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Social and preventive medicine in the pre-school age group
SOCIAL AND PREVENTIVE MEDICINE IN THE PRE-SCHOOL AGE GROUP (The Concept of a Health and Development Clinic) By K.
C. P A S I ,
M.B., B.S.
Assistant Medical O[ficer of Health and School Medical Q[iqcer, City of SheffieM and J,
G.
M c H U G H,
M.r~., M.R.C.P.E.
Assistant CounO, Medical Officer, West Riding of Yorkshire THE full development of the Child Welfare Service dates from the 1920s. The main objective in the 1920s and 1930s was to lower the infant mortality rate and to enable the child to enter its second year in good physical health. The service was therefore geared to achieving the maximum amount of medical supervision of childrela, especially those under the age of one year. Advice in child health care was given but little stress was placed on the "toddler years". Child Welfare Clinics have grown up as a part of the Local Authority preventive service in a social and economic climate which produced a strong tendency towards authoritarianism. In the early twentieth century an enormous gulf existed between the educated business and professional classes, and the poorly educated classes, yet across this gulf had to be passed the information about the nutritional requirements of children and the prevention of disease and disability, which was becoming available through the advances of medical research. The hierarchic i~rofessional structure of the medical and nursing professions tended to dominate the Child Welfare Service and, in the main, the approach was authoritarian. Little emphasis was put on social and environmental factors in child development. By the 1930s the pattern of child welfare Clinics was well established in an extremely rigid mould. Mothers were seen by the health visitor, routine weighing of the babies was carried out, feeding problems were discussed and a rather apprehensive mother was shown into the doctor's room and the child was medically examined. Children over one year were given a medical check at varying intervals and at least annually, any defects found were recorded and arrangements were made for necessary treatment. The traditional system in child welfare clinics is still widespread in England a n d Wales. Kershaw (1961) in his article on "The Child Health Services" points out that Child Welfare Services are still orientated too much towards the physical well being of the child and urges considerable re-orientation to meet the changing conditions of the 1960s. He rightly states that the doctor is overwhehned with trivialities while the child is young and has no 342
SOCIAL
AND
PREVENTIVE
MEDICINE
343
opportunity to watch him during the important toddler years. The emphasis on physical health, the rigidity of appointment systems for physical examination at birthdays, the failure to provide clues to the child's development by observation of its behaviour, and the formal atmosphere of the doctor's interview may render the young mother unreceptive to new attitudes while she slavishly follows verbal instructions; all these seem to require a new approach. Furthermore the pattern of mortality and morbidity in the preschool age group has altered so enormously since 1940 (as a result of such influences as protective inoculations, universal availability of free general medical care, antibiotic therapy and nutritional improvements arising from a raised level of family income) that emphasis in the Service should be radically altered. We are challenged to provide the needs of a Child Welfare Service for the 1960s and 1970s and urgently require a review of the service in the light of changing morbidity and mortality in the 1 to 4 years age-group and in the light of our present knowledge of child health and development. In our view, the service of the future would lay emphasis on a broader concept of health. Besides physical health it should be particularly directed to the development of communication, special senses, social adjustment, mental health, handicapped children, and the mother-child relationship. We have chosen a few pieces of statistical information to highlight the changing pattern of disease in the pre-school age-group.
Mortality in the Pre-school Child (1 to 4 Years) The following comments are reproduced from the Registrar General's Statistical Review of England and Wales for the year 1960 (Part III, Commentary). "In the age group 1 to 4 years, total deaths in Eng!and and Wales in 1960 were 2,431 as compared with 4,087 in 1950. "The decline in tuberculosis deaths has been most remarkable. In 1950 there were 489 deaths attributed to various forms of tuberculosis, in I960 there were 15 and in particular tuberculous meningitis declined from 356 to 9. "Mortality from other infectious diseases also declined but the most striking decline was in poliomyelitis, where deaths fell from 116 in 1950 to 3 in 1960. The remainder of the infectious diseases caused 123 deaths in 1960, of which meningococc.~l infection caused 31, acute infectious encephalitis 24, measles 19 and infectious hepatitis 12. "Neoplasms have now emerged as a relatively important cause of loss in childhood, not because of an increase but because they have remained fairly stable. In 1950, there were 352 neoplastic deaths between ages 1 and 4; in 1960, 301. "Inflammatory disease of the central nervous system remained a potent killer of the pre-school child, causing 142 deaths as shown below."
