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What is child guidance?
PUBLIC HEALTH