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The neglected child
THE NEGLECTED CHILD Memorandum of evidence submitted by the Society oJ Medical Officers of Health to the Children and Young Persons Committee appointed by the Secretary of State [or the Home Department. (1) Constitution o[ The Society of Medical Officers of Health The Society of Medical Officers of Health which was founded in 1856 has over 2,200 public health and dental officer members, most of whom are directly concerned with some aspect of child care through the maternity and child welfare services, the school health service and the local authority health services generally. The Society, through its specialist groups, keeps under review the various aspects of child welfare which are the responsibilities of its members, and their experience qualifies it to present evidence and express opinions oi~ matters within the terms of reference of the lngleby Committee. (2) Whether Local Authorities Should be Given New Powers and Duties The Society desires to comment on certain aspects of the working of the law, but more specifically to address itself to the question "as to whether local authorities responsible for child care under the Children Act, 1948, should be given new powers and duties to prevent or forestall the suffering of children through neglect in their own homes." (3) The Society's Agreement with Large Part of "Report of Joint Committee" This memorandum makes repeated ~eferences to a "Report of a Joint Committee of the British Medical Association and the Magistrates' Association--'Cruelty to and Neglect of Children.'" Many of the Society's members are also members of the British Medical Association with which it has close links and common interests. The Society endorses generally, with one important exception, paras. 130 to 131 (Recommendation 15) the views and recommendations of the Report. The Society agrees (p. 12) that: "cruelty and neglect constitute treatment as the result of which a child's potential development is retarded or completely suppressed by mental, emotional and/or physical suffering produced as the outcome of a deprivation of minimal requirements." (4) Existing La~ Adequate to Prevent Physical Cruelty Concepts of cruelty are conditioned by the time and society in which one lives. The Societ~r believes that physical cruelty is decreasing; mental cruelty and suffering, although at least of equal importance, are less susceptible of demonstration. Mental cruelty can be so varied that it is scarcely surprising that there is no general consensus of opinion as to its constitution. The Society considers the existing law to be adequate to deal with physical cruelty, but has some reservations about mental cruelty, believing that difficulties of definition and proof discourage legal proceedings. No information is available from which the Society could conclude that the law has been adequately tested in this direction. If doubts can be entertained in regard to degrees of mental cruelty which would justify penal sanction, it must, a fortiori, follow that the Society fears that the law may be inadequate where child suffering is occasioned by mental illness or inadequacy in the parents. Every experienced social worker must know of 183
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instances where, because of his mental condition, a parent could rightly be considered "unfit to exercise proper care and guardianship" (Children and Young Persons Act, 1933, Section 61) although a recommendation for legal proceedings for a Fit Person Order has not been made because of doubts about the outcome. The Society recognises that the removal of a child from his parent by legal process, particularly a removal which must in many instances continue throughout childhood and adolescence, is a matter of great gravity but it believes that there are instances where the child's best interests can only be secured in this way. In consequence, the Society urges consideration of this aspect of the law, particularly as a recent judgment in a case arising out of the Mental Deficiency Acts (Regina v. The Board of Control and Others ex parle Rutty) construes "neglect" in a hmited physical sense. (5) Other Aspects of Existing Law There are other aspects of the existing law upon which the Society wishes to comment briefly. (a) The Society considers that present procedure whereby a parent may initiate proceedings and charge his child as being "beyond control" and give evidence in this behalf, is undesirable because it may represent to the child a final repudiation by a parent, whose own inadequacies are primarily to blame. The Society, therefore, recommends that some alternative procedure should be sought. (b) The Society considers that in proceedings under the Matrimonial Causes Act, 1937, the interests of the children may receive inadequate consideration, and welcomes the observations and recommendations of the Report of the Royal Commission on Marriage and Divorce (paras. 408 and 412 inclusive) on this matter: "'(i)
a magistrates' court should have power to make an order for custody under the Summary Jurisdiction (Separation and Maintenance) Acts, 18951949, in respect of: (a) illegitimate children of the two spouses; (b) children of either spouse (including a child adopted by either spouse), if living in family at the time when the home broke up; (c) illegitimate children of either spouse, if living in family at the time when the home broke up; (d) other children (excluding boarded-out children) who were living in family with the spouses and maintained by one or both of them at the time when the home broke up; (ii) a magistrates' court should have power to order continuing supervision for such period as it thinks fit, after an order for custody has been made under the Summary Jurisdiction (Separation and Maintenance) Acts, 18951949. Where supervision has been ordered, the court should have power to reopen the question of custody at any lime on its own motion." The Royal Commission's Report also refers (para. 412) to the inquiries made by the probation service in matters affecting the custody of children and recommends statutory sanction for them. The Society considers that the fullest information should be available to the courts when questions of custody arise, and without seeking to minimise the value of what has been accomplished already, draws attention to recommendations 13 (a) of the Joint Report, namely, that trained social workers should be available at all courts to assist the court where questions involving the welfare of children arise. The Society urges that where children are concerned, the fullest use be made of the information which health departments could furnish.
