treating cerebral tumours, and to protection of Haversian canals in bone all Are these
we
’
now
looking
are
experiments
Empire Cancer Campaign : Twenty-fourth Annual Report, 1947. Issued from 11, Grosvenor Crescent, London,
3. British
S.W.1.
point
to
a
recognition
of the
sensitivity of parts
at
least of the vascular system to damage by irradiation. It is perhaps not inopportune to suggest that the whole of this damage cannot be demonstrated by histological methods, and to inquire what, for example, may be the effect in the brain of protracted stasis of blood in vessels which nevertheless do not subsequently undergo gross structural damage. Dr. F. R. SELBIE has now succeeded in transmitting the Shope papilloma virus to its 9th passage ih domestic rabbits. This has been done with the aid of contaminating micro-organisms ; but just which ones are responsible has yet to be decided. If the price of liberty is eternal vigilance, the Campaign has set an example to us all. As mentioned at the annual meeting reported on p. 847 the campaigners have had the forethought to obtain from the Minister of Health an assurance that the control of their resources is to remain unaltered. The report reveals that work is fast gathering way. In the past year a British Journal of Cancer has appeared ; a grant of 25,000 has been allotted for intensification of virus research in cancer ; and, best of all, the number of new names among the staffs of the various centres suggests that there is some more young blood in circulation.
Child Guidance WHERE should maladjusted children get their treatment ?1 Is child guidance a branch of general psychiatry or a specialty in its own right ?1 Is it more properly ’allied to paediatrics, or does it belong to education as part of modern educational psychology ?1 Inherent in the child-guidance movement tensions derived from the traditional element of competition between doctors, teachers, and the Church-all seeking to influence the mind of the young. Child guidance, however, owes its existence to the principle of partnership between psychiatrist, educational psychologist, and psychiatric social worker, with each member of the team playing the leading part in his appropriate field. When first achieved, this harnessing in unity of potentially divergent forces was unique in medical relationships, and it remains the main strength of the movement. As the Royal Society of Medicine was reminded at last week’s meeting (see p. 833), it was worked out from first principles by the non-medical wife of a Chicago banker interested in juvenile delinquency. With this dubious origin, child guidance has been regarded with equal suspicion by orthodox medicine and by the teaching profession, and it has been developed by individuals somewhat outside the main streams of their professions. But with success has come recognition and a desire for adoption. Of public bodies, education has so far given child are
most support, and today more than 80% of clinics work under the local education authority, either directly or (less commonly) indirectly by an arrangement. with the local health authority, the normal administrative machine being the School Medical Service. With two or three notable exceptions the mental-health services have not undertaken child guidance, except in so far as some mental hospitals accept children in their outpatient departments. About 15% of clinics belong to general hospitals, and lately there has been a welcome tendency
guidance
837
for children’s hospitals to establish them. It would be a mistake, however, to shape our plans for the future in accordance with present experience of the sources and types of children treated ; for in an area which is exceptionally well served only twosevenths of the modest requirements laid down by BLACKERand others are met.. Until a service is nearly adequate, sampling by clinic records is quite arbitrary, because the case-load of a clinic is quantitatively and qualitatively merely a reflection of the reputation, interests, and capabilities of the clinic’s staff. Another principle to be observed in planning is that first consideration must be given to, the interests of the children and their parents rather -than to any popular administrative doctrine such as the contemporary urge for unification. The solution proposed by BLACKER and supported in a Nuffield Provincial Hospitals’ Trust report2 is that child guidance should be undertaken at centres controlled by the education authority, where mainly educational problems would be dealt with by a psychologist, and from which children deemed to be psychiatrically ill would be sent to clinics under the health authority, where a psychiatrist would preside. With its obvious administrative-convenience, this proposal is approved by some educationists and mental-hospital authorities , but it is opposed by the Child Guidance Council (now merged with the National Association for Mental Health), which stands for the team principle. Objections raised to the scheme are that, in applying the ominous political device of partition, it depends for success on a mutual tolerance not always evident except where the working bond js close, and that it presupposes among educational psychologists a state of clinical experience which seldom exists : it entrusts to untrained persons the difficult task of recognising psychiatric illness among school-children, while the psychiatrist, against the trend of modern psychiatric practice, retreats once more to his clinical castle. Although this does not apply to the authors of the present proposals, similar schemes in the past have derived some support from a refusal to recognise the full implications of emotional disturbances in children, with a consequent desire to establish a cordon sanitaire to protect maladjusted children from psychiatrists unless all else fails. This may even take the form of a standing committee whose function is -to review reports from all possible sources before agreeing to send a child to a clinic. Another escapist argument is that most children’s maladjustments may be satisfactorily dealt with by the light of nature and that psychotherapy is little more than applied common sense. But common sense, and persuasiveness, are common among those who handle children, and they will continue to fail where it is necessary to face the deeper emotional issues. At first sight, the obvious place for child psychiatry is with the mental-health services ; but child guidance is far wider than child psychiatry, and even the latter has derived comparatively little from the study of adult problems. Again, public opinion is not such that the prevention of children’s 1.