344
PUBLIC
HEALTH
VOL.
TABLE
LXXVIII
NO.
6
I Deaths in 1960
Causes o f death
Meningococcal infections Infectious encephalitis Meningitis Encephalitis
3I 24 50 37
DEATHS (MOTOR VEHICLE ACCIDENTS ACCIDENTAL POISONING) 1N E N G L A N D WALES 1962.
AND AND
50(
450
4O0
/
350
300 O
c,
__
250 n," uJ
~200 :D Z
~
-
t50
-5
I00
:,
50
,,."
--.
--.~fo~-v -
./
°-'1
"". ~ ~'4 ~:
"s
I AGE
s
p O l s O N I I'IG
i
,o-,s
i
--YEARS
(Figures obtained from tile Registrar General's Statistical Review of England and Wales, 1962
"The commonest cause of death at this age was disease of the respiratory system with 559 deaths. "Accidents with 527 deaths were the second most important group of causes, and of these motor vehicle traffic accidents were responsible for 177 arid drowning accidents for 103."
SOCIAL
AND
Morbidity in the Pre-zchool The following figures have Leeds General Infirmary. poisoning and respiratory in this age group.
PREVENTIVE
MEDICINE
345
Child (1 to 4 years) been obtained from the Children's Units (Medical), They direct acute attention to the importance of illness in bringing about the admission of children TABLE
II
N u m b e r of cases Poisoning Respiratory disease Total Discharges
1961
1962
38 44 175
51 40 208
Other major causes of admission to hospital in this age group are accidents (particularly motor vehicle accidents and burns) and the operation of tonsillectomy. The Hospital Morbidity Statistics (General Register Office publication) quote that burns and scalds accounted for a quarter of all cases (recorded as discharges) relating to injury and amounted to 2.5 per cent. of all discharges in this age group, which is a higher proportion than at any other age. The following table is reproduced from the publication: TABLE All ages
0-
]II
1-
5-
15_
45-
65 a n d over
Percentage discharges due to burns and scalds
0"4
0"8
2-5
0"4
0-3
0'2
0-2
score OF THE CXaILD W E L F A R E S E R V I C E We regard the Child Welfare Service as composed of two distinct components: (i) Care of the infant up to one year of age. The clinic serves the functions of advising the mother about feeding and care and physical examination to ascertain congenital abnormalities and other deviations from the normal, including special attention to children on the " risk register." (ii) Care of the pre-school child from I to 5 years. Clinics for pre-school children require greater attention to be directed to the development of the child, mental health and social adjustment besides physical health. Health education falls within the scope of both types of clinics; but, as is clear, the topics on which health education is desirable are entirely different. D
346
PUBLIC
HEALTH
VOL.
LXXVIII
NO.