THE NEGLECTED CHILD
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(c) The Society is impressed by the hardship which the separation of parents can occasion their children. In general, children who have a competent mother may escape the worst effects of the failure of their parents' marriage if they are not made homeless. Under existing law, however, a husband against whom an Order of Separation is obtained, can terminate the tenancy of the house occupied by his family, dispose of the contents of the matrimonial home and render homeless his wife and children for whom the court has ordered him to be financially responsible. We urge that consideration be given to possible ways of protecting children from these occurrences. (d) The Society supports the recommendation (Joint Report paras. 63 and 121) that courts should have available adequate psychiatric and social reports to enable them to decide the treatment of the parents and children and would make mention here of the assistance already forthcoming from child guidance clinics. (e) The Society considers that interrogation of children, particularly those who have been the victim of sexual assaults, should, as far as possible, be undertaken by persons who have undergone psychiatric training, and endorses the recommendation of the Joint Report that where children have to give evidence in court, it should be taken at the first opportumty. (6) Prevention The Society endorses the findings of the Joint Report both as regards the underlying causes of cruelty and neglect, namely: (i) subnormal or mentally deficient parents or those suffering from mental illness or instability; (ii) character defects in parents including lack of normal discipline or low standards of behaviour; (iii) rejection of an unwanted or handicapped child; (iv) ignorance of parents in regard to the management of home and family; (v) marital disharmony; (vi) illegitimacy; (vii) overcrowded or insanitary homes; (viii) financial difficulties; (ix) drunkenness; (x) growing absorption of mothers mto full employment. (7) Forms of Cruelty and Neglect The Society also agrees with the Joint Report that the forms in which these are manifested include: (a) failure to provide adequate physical and mental care because of low mentality, bad management, laziness, ill health, etc., often coupled with frequent pregnancies resulting in, e.g., uncleanliness, both of children and the home, insufficient clothing, inadequate sleeping accommodation and covering; inadequate amount of sleep where parents allow the children to stay out late at night, lack of adequate heating in the home, unhygienic methods of food preparation, and absence of regular staple diet and regular meal times; (b) intentional or thoughtless deprivation of an unwanted and/or rejected child; (c) physical violence which may often take the form of inappropriate or excessive punishment; (d) leaving a young child alone for long periods, especially at night; (e) illegitimacy where the mother has difficulties in caring for the child; (f) failure to provide adequate accommodation, due to fecklessness of parents;
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PUBLIC HEALTH VOL. LXXI NO. 5 (g) desertion or abandonment; (h) broken homes; (i) children placed by parent in private foster homes and (1) abandoned financially, or (2) subjected to frequent changes of foster parents; (j) persistent nagging; (k) over-ambitious parents; (1) children left in care of elderly, incompetent relatives.
The Society would point out that the majority of these forms of cruelty and neglect are matters which already come within the official purview of its members. (8) Education of General Public to Prevent Cruelty The Society agrees that it is by the treatment of the underlying causes of cruelty and neglect that they can be prevented and that progress is dependent upon the widest and most systematic education of the public, and, in particular, of the future generation. (9) Powers o[ Local Authorities The Society desires to place on record its opinion that local health authorities already have the following powers, namely: (a) to employ staff to teach mothers in their own homes; (b) to employ home helps to assist and instruct incompetent mothers of children under school age; (c) to make payments to voluntary organisations engaged in prevention and rehabilitation, such as Family Service Units; and (d) to pay for the accommodation of mothers and their children in special homes such as Brentwood. The most serious deficiency in local authority powers is the inability to provide essential articles of household equipment, bedding and the like. The quantity of the equipment required to sustain any acceptable standard of living is beyond the capacity of many families in difficulties to provide from their own resources. Without it, what they already have, is often abused and wastefully expended; in its absence there can be no efficient instruction in home making, and attempts to improve health by better feeding, improved rest and comfort are frustrated at the outset. In the light of the foregoing, the Society recommends that serious attention be given to this matter and hopes that the Ingleby Committee will make suggestions as to the source from which this essential provision is to be forthcoming. (10) Exercise of these Powers The Society dissents strongly from the recommendation of the Joint Report that extended powers be given to local authorities for exercise by children's departments. This memorandum will show the unique position of the health department in this matter. The assistance of specialist agencies is from time to time indispensable to it, but it already deals with most aspects of family life where there are children. The health department must, therefore, be regarded as the general practitioner of social and preventive medicine. Ordinarily, like the family doctor, it should be able to command expert assistance when this is required and take over again when treatment is within its scope. This would in no way affect its continuing responsibilities to the family.