2.
Blacker, C. P. Neurosis and the Mental Health Services, London, 1946. Appendix to a report on the planning of hospital services in the Berks, Bucks, and Oxon region, Nuffield Provincial Hospitals Trust, 1947; see Lancet, 1947, i, 421.
maladjustments will thrive on close identification with adult psychiatry; the change in name from Mental Hospital Services to Mental Health Services has yet to be associated with an equal change in orientation, and mental hospitals have contributed little to Recent the understanding of the difficult child. has shown that moreover, psychiatry experience, is most effective when nearest to the problem as it occurs in life. Modern child guidance comprises work in maternity and child-welfare clinics ; in schools, by selection and grading of pupils and by special teaching methods ; in foster-homes, boarding homes, and residential schools ; in children’s hospitals, notably orthopaedic and fever ; and finally in diagnosis, disposal and treatment, at the clinic itself, in work in the home, and in the provision of special hostels for treatment. The authorities concerned in all this will include regional hospital boards, local health authorities, local education authorities, and the Home Office, and we should recognise that the first-named has no pre-eminence of interest : indeed the highest common factor, as it were, is the local education authority, which of all public bodies now has far the most intimate concern for the mental and physical development of children between the ages of 2 and 18. It seems logical, therefore, for the great preventive mental-health service of childhood to remain an integral part of that system, and there seems to be no paramount administrative reason for changing the existing arrangements by which child guidance is administered by the School Medical Service, which is itself intermediate between the education Thus placed, the childand the health interests. services can be linked through the School guidance Medical Service with hospitals and specialists, and particularly with paediatrics ; and there is no reason why the psychiatrists employed in this work should not be carried on the establishments of regional hospital boards. Both the medical and the educational aspects of child guidance should be under the unified control of experienced clinicians, and the operations of educational psychologists in the schools should be firmly based on the clinical team ; though this does not mean that the psychiatrist must necessarily be the administrative head of the service. In addition there is every reason for general and psychiatric hospitals to develop their own departments of child guidance so that psychiatric principles may permeate medical teaching, so that research can be undertaken, and so that patients can readily be given any special form of treatment they may require. Despite the demand, however, there may be no future in this country for child guidance unless the supply of clinically trained workers of all disciplines is radically increased. This is not a matter of giving courses of lectures and of amending the .regulations for diplomas, but of providing clinical experience in therapy under the supervision of those who are qualified to teach. Concentrated courses of a few months give time neither to absorb the subtleties of treatment nor to learn about children at home and at school. Diagnosis and disposal can be learnt fairly easily, but to acquire therapeutic skill needs longcontinued practice under supervision. In the shortage of adequately trained therapists, competent and willing to treat difficult cases, lies the most dangerous threat to child guidance.