6
We feel that clinics for babies under 1 year, infant welfare clinics, are at present offering a comprehensive service, but the clinics for 1 to 5 years, toddlers clinics, should be modified in an attempt to cover the widened scope of welfare services which ought to be provided. There is much literatme stressing the need for changes in this field of child welfare service----(Kershaw, 1961 ; and Paterson, 1961). New patterns ought to be tried and their value assessed. Combined infant and toddlers clinics known as child welfare clinics are at present operating Ln many areas. We suggest that as a first step, consideration should be given to separating the infant welfare work from the toddlers" work. We present the concept of Health and Development Clinics for children aged 1 to 5 years in the hope that it will stimulate discussion and help to shape our future pre-school child welfare service. We believe it will meet the changing needs of the 1960s. HEALTH
AND
DEVELOPMENT
CLINICS
1 TO 5 YEARS We would make the following suggestions for organisation of these clinics. The basis of a Health and Development Clinic is the observation of the toddlers at play and the use of such a situation to assess the physical, mental, social and performance state of the child. The clinic is suggested for children between 1 and 5 years of age. The health visitor should invite about 8 to 10 children in this age group. In the beginning some selection may have to be used for those considered suitable to attend such a clinic, but the aim should be to extend this service to all toddlers. All children should be invited to attend at about the same time. The clinic should be conducted in :an atmosphere of informality. The main hall or a large room should be set to act as a playroom for the toddlers. Suitable and attractive toys should be arranged ill groups for several age groups. Toys should be chosen with care so that they have some performance value. This will enable the observer to draw conclusions about the developmental stages of the child. The medical officer should observe the children at play and note the following aspects: FOR
1. General nourishment and state 2. Motor activity, performance 3. Visual and auditory functions 4. Social behaviour of the child in the group 5. Emotional behaviour of the child towards the mother 6. Speech and general communication level 7. Orthopaedic abnormalities
SOCIAL
AND
PREVENTIVE
MEDICINE
347
The health visitor will be able to give the social background of the case and help the doctor in identifying the child. Record cards should be used to note any comments and the progress of the child recorded. Such a record would later be of immense value in assessing a particular case. Complete physical examination should be carried out if an abnormality is detected by the M.O. on observation, or if requested by the mother. Provided a thorough physical examination is carried out when the child is one year old, we believe that hardly any physical defect of importance will be missed by using this procedure, whereas more information about the physical, mental and emotional development will be acquired. There will be an excellent opportunity for early detection of orthopaedic, speech, visual or auditory defects. It would thus be possible to handle such defects at any early stage. An assessment of mother-child relationship should be made and appropriate advice on such matters should be given where indicated. Health education on both formal and informal levels should be undertaken at the Health and Development Clinic. While one group of mothers look after their children in the play hall, the other group should be given health education with visual aids and films on suitable subjects (such as accidents, poisoning, behaviour problems, management of bed wetting, nutrition, dental care and so on). Discussion should be encouraged. The whole health education session should not last more than about 15 minutes. Informal discussion and advice can be given while the mothers sit watching the children at play. Most of the health education can be carried out by the health visitor, but, depending on the time available, the M.O. should try to join in. Associated with the Health and Development Clinic should be facilities for investigation of handicapped children, children on the risk register and children showing communication defects. Sheridan (1964) stresses the importance of detection of communication and hearing defects, and she urges the observation of normal development of communication in the pre-school age group so that many defects can be detected early. Screening tests for hearing in the very young could be employed, concentrating especially on children at risk. Special clinics designed on the pattern of Health and Development Clinics could be of very great value for assessment of handicapped children of pre-school age. We suggest that toddlers from 1½ years to 4½ years should be seen at a. Health and Development Clinic every 6 months or so. We feel that such clinical assessment of health will be of more value than carrying out an annual physical examination only. The sarr/e principles could be modified to suit examination of toddlers in day nurseries and nursery schools.
348
PUBLIC
HEALFH
VOL.
LXXVIII
NO.
6
DISCUSSION
The changing pattern of disease in the toddler age group calls for review of services available from the local authority clinics. The G.P.s feel that the local ,authorities are encroaching upon their interests as there appears to be duplication of work. Perhaps the community is becoming increasingly aware that the services from the G.P. and the L.A. are both orientated towards physical health only. Douglas and Blomfield (1958) in their survey found that mothers show a marked falling off in attendance at ,Child Welfare Clinics when their child passes its first birthday. TABLE
Child's year
1st 2nd 3rd 4th
IV
Percentage o f mothers using welfare centres
66-2 43 -3 35 22
Douglas & B l o m f i e l d h " C h i l d r e n under Fivo."