THE NEGLECTED CHILD
187
(11) Prevention and Rehabilitation Complementary Prevention and rehabilitation are complementary, being parts of a continuous and indivisible process which begins with the education of the group and the individual from an early age. It is intensified with the expectant mother, and is given a very practical bias by the teaching of the health visitor, who, as will be shown, reinforces this by assistance of varying kinds. The Society considers the principle that prime responsibility for prevention and rehabilitation rests with health departments should be affirmed and all developments in these fields should have regard to it. Any measures which would create a parallel organisation which could only lead to overlapping and competition, would occasion concern. It is recognised that children's departments establish a valuable personal relationship with the families of children whom they have "in care" and are in some instances best fitted to rehabilitate them. It is urged, however, that these measures should be designed in co-operation with the health departments, and should utilise to the full the powers and resources which the latter command. The Society urges t h a t publicity should be given to existing powers of local authorities and that the central departments should actively and persistently encourage their utilisation to the full. (12) The Import~we of the Health Department in Preventing Cruelty The Society considers it essential to refer to the position of the health department in this matter. The existing services of the local health authority with a medical off• in charge are eminently suited by constitution, personnel and powers, to prevent or forestall the suffering of children in their own homes. Through the maternity and child welfare service and the school health service there is continuous association with the family from the first early pregnancy until the youngest child ceases to be of school age. This association is by reason of its universality, its duration and intimacy, unique in the social services. The local health authority service is concerned essentially with the preservation of sound family life; and it is the only one able by its nature to deal through its wide range of personal health services with every aspect of this work. The health visitor visits lamilies before there is any specific need or occasion for the community to help them; therefore she is on a different footing Item all other social workers concerned with families. A recent survey has shown that 95% of families receive regular visits from a health visitor for one or more of their children and 82% have received visits in respect of all their children. The number of visits has risen continually since 1939. These figures reflect concern not only with physical questions, but also with matters of a psychological and socio-economic character, the latter representing 25% of health visitors' work as a whole. (Para. 195 of the Working Party's report on Health Visitors.) The Society has made special inquiries about what health visitors i r e doing to prevent the break-up of families and to rehabilitate them when this occurs. It has every reason to be proud of what members and their staffs h a w accomplished. Health visitors have taught many mothers the basic elements of home-making, advised them about budgeting, and even accompanied them when they shopped. They have taught mothers how to cook and to clean, and have worked alongside their adult pupils. When immediate difficulties have threatened, health visitors have been able to secure postponement of eviction, made arrangements for the payment by instalments of rents which were long in arrears, negotiated settlements with pressing creditors and have even seen to it that these arrangements were honoured. They have provided clothing and equipment, either from their own
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resources or other agencies with which they were in touch. They have interviewed employers and National Assistance Board officials in order to explain needs and to negotiate adjustments. A good deal of this work has been carded out outside the normal working hours. What they have done in times of emergency occasioned by sickness or mental breakdown is equally impressive. (13) Home Help Service The health visitor is not the only member of the health department staff who can make an important contribution to prevention and rehabilitation. The Society considers that the home help service can do much. Indeed, it knows of no other source from which practical workers could be recruited in numbers sufficient to meet the need. Some authorities, such as Leicester and the Kent County Council, have already experimented with the employment of home helps in families where break-up is threatened by reason of ignorance, fecklessness, mismanagement and apathy, and have been encouraged to continue with them. The Society is of the opinion that the Ministry of Health should be recommended to give general direction and advice as to the deployment of the home help service in this work. (14) Avoidance of Overlapping The number and variety of agencies that may be called in to assist the family may be large; but in some cases where many different specialities may be necessary, co-ordination of effort is needed to prevent overlap. The medical officer of health, by virtue of his office, is able to keep in touch with agencies needed to assist the family. His work has been strengthened by the establishment of co-ordinating committees which were set up in response to the joint circular 78/50. The Society has been encouraged by reports which have been received of the success which has already attended efforts to co-ordinate work of this kind and to reduce overlapping. (15) Co-ordination The joint circular (31/7/1950) from the Home Office and the Ministries of Health and Education informed local authorities as follows: "It is essential that there should be co-ordinated use of the statutory and voluntary services." The circular asked local authorities to designate "an officer to be responsible under them for enlisting the interest of those concerned and devising arrangements to secure full co-operation among all the local services, statutory and voluntary, which are concerned with the welfare of children in their own homes." The information available to the Society indicates that wherever co-ordination has been effectively organised, and particularly where the medical officer of health has been appointed co-ordinating officer, the exchange of information has been facilitated, a more balanced view of the family situation has emerged and more effective action has followed. Almost invariably, a greater understanding between the personnel of the agencies concerned has grown up making for increased harmony in working. The Society's submission is that co-ordination rather than centralisation should be the immediate objective; for time is required for the fullest development of existing powers of the local authority for the prevention of suffering and neglect of children in their own homes. It follows from what is said in para. 12 supra that the Society considers that, in most instances, the medical officer of health should be the co-ordinating officer.