‘
visible particles in fact the agent for ? Certainly their absence from oancer-free strains makes them worth pursuit, and the Leeds team is proposing to ascertain whether they can be found in the tissues of strains which lack the agent though they have similar hereditary characters. It is of great interest to hear that the particles are absent also from mammary tumours induced by chemical carcinogens, which suggests either that they are not extractable from, or that they are not present in, the original tumours. The next step is to discover whether they are viable and capable of producing tumours when reinjected into suitable mice : instead of being the agent itself they might be a product of its presence. Inquiries into these problems will not be complete for some months, and even then a negative result will not be final, since the process of extraction might itself destroy tumour-producing potency. Meanwhile PASSEY and his colleagues may be encouraged by the similarity between the appearance of their small particles and that of the larger known animal viruses-a similarity which so experienced an observer as Dr. MERVYN GORDON considers significant. This work is referred to in the 24th annual report of the British Empire Cancer Campaign,3 from which it is clear that many long-standing problems have been solved or are nearing solution. For example, a source of naturally occurring carcinogens has long been sought. It was thought at one time that these might be formed in, the liver, since extracts could be made of this organ, whether cancerous or not, that produced sarcomas on injection into animals. It now seems. from Dr. I. HIEGER,’s work that cholesterolrich fractions of the unsaponifiable part of various tissues contain the responsible agent. Commercial cholesterol,. which is impure, is sometimes carcinogeaiic. Purer cholesterol has been prepared, and is next to be tested to determine whether it is itself carcinogenic. The same end is being pursued by Prof. F. DICKENS, F.R.s., from another angle, in the formation of aromatic-ring structures by intact living cells. The inhibition of growth by carcinogenic growth-promoting chemicals has been shown by Dr. L. A. ELSON to depend on the nutrition of the animal. A diet sufficiently high in protein reduces or neutralises the inhibitory action. Since radiotherapy was first introduced a controversy has been carried on as to the mode of action of the rays. Some fifteen years ago it was hotly denied by many that indirect action caused the death of either normal or malignant cells under proper conditions of irradiation. The present report acknowledges in many places an indirect action on the tumour bed, as the vascular connective-tissue is now familiarly but inaccurately called. In welldevised Dr. I. LASNITZKI has computed that at the surface of tumour tissue the direct effect accounts for about one-third and the indirect effect .(ascribed to vascular damage) for two-thirds of the total lethal effect. The attention shown by various authors to radionecrosis, to necrosis in normal brain irradiated in the process of treating cerebral tumours, and to protection of Haversian canals in bone all Are these
we
’
now
looking
are
experiments
Empire Cancer Campaign : Twenty-fourth Annual Report, 1947. Issued from 11, Grosvenor Crescent, London,
3. British
S.W.1.
point
to
a
recognition
of the
sensitivity of parts
at
least of the vascular system to damage by irradiation. It is perhaps not inopportune to suggest that the whole of this damage cannot be demonstrated by histological methods, and to inquire what, for example, may be the effect in the brain of protracted stasis of blood in vessels which nevertheless do not subsequently undergo gross structural damage. Dr. F. R. SELBIE has now succeeded in transmitting the Shope papilloma virus to its 9th passage ih domestic rabbits. This has been done with the aid of contaminating micro-organisms ; but just which ones are responsible has yet to be decided. If the price of liberty is eternal vigilance, the Campaign has set an example to us all. As mentioned at the annual meeting reported on p. 847 the campaigners have had the forethought to obtain from the Minister of Health an assurance that the control of their resources is to remain unaltered. The report reveals that work is fast gathering way. In the past year a British Journal of Cancer has appeared ; a grant of 25,000 has been allotted for intensification of virus research in cancer ; and, best of all, the number of new names among the staffs of the various centres suggests that there is some more young blood in circulation.
Child Guidance WHERE should maladjusted children get their treatment ?1 Is child guidance a branch of general psychiatry or a specialty in its own right ?1 Is it more properly ’allied to paediatrics, or does it belong to education as part of modern educational psychology ?1 Inherent in the child-guidance movement tensions derived from the traditional element of competition between doctors, teachers, and the Church-all seeking to influence the mind of the young. Child guidance, however, owes its existence to the principle of partnership between psychiatrist, educational psychologist, and psychiatric social worker, with each member of the team playing the leading part in his appropriate field. When first achieved, this harnessing in unity of potentially divergent forces was unique in medical relationships, and it remains the main strength of the movement. As the Royal Society of Medicine was reminded at last week’s meeting (see p. 833), it was worked out from first principles by the non-medical wife of a Chicago banker interested in juvenile delinquency. With this dubious origin, child guidance has been regarded with equal suspicion by orthodox medicine and by the teaching profession, and it has been developed by individuals somewhat outside the main streams of their professions. But with success has come recognition and a desire for adoption. Of public bodies, education has so far given child are
most support, and today more than 80% of clinics work under the local education authority, either directly or (less commonly) indirectly by an arrangement. with the local health authority, the normal administrative machine being the School Medical Service. With two or three notable exceptions the mental-health services have not undertaken child guidance, except in so far as some mental hospitals accept children in their outpatient departments. About 15% of clinics belong to general hospitals, and lately there has been a welcome tendency
guidance
837