The concept of health has widened considerably and the services should take into consideration mental, emotional and social health besides physical health. The functions of the general medical service are complementary to the Child Welfare Service. We have to develop welfare services to meet the changing needs of the 1960s and have also to educate the public that Child Welfare Services are designed to achieve positive health in children--health in its broader meaning. A concept of Health and Development Clinics is put forward whereby information about physical, mental and social health can be obtained and used to provide comprehenSive Child Welfare Services for the toddler. This is based on the fact that information about these aspects can be best obtained by watching the child in play-groups and an attempt is made to incorporate health education by group discussion on important subjects, such as accidents and poisoning. Death from accidents and poisoning form the important groups and are preventable in a great many cases. The recent report of a joint committee of the Central and Scottish Health Services Councils on Health Education recommends that health visitors should undertake group discussion on health education in the child welfare field. The system is also designed to provide facilities for early and more efficient assessment of handicaps. ACKNOWLEDGEMENTS
Our thanks are due to Dr R. W. EUiott, County M.O., West Riding of Yorkshire, and to Dr Llywclyn Roberts, M.O.H., City of Sheffield, for publication
SOCIAL
AND
PREVENTIVE
MEDICINE
349
permission; and to Professor W. S. Craig and Dr E. C. Allibone, Children's Department, General Infirmary at Leeds, for permission to use their figures for discharges in the pre-school age group. We are indebted to Mr E. N. Hill, Records Officer, General Infirmary at Leeds for his help and co-operation. The views expressed in this article are those of the authors, and are not necessarily those of their employing authorities. REFERENCES D o u o L A S, J. W. B. a n d B L O M r I E L D, J. M. (1958). Children Under Five. London, George Allen & U n w i n L t d . K E R S H A W, J. D. (1961).Public Health, L X X V , 322. M i n i s t r y o f Health. (1964). Health Education--Report o f a J o i n t C o m m i t t e e o f the Central a n d Scottish Health Services C o u n c i l . L o n d o n , H . M . S . O . P A T g R S O N, M A R Y T. (1961). Public H~ealth, L X X V , 353. R E G I S T R AR G E N E R AL. (1962). StatiMical Review o f England and Wales for the Year 1960. P a r t III, C o m m e n t a r y . L o n d o n , H . M . g . O . S H E R I D A N, M A R Y D . (1964). Monthly Bulletin, F e b r u a r y . L o n d o n , H . M . S . O .
C. P A S I ,
M.B., B.S.
Assistant Medical O[ficer of Health and School Medical Q[iqcer, City of SheffieM and J,
G.
M c H U G H,
M.r~., M.R.C.P.E.
Assistant CounO, Medical Officer, West Riding of Yorkshire THE full development of the Child Welfare Service dates from the 1920s. The main objective in the 1920s and 1930s was to lower the infant mortality rate and to enable the child to enter its second year in good physical health. The service was therefore geared to achieving the maximum amount of medical supervision of childrela, especially those under the age of one year. Advice in child health care was given but little stress was placed on the "toddler years". Child Welfare Clinics have grown up as a part of the Local Authority preventive service in a social and economic climate which produced a strong tendency towards authoritarianism. In the early twentieth century an enormous gulf existed between the educated business and professional classes, and the poorly educated classes, yet across this gulf had to be passed the information about the nutritional requirements of children and the prevention of disease and disability, which was becoming available through the advances of medical research. The hierarchic i~rofessional structure of the medical and nursing professions tended to dominate the Child Welfare Service and, in the main, the approach was authoritarian. Little emphasis was put on social and environmental factors in child development. By the 1930s the pattern of child welfare Clinics was well established in an extremely rigid mould. Mothers were seen by the health visitor, routine weighing of the babies was carried out, feeding problems were discussed and a rather apprehensive mother was shown into the doctor's room and the child was medically examined. Children over one year were given a medical check at varying intervals and at least annually, any defects found were recorded and arrangements were made for necessary treatment. The traditional system in child welfare clinics is still widespread in England a n d Wales. Kershaw (1961) in his article on "The Child Health Services" points out that Child Welfare Services are still orientated too much towards the physical well being of the child and urges considerable re-orientation to meet the changing conditions of the 1960s. He rightly states that the doctor is overwhehned with trivialities while the child is young and has no 342
SOCIAL
AND
PREVENTIVE
MEDICINE
343
opportunity to watch him during the important toddler years. The emphasis on physical health, the rigidity of appointment systems for physical examination at birthdays, the failure to provide clues to the child's development by observation of its behaviour, and the formal atmosphere of the doctor's interview may render the young mother unreceptive to new attitudes while she slavishly follows verbal instructions; all these seem to require a new approach. Furthermore the pattern of mortality and morbidity in the preschool age group has altered so enormously since 1940 (as a result of such influences as protective inoculations, universal availability of free general medical care, antibiotic therapy and nutritional improvements arising from a raised level of family income) that emphasis in the Service should be radically altered. We are challenged to provide the needs of a Child Welfare Service for the 1960s and 1970s and urgently require a review of the service in the light of changing morbidity and mortality in the 1 to 4 years age-group and in the light of our present knowledge of child health and development. In our view, the service of the future would lay emphasis on a broader concept of health. Besides physical health it should be particularly directed to the development of communication, special senses, social adjustment, mental health, handicapped children, and the mother-child relationship. We have chosen a few pieces of statistical information to highlight the changing pattern of disease in the pre-school age-group.