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(16) Importance of Co-operation of General Practitioner The co-operation of the general practitioner dealing with this problem is vital. His authoritative approach, particularly to the father, is much needed. The general practitioner is now more aware of the implications of social medicine and readier to co-operate with statutory authorities. Of late years, there has been a considerable growth of interest in social medicine and in the number of university departments devoted to it. An impact on the training of the medical student which, in the opinion of the Society, will become even more important in the future, has already been made. A most helpful development has been the drawing together of the general practitioner and the medical and ancillary staff of local health authorities, which is essential for the family in difficulties. The habits of professional confidence are, however, deeply ingrained; and while it is natural for our medical colleagues to turn to the health department for help for their patients, they are much less likely to be either candid or forthcoming with other agencies. In consequence, the health department is the natural channel for communication with the general practitioner, who to-day is in a unique position to diagnose the family's disabilities and indicate its needs. (17) Mental Deficiency in Mothers Mental deficiency in the mother is a well-recognised, significant factor in the creation of the problem families. It is rare, in our experience, for a woman of low intelligence to make a satisfactory home unless she is supported tirelessly and sympathetically by her husband and other relatives. Supervision of defectives and their cure in the community is a function of the local health authority and mental deficiency officers come to have great influence over the defectives whom they supervise for lengthy periods. In this matter, too, the health department has a prime part to play; a part, moreover, which could not satisfactorily be delegated to any other agency. (18) Mental Illness We have already referred to the importance of mental illness as a cause of suffering to children. The prevention and after-care of mental illness, as well as arranging admission to hospital, are among the duties of the health department which more often has the first knowledge of mental illness and its effects upon a family. Mental health service workers are increasingly accepted by the public and patient, and relatives turn to them for advice and guidance with growing frequency. The Society considers that the mental health service will be involved in the future with family case work to a much greater extent than at present. (19) Prevention of Mental 1ll Health Local health authorities are actively concerning themselves with the provision of preventive mental services in the field of maternity and child welfare. The child guidance service, primarily conceived for the child of school age, has demonstrated how large a proportion of emotional difficulties arise in pre-scbool years, at a time when their cure is at once easier to effect and more certain of accomplishment. The importance of the early recognition of conditions which may cause behaviour disturbances and maladjustment is now being recognised. The clinical medical officer and the health visitor, in their daily contact with mothers in ante-natal child welfare centres, meet with these conditions repeatedly.