for children’s hospitals to establish them. It would be a mistake, however, to shape our plans for the future in accordance with present experience of the sources and types of children treated ; for in an area which is exceptionally well served only twosevenths of the modest requirements laid down by BLACKERand others are met.. Until a service is nearly adequate, sampling by clinic records is quite arbitrary, because the case-load of a clinic is quantitatively and qualitatively merely a reflection of the reputation, interests, and capabilities of the clinic’s staff. Another principle to be observed in planning is that first consideration must be given to, the interests of the children and their parents rather -than to any popular administrative doctrine such as the contemporary urge for unification. The solution proposed by BLACKER and supported in a Nuffield Provincial Hospitals’ Trust report2 is that child guidance should be undertaken at centres controlled by the education authority, where mainly educational problems would be dealt with by a psychologist, and from which children deemed to be psychiatrically ill would be sent to clinics under the health authority, where a psychiatrist would preside. With its obvious administrative-convenience, this proposal is approved by some educationists and mental-hospital authorities , but it is opposed by the Child Guidance Council (now merged with the National Association for Mental Health), which stands for the team principle. Objections raised to the scheme are that, in applying the ominous political device of partition, it depends for success on a mutual tolerance not always evident except where the working bond js close, and that it presupposes among educational psychologists a state of clinical experience which seldom exists : it entrusts to untrained persons the difficult task of recognising psychiatric illness among school-children, while the psychiatrist, against the trend of modern psychiatric practice, retreats once more to his clinical castle. Although this does not apply to the authors of the present proposals, similar schemes in the past have derived some support from a refusal to recognise the full implications of emotional disturbances in children, with a consequent desire to establish a cordon sanitaire to protect maladjusted children from psychiatrists unless all else fails. This may even take the form of a standing committee whose function is -to review reports from all possible sources before agreeing to send a child to a clinic. Another escapist argument is that most children’s maladjustments may be satisfactorily dealt with by the light of nature and that psychotherapy is little more than applied common sense. But common sense, and persuasiveness, are common among those who handle children, and they will continue to fail where it is necessary to face the deeper emotional issues. At first sight, the obvious place for child psychiatry is with the mental-health services ; but child guidance is far wider than child psychiatry, and even the latter has derived comparatively little from the study of adult problems. Again, public opinion is not such that the prevention of children’s 1.
2.
Blacker, C. P. Neurosis and the Mental Health Services, London, 1946. Appendix to a report on the planning of hospital services in the Berks, Bucks, and Oxon region, Nuffield Provincial Hospitals Trust, 1947; see Lancet, 1947, i, 421.
maladjustments will thrive on close identification with adult psychiatry; the change in name from Mental Hospital Services to Mental Health Services has yet to be associated with an equal change in orientation, and mental hospitals have contributed little to Recent the understanding of the difficult child. has shown that moreover, psychiatry experience, is most effective when nearest to the problem as it occurs in life. Modern child guidance comprises work in maternity and child-welfare clinics ; in schools, by selection and grading of pupils and by special teaching methods ; in foster-homes, boarding homes, and residential schools ; in children’s hospitals, notably orthopaedic and fever ; and finally in diagnosis, disposal and treatment, at the clinic itself, in work in the home, and in the provision of special hostels for treatment. The authorities concerned in all this will include regional hospital boards, local health authorities, local education authorities, and the Home Office, and we should recognise that the first-named has no pre-eminence of interest : indeed the highest common factor, as it were, is the local education authority, which of all public bodies now has far the most intimate concern for the mental and physical development of children between the ages of 2 and 18. It seems logical, therefore, for the great preventive mental-health service of childhood to remain an integral part of that system, and there seems to be no paramount administrative reason for changing the existing arrangements by which child guidance is administered by the School Medical Service, which is itself intermediate between the education Thus placed, the childand the health interests. services can be linked through the School guidance Medical Service with hospitals and specialists, and particularly with paediatrics ; and there is no reason why the psychiatrists employed in this work should not be carried on the establishments of regional hospital boards. Both the medical and the educational aspects of child guidance should be under the unified control of experienced clinicians, and the operations of educational psychologists in the schools should be firmly based on the clinical team ; though this does not mean that the psychiatrist must necessarily be the administrative head of the service. In addition there is every reason for general and psychiatric hospitals to develop their own departments of child guidance so that psychiatric principles may permeate medical teaching, so that research can be undertaken, and so that patients can readily be given any special form of treatment they may require. Despite the demand, however, there may be no future in this country for child guidance unless the supply of clinically trained workers of all disciplines is radically increased. This is not a matter of giving courses of lectures and of amending the .regulations for diplomas, but of providing clinical experience in therapy under the supervision of those who are qualified to teach. Concentrated courses of a few months give time neither to absorb the subtleties of treatment nor to learn about children at home and at school. Diagnosis and disposal can be learnt fairly easily, but to acquire therapeutic skill needs longcontinued practice under supervision. In the shortage of adequately trained therapists, competent and willing to treat difficult cases, lies the most dangerous threat to child guidance.
‘