Mortality in the Pre-school Child (1 to 4 Years) The following comments are reproduced from the Registrar General's Statistical Review of England and Wales for the year 1960 (Part III, Commentary). "In the age group 1 to 4 years, total deaths in Eng!and and Wales in 1960 were 2,431 as compared with 4,087 in 1950. "The decline in tuberculosis deaths has been most remarkable. In 1950 there were 489 deaths attributed to various forms of tuberculosis, in I960 there were 15 and in particular tuberculous meningitis declined from 356 to 9. "Mortality from other infectious diseases also declined but the most striking decline was in poliomyelitis, where deaths fell from 116 in 1950 to 3 in 1960. The remainder of the infectious diseases caused 123 deaths in 1960, of which meningococc.~l infection caused 31, acute infectious encephalitis 24, measles 19 and infectious hepatitis 12. "Neoplasms have now emerged as a relatively important cause of loss in childhood, not because of an increase but because they have remained fairly stable. In 1950, there were 352 neoplastic deaths between ages 1 and 4; in 1960, 301. "Inflammatory disease of the central nervous system remained a potent killer of the pre-school child, causing 142 deaths as shown below."
344
PUBLIC
HEALTH
VOL.
TABLE
LXXVIII
NO.
6
I Deaths in 1960
Causes o f death
Meningococcal infections Infectious encephalitis Meningitis Encephalitis
3I 24 50 37
DEATHS (MOTOR VEHICLE ACCIDENTS ACCIDENTAL POISONING) 1N E N G L A N D WALES 1962.
AND AND
50(
450
4O0
/
350
300 O
c,
__
250 n," uJ
~200 :D Z
~
-
t50
-5
I00
:,
50
,,."
--.
--.~fo~-v -
./
°-'1
"". ~ ~'4 ~:
"s
I AGE
s
p O l s O N I I'IG
i
,o-,s
i
--YEARS
(Figures obtained from tile Registrar General's Statistical Review of England and Wales, 1962
"The commonest cause of death at this age was disease of the respiratory system with 559 deaths. "Accidents with 527 deaths were the second most important group of causes, and of these motor vehicle traffic accidents were responsible for 177 arid drowning accidents for 103."
SOCIAL
AND
Morbidity in the Pre-zchool The following figures have Leeds General Infirmary. poisoning and respiratory in this age group.