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The Society welcomes the growing interest of the maternity and child welfare services in the prevention and cure of early difficulties which are rooted in emotional causes, and urges an intensification of the training in this field which their staffs already undergo. The Society regards as highly important the closer integration of maternity and child welfare and child guidance services as being likely to prevent neglect and suffering in this and succeeding generations. (20) Housing The importance of satisfactory housing conditions and the devastating effects on the family of eviction are too well recognised to require emphasis. Health departments have rightly earned the confidence and support of housing authorities and housing committees, and their advice is generally sought when difficult decisions are to be made. Health departments often support and encourage those families whose rehousing has been effected and eviction prevented by their efforts. (21) Summary 1. The recommendations of the Joint Committee of the British Medical Association and the Magistrates' Association (pages 54-56) are, save for para. 15, endorsed by the Society. 2. Consideration is required of existing law in regard to mental cruelty, and, particularly, suffering and hardship occasioned by the illness or inadequacy of a parent in relation to the making of Fit Person Orders. 3. In matrimonial cases there should be full information bearing on the question of custody and the best interests of any children concerned. 4. The position of a wife who obtains the custody of her children requires consideration so that she may be protected against being rendered homeless. 5. There is a need for a variety .of social workers to assist families in difficulties. Their efforts should be co-ordinated rather than their number be reduced. Local authorities should be urged to overhaul and make effective their co-ordinating machinery wherever this is necessary. 6. Local authority powers to prevent the break-up of families and to rehabilitate should be clarified and extended so as to allow of assistance in the provision of essential furniture and equipment. Local authorities should devise, administrative arrangements, which while they best suit local needs, preserve the central role of the health departments in this field. 7. Public health departments should be regarded as agencies primarily concerned with the prevention of neglect and the break-up of families. Rehabilitation should be their aim where there has been failure to prevent. Their need of specialised assistance should be recognised and it should be obtained in co-operation with other agencies. Health departments should resume the care and supervision of families when the need for specialised assistance from outside agencies no longer exists. J. Stevenson Logan, Chairman, Children and Young Persons Acts Sub-committee. H. D. Chalke, Chairman, Executive Committee. Selwyn Selwyn-Clarke, Secretary, The Society of Medical Officers of Health, Tavistock House South, Tavistock Square, W.C.1.
19th March, 1957.
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instances where, because of his mental condition, a parent could rightly be considered "unfit to exercise proper care and guardianship" (Children and Young Persons Act, 1933, Section 61) although a recommendation for legal proceedings for a Fit Person Order has not been made because of doubts about the outcome. The Society recognises that the removal of a child from his parent by legal process, particularly a removal which must in many instances continue throughout childhood and adolescence, is a matter of great gravity but it believes that there are instances where the child's best interests can only be secured in this way. In consequence, the Society urges consideration of this aspect of the law, particularly as a recent judgment in a case arising out of the Mental Deficiency Acts (Regina v. The Board of Control and Others ex parle Rutty) construes "neglect" in a hmited physical sense. (5) Other Aspects of Existing Law There are other aspects of the existing law upon which the Society wishes to comment briefly. (a) The Society considers that present procedure whereby a parent may initiate proceedings and charge his child as being "beyond control" and give evidence in this behalf, is undesirable because it may represent to the child a final repudiation by a parent, whose own inadequacies are primarily to blame. The Society, therefore, recommends that some alternative procedure should be sought. (b) The Society considers that in proceedings under the Matrimonial Causes Act, 1937, the interests of the children may receive inadequate consideration, and welcomes the observations and recommendations of the Report of the Royal Commission on Marriage and Divorce (paras. 408 and 412 inclusive) on this matter: "'(i)
a magistrates' court should have power to make an order for custody under the Summary Jurisdiction (Separation and Maintenance) Acts, 18951949, in respect of: (a) illegitimate children of the two spouses; (b) children of either spouse (including a child adopted by either spouse), if living in family at the time when the home broke up; (c) illegitimate children of either spouse, if living in family at the time when the home broke up; (d) other children (excluding boarded-out children) who were living in family with the spouses and maintained by one or both of them at the time when the home broke up; (ii) a magistrates' court should have power to order continuing supervision for such period as it thinks fit, after an order for custody has been made under the Summary Jurisdiction (Separation and Maintenance) Acts, 18951949. Where supervision has been ordered, the court should have power to reopen the question of custody at any lime on its own motion." The Royal Commission's Report also refers (para. 412) to the inquiries made by the probation service in matters affecting the custody of children and recommends statutory sanction for them. The Society considers that the fullest information should be available to the courts when questions of custody arise, and without seeking to minimise the value of what has been accomplished already, draws attention to recommendations 13 (a) of the Joint Report, namely, that trained social workers should be available at all courts to assist the court where questions involving the welfare of children arise. The Society urges that where children are concerned, the fullest use be made of the information which health departments could furnish.