PREVENTIVE
MEDICINE
345
Child (1 to 4 years) been obtained from the Children's Units (Medical), They direct acute attention to the importance of illness in bringing about the admission of children TABLE
II
N u m b e r of cases Poisoning Respiratory disease Total Discharges
1961
1962
38 44 175
51 40 208
Other major causes of admission to hospital in this age group are accidents (particularly motor vehicle accidents and burns) and the operation of tonsillectomy. The Hospital Morbidity Statistics (General Register Office publication) quote that burns and scalds accounted for a quarter of all cases (recorded as discharges) relating to injury and amounted to 2.5 per cent. of all discharges in this age group, which is a higher proportion than at any other age. The following table is reproduced from the publication: TABLE All ages
0-
]II
1-
5-
15_
45-
65 a n d over
Percentage discharges due to burns and scalds
0"4
0"8
2-5
0"4
0-3
0'2
0-2
score OF THE CXaILD W E L F A R E S E R V I C E We regard the Child Welfare Service as composed of two distinct components: (i) Care of the infant up to one year of age. The clinic serves the functions of advising the mother about feeding and care and physical examination to ascertain congenital abnormalities and other deviations from the normal, including special attention to children on the " risk register." (ii) Care of the pre-school child from I to 5 years. Clinics for pre-school children require greater attention to be directed to the development of the child, mental health and social adjustment besides physical health. Health education falls within the scope of both types of clinics; but, as is clear, the topics on which health education is desirable are entirely different. D
346
PUBLIC
HEALTH
VOL.
LXXVIII
NO.
6
We feel that clinics for babies under 1 year, infant welfare clinics, are at present offering a comprehensive service, but the clinics for 1 to 5 years, toddlers clinics, should be modified in an attempt to cover the widened scope of welfare services which ought to be provided. There is much literatme stressing the need for changes in this field of child welfare service----(Kershaw, 1961 ; and Paterson, 1961). New patterns ought to be tried and their value assessed. Combined infant and toddlers clinics known as child welfare clinics are at present operating Ln many areas. We suggest that as a first step, consideration should be given to separating the infant welfare work from the toddlers" work. We present the concept of Health and Development Clinics for children aged 1 to 5 years in the hope that it will stimulate discussion and help to shape our future pre-school child welfare service. We believe it will meet the changing needs of the 1960s. HEALTH
AND
DEVELOPMENT
CLINICS
1 TO 5 YEARS We would make the following suggestions for organisation of these clinics. The basis of a Health and Development Clinic is the observation of the toddlers at play and the use of such a situation to assess the physical, mental, social and performance state of the child. The clinic is suggested for children between 1 and 5 years of age. The health visitor should invite about 8 to 10 children in this age group. In the beginning some selection may have to be used for those considered suitable to attend such a clinic, but the aim should be to extend this service to all toddlers. All children should be invited to attend at about the same time. The clinic should be conducted in :an atmosphere of informality. The main hall or a large room should be set to act as a playroom for the toddlers. Suitable and attractive toys should be arranged ill groups for several age groups. Toys should be chosen with care so that they have some performance value. This will enable the observer to draw conclusions about the developmental stages of the child. The medical officer should observe the children at play and note the following aspects: FOR
1. General nourishment and state 2. Motor activity, performance 3. Visual and auditory functions 4. Social behaviour of the child in the group 5. Emotional behaviour of the child towards the mother 6. Speech and general communication level 7. Orthopaedic abnormalities
SOCIAL
AND
PREVENTIVE
MEDICINE
347
The health visitor will be able to give the social background of the case and help the doctor in identifying the child. Record cards should be used to note any comments and the progress of the child recorded. Such a record would later be of immense value in assessing a particular case. Complete physical examination should be carried out if an abnormality is detected by the M.O. on observation, or if requested by the mother. Provided a thorough physical examination is carried out when the child is one year old, we believe that hardly any physical defect of importance will be missed by using this procedure, whereas more information about the physical, mental and emotional development will be acquired. There will be an excellent opportunity for early detection of orthopaedic, speech, visual or auditory defects. It would thus be possible to handle such defects at any early stage. An assessment of mother-child relationship should be made and appropriate advice on such matters should be given where indicated. Health education on both formal and informal levels should be undertaken at the Health and Development Clinic. While one group of mothers look after their children in the play hall, the other group should be given health education with visual aids and films on suitable subjects (such as accidents, poisoning, behaviour problems, management of bed wetting, nutrition, dental care and so on). Discussion should be encouraged. The whole health education session should not last more than about 15 minutes. Informal discussion and advice can be given while the mothers sit watching the children at play. Most of the health education can be carried out by the health visitor, but, depending on the time available, the M.O. should try to join in. Associated with the Health and Development Clinic should be facilities for investigation of handicapped children, children on the risk register and children showing communication defects. Sheridan (1964) stresses the importance of detection of communication and hearing defects, and she urges the observation of normal development of communication in the pre-school age group so that many defects can be detected early. Screening tests for hearing in the very young could be employed, concentrating especially on children at risk. Special clinics designed on the pattern of Health and Development Clinics could be of very great value for assessment of handicapped children of pre-school age. We suggest that toddlers from 1½ years to 4½ years should be seen at a. Health and Development Clinic every 6 months or so. We feel that such clinical assessment of health will be of more value than carrying out an annual physical examination only. The sarr/e principles could be modified to suit examination of toddlers in day nurseries and nursery schools.