THE NEGLECTED CHILD
185
(c) The Society is impressed by the hardship which the separation of parents can occasion their children. In general, children who have a competent mother may escape the worst effects of the failure of their parents' marriage if they are not made homeless. Under existing law, however, a husband against whom an Order of Separation is obtained, can terminate the tenancy of the house occupied by his family, dispose of the contents of the matrimonial home and render homeless his wife and children for whom the court has ordered him to be financially responsible. We urge that consideration be given to possible ways of protecting children from these occurrences. (d) The Society supports the recommendation (Joint Report paras. 63 and 121) that courts should have available adequate psychiatric and social reports to enable them to decide the treatment of the parents and children and would make mention here of the assistance already forthcoming from child guidance clinics. (e) The Society considers that interrogation of children, particularly those who have been the victim of sexual assaults, should, as far as possible, be undertaken by persons who have undergone psychiatric training, and endorses the recommendation of the Joint Report that where children have to give evidence in court, it should be taken at the first opportumty. (6) Prevention The Society endorses the findings of the Joint Report both as regards the underlying causes of cruelty and neglect, namely: (i) subnormal or mentally deficient parents or those suffering from mental illness or instability; (ii) character defects in parents including lack of normal discipline or low standards of behaviour; (iii) rejection of an unwanted or handicapped child; (iv) ignorance of parents in regard to the management of home and family; (v) marital disharmony; (vi) illegitimacy; (vii) overcrowded or insanitary homes; (viii) financial difficulties; (ix) drunkenness; (x) growing absorption of mothers mto full employment. (7) Forms of Cruelty and Neglect The Society also agrees with the Joint Report that the forms in which these are manifested include: (a) failure to provide adequate physical and mental care because of low mentality, bad management, laziness, ill health, etc., often coupled with frequent pregnancies resulting in, e.g., uncleanliness, both of children and the home, insufficient clothing, inadequate sleeping accommodation and covering; inadequate amount of sleep where parents allow the children to stay out late at night, lack of adequate heating in the home, unhygienic methods of food preparation, and absence of regular staple diet and regular meal times; (b) intentional or thoughtless deprivation of an unwanted and/or rejected child; (c) physical violence which may often take the form of inappropriate or excessive punishment; (d) leaving a young child alone for long periods, especially at night; (e) illegitimacy where the mother has difficulties in caring for the child; (f) failure to provide adequate accommodation, due to fecklessness of parents;
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PUBLIC HEALTH VOL. LXXI NO. 5 (g) desertion or abandonment; (h) broken homes; (i) children placed by parent in private foster homes and (1) abandoned financially, or (2) subjected to frequent changes of foster parents; (j) persistent nagging; (k) over-ambitious parents; (1) children left in care of elderly, incompetent relatives.
The Society would point out that the majority of these forms of cruelty and neglect are matters which already come within the official purview of its members. (8) Education of General Public to Prevent Cruelty The Society agrees that it is by the treatment of the underlying causes of cruelty and neglect that they can be prevented and that progress is dependent upon the widest and most systematic education of the public, and, in particular, of the future generation. (9) Powers o[ Local Authorities The Society desires to place on record its opinion that local health authorities already have the following powers, namely: (a) to employ staff to teach mothers in their own homes; (b) to employ home helps to assist and instruct incompetent mothers of children under school age; (c) to make payments to voluntary organisations engaged in prevention and rehabilitation, such as Family Service Units; and (d) to pay for the accommodation of mothers and their children in special homes such as Brentwood. The most serious deficiency in local authority powers is the inability to provide essential articles of household equipment, bedding and the like. The quantity of the equipment required to sustain any acceptable standard of living is beyond the capacity of many families in difficulties to provide from their own resources. Without it, what they already have, is often abused and wastefully expended; in its absence there can be no efficient instruction in home making, and attempts to improve health by better feeding, improved rest and comfort are frustrated at the outset. In the light of the foregoing, the Society recommends that serious attention be given to this matter and hopes that the Ingleby Committee will make suggestions as to the source from which this essential provision is to be forthcoming. (10) Exercise of these Powers The Society dissents strongly from the recommendation of the Joint Report that extended powers be given to local authorities for exercise by children's departments. This memorandum will show the unique position of the health department in this matter. The assistance of specialist agencies is from time to time indispensable to it, but it already deals with most aspects of family life where there are children. The health department must, therefore, be regarded as the general practitioner of social and preventive medicine. Ordinarily, like the family doctor, it should be able to command expert assistance when this is required and take over again when treatment is within its scope. This would in no way affect its continuing responsibilities to the family.
THE NEGLECTED CHILD
187
(11) Prevention and Rehabilitation Complementary Prevention and rehabilitation are complementary, being parts of a continuous and indivisible process which begins with the education of the group and the individual from an early age. It is intensified with the expectant mother, and is given a very practical bias by the teaching of the health visitor, who, as will be shown, reinforces this by assistance of varying kinds. The Society considers the principle that prime responsibility for prevention and rehabilitation rests with health departments should be affirmed and all developments in these fields should have regard to it. Any measures which would create a parallel organisation which could only lead to overlapping and competition, would occasion concern. It is recognised that children's departments establish a valuable personal relationship with the families of children whom they have "in care" and are in some instances best fitted to rehabilitate them. It is urged, however, that these measures should be designed in co-operation with the health departments, and should utilise to the full the powers and resources which the latter command. The Society urges t h a t publicity should be given to existing powers of local authorities and that the central departments should actively and persistently encourage their utilisation to the full. (12) The Import~we of the Health Department in Preventing Cruelty The Society considers it essential to refer to the position of the health department in this matter. The existing services of the local health authority with a medical off• in charge are eminently suited by constitution, personnel and powers, to prevent or forestall the suffering of children in their own homes. Through the maternity and child welfare service and the school health service there is continuous association with the family from the first early pregnancy until the youngest child ceases to be of school age. This association is by reason of its universality, its duration and intimacy, unique in the social services. The local health authority service is concerned essentially with the preservation of sound family life; and it is the only one able by its nature to deal through its wide range of personal health services with every aspect of this work. The health visitor visits lamilies before there is any specific need or occasion for the community to help them; therefore she is on a different footing Item all other social workers concerned with families. A recent survey has shown that 95% of families receive regular visits from a health visitor for one or more of their children and 82% have received visits in respect of all their children. The number of visits has risen continually since 1939. These figures reflect concern not only with physical questions, but also with matters of a psychological and socio-economic character, the latter representing 25% of health visitors' work as a whole. (Para. 195 of the Working Party's report on Health Visitors.) The Society has made special inquiries about what health visitors i r e doing to prevent the break-up of families and to rehabilitate them when this occurs. It has every reason to be proud of what members and their staffs h a w accomplished. Health visitors have taught many mothers the basic elements of home-making, advised them about budgeting, and even accompanied them when they shopped. They have taught mothers how to cook and to clean, and have worked alongside their adult pupils. When immediate difficulties have threatened, health visitors have been able to secure postponement of eviction, made arrangements for the payment by instalments of rents which were long in arrears, negotiated settlements with pressing creditors and have even seen to it that these arrangements were honoured. They have provided clothing and equipment, either from their own
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resources or other agencies with which they were in touch. They have interviewed employers and National Assistance Board officials in order to explain needs and to negotiate adjustments. A good deal of this work has been carded out outside the normal working hours. What they have done in times of emergency occasioned by sickness or mental breakdown is equally impressive. (13) Home Help Service The health visitor is not the only member of the health department staff who can make an important contribution to prevention and rehabilitation. The Society considers that the home help service can do much. Indeed, it knows of no other source from which practical workers could be recruited in numbers sufficient to meet the need. Some authorities, such as Leicester and the Kent County Council, have already experimented with the employment of home helps in families where break-up is threatened by reason of ignorance, fecklessness, mismanagement and apathy, and have been encouraged to continue with them. The Society is of the opinion that the Ministry of Health should be recommended to give general direction and advice as to the deployment of the home help service in this work. (14) Avoidance of Overlapping The number and variety of agencies that may be called in to assist the family may be large; but in some cases where many different specialities may be necessary, co-ordination of effort is needed to prevent overlap. The medical officer of health, by virtue of his office, is able to keep in touch with agencies needed to assist the family. His work has been strengthened by the establishment of co-ordinating committees which were set up in response to the joint circular 78/50. The Society has been encouraged by reports which have been received of the success which has already attended efforts to co-ordinate work of this kind and to reduce overlapping. (15) Co-ordination The joint circular (31/7/1950) from the Home Office and the Ministries of Health and Education informed local authorities as follows: "It is essential that there should be co-ordinated use of the statutory and voluntary services." The circular asked local authorities to designate "an officer to be responsible under them for enlisting the interest of those concerned and devising arrangements to secure full co-operation among all the local services, statutory and voluntary, which are concerned with the welfare of children in their own homes." The information available to the Society indicates that wherever co-ordination has been effectively organised, and particularly where the medical officer of health has been appointed co-ordinating officer, the exchange of information has been facilitated, a more balanced view of the family situation has emerged and more effective action has followed. Almost invariably, a greater understanding between the personnel of the agencies concerned has grown up making for increased harmony in working. The Society's submission is that co-ordination rather than centralisation should be the immediate objective; for time is required for the fullest development of existing powers of the local authority for the prevention of suffering and neglect of children in their own homes. It follows from what is said in para. 12 supra that the Society considers that, in most instances, the medical officer of health should be the co-ordinating officer.