348
PUBLIC
HEALFH
VOL.
LXXVIII
NO.
6
DISCUSSION
The changing pattern of disease in the toddler age group calls for review of services available from the local authority clinics. The G.P.s feel that the local ,authorities are encroaching upon their interests as there appears to be duplication of work. Perhaps the community is becoming increasingly aware that the services from the G.P. and the L.A. are both orientated towards physical health only. Douglas and Blomfield (1958) in their survey found that mothers show a marked falling off in attendance at ,Child Welfare Clinics when their child passes its first birthday. TABLE
Child's year
1st 2nd 3rd 4th
IV
Percentage o f mothers using welfare centres
66-2 43 -3 35 22
Douglas & B l o m f i e l d h " C h i l d r e n under Fivo."
The concept of health has widened considerably and the services should take into consideration mental, emotional and social health besides physical health. The functions of the general medical service are complementary to the Child Welfare Service. We have to develop welfare services to meet the changing needs of the 1960s and have also to educate the public that Child Welfare Services are designed to achieve positive health in children--health in its broader meaning. A concept of Health and Development Clinics is put forward whereby information about physical, mental and social health can be obtained and used to provide comprehenSive Child Welfare Services for the toddler. This is based on the fact that information about these aspects can be best obtained by watching the child in play-groups and an attempt is made to incorporate health education by group discussion on important subjects, such as accidents and poisoning. Death from accidents and poisoning form the important groups and are preventable in a great many cases. The recent report of a joint committee of the Central and Scottish Health Services Councils on Health Education recommends that health visitors should undertake group discussion on health education in the child welfare field. The system is also designed to provide facilities for early and more efficient assessment of handicaps. ACKNOWLEDGEMENTS
Our thanks are due to Dr R. W. EUiott, County M.O., West Riding of Yorkshire, and to Dr Llywclyn Roberts, M.O.H., City of Sheffield, for publication
SOCIAL
AND
PREVENTIVE
MEDICINE
349
permission; and to Professor W. S. Craig and Dr E. C. Allibone, Children's Department, General Infirmary at Leeds, for permission to use their figures for discharges in the pre-school age group. We are indebted to Mr E. N. Hill, Records Officer, General Infirmary at Leeds for his help and co-operation. The views expressed in this article are those of the authors, and are not necessarily those of their employing authorities. REFERENCES D o u o L A S, J. W. B. a n d B L O M r I E L D, J. M. (1958). Children Under Five. London, George Allen & U n w i n L t d . K E R S H A W, J. D. (1961).Public Health, L X X V , 322. M i n i s t r y o f Health. (1964). Health Education--Report o f a J o i n t C o m m i t t e e o f the Central a n d Scottish Health Services C o u n c i l . L o n d o n , H . M . S . O . P A T g R S O N, M A R Y T. (1961). Public H~ealth, L X X V , 353. R E G I S T R AR G E N E R AL. (1962). StatiMical Review o f England and Wales for the Year 1960. P a r t III, C o m m e n t a r y . L o n d o n , H . M . g . O . S H E R I D A N, M A R Y D . (1964). Monthly Bulletin, F e b r u a r y . L o n d o n , H . M . S . O .