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(16) Importance of Co-operation of General Practitioner The co-operation of the general practitioner dealing with this problem is vital. His authoritative approach, particularly to the father, is much needed. The general practitioner is now more aware of the implications of social medicine and readier to co-operate with statutory authorities. Of late years, there has been a considerable growth of interest in social medicine and in the number of university departments devoted to it. An impact on the training of the medical student which, in the opinion of the Society, will become even more important in the future, has already been made. A most helpful development has been the drawing together of the general practitioner and the medical and ancillary staff of local health authorities, which is essential for the family in difficulties. The habits of professional confidence are, however, deeply ingrained; and while it is natural for our medical colleagues to turn to the health department for help for their patients, they are much less likely to be either candid or forthcoming with other agencies. In consequence, the health department is the natural channel for communication with the general practitioner, who to-day is in a unique position to diagnose the family's disabilities and indicate its needs. (17) Mental Deficiency in Mothers Mental deficiency in the mother is a well-recognised, significant factor in the creation of the problem families. It is rare, in our experience, for a woman of low intelligence to make a satisfactory home unless she is supported tirelessly and sympathetically by her husband and other relatives. Supervision of defectives and their cure in the community is a function of the local health authority and mental deficiency officers come to have great influence over the defectives whom they supervise for lengthy periods. In this matter, too, the health department has a prime part to play; a part, moreover, which could not satisfactorily be delegated to any other agency. (18) Mental Illness We have already referred to the importance of mental illness as a cause of suffering to children. The prevention and after-care of mental illness, as well as arranging admission to hospital, are among the duties of the health department which more often has the first knowledge of mental illness and its effects upon a family. Mental health service workers are increasingly accepted by the public and patient, and relatives turn to them for advice and guidance with growing frequency. The Society considers that the mental health service will be involved in the future with family case work to a much greater extent than at present. (19) Prevention of Mental 1ll Health Local health authorities are actively concerning themselves with the provision of preventive mental services in the field of maternity and child welfare. The child guidance service, primarily conceived for the child of school age, has demonstrated how large a proportion of emotional difficulties arise in pre-scbool years, at a time when their cure is at once easier to effect and more certain of accomplishment. The importance of the early recognition of conditions which may cause behaviour disturbances and maladjustment is now being recognised. The clinical medical officer and the health visitor, in their daily contact with mothers in ante-natal child welfare centres, meet with these conditions repeatedly.
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The Society welcomes the growing interest of the maternity and child welfare services in the prevention and cure of early difficulties which are rooted in emotional causes, and urges an intensification of the training in this field which their staffs already undergo. The Society regards as highly important the closer integration of maternity and child welfare and child guidance services as being likely to prevent neglect and suffering in this and succeeding generations. (20) Housing The importance of satisfactory housing conditions and the devastating effects on the family of eviction are too well recognised to require emphasis. Health departments have rightly earned the confidence and support of housing authorities and housing committees, and their advice is generally sought when difficult decisions are to be made. Health departments often support and encourage those families whose rehousing has been effected and eviction prevented by their efforts. (21) Summary 1. The recommendations of the Joint Committee of the British Medical Association and the Magistrates' Association (pages 54-56) are, save for para. 15, endorsed by the Society. 2. Consideration is required of existing law in regard to mental cruelty, and, particularly, suffering and hardship occasioned by the illness or inadequacy of a parent in relation to the making of Fit Person Orders. 3. In matrimonial cases there should be full information bearing on the question of custody and the best interests of any children concerned. 4. The position of a wife who obtains the custody of her children requires consideration so that she may be protected against being rendered homeless. 5. There is a need for a variety .of social workers to assist families in difficulties. Their efforts should be co-ordinated rather than their number be reduced. Local authorities should be urged to overhaul and make effective their co-ordinating machinery wherever this is necessary. 6. Local authority powers to prevent the break-up of families and to rehabilitate should be clarified and extended so as to allow of assistance in the provision of essential furniture and equipment. Local authorities should devise, administrative arrangements, which while they best suit local needs, preserve the central role of the health departments in this field. 7. Public health departments should be regarded as agencies primarily concerned with the prevention of neglect and the break-up of families. Rehabilitation should be their aim where there has been failure to prevent. Their need of specialised assistance should be recognised and it should be obtained in co-operation with other agencies. Health departments should resume the care and supervision of families when the need for specialised assistance from outside agencies no longer exists. J. Stevenson Logan, Chairman, Children and Young Persons Acts Sub-committee. H. D. Chalke, Chairman, Executive Committee. Selwyn Selwyn-Clarke, Secretary, The Society of Medical Officers of Health, Tavistock House South, Tavistock Square, W.C.1.
19th March, 1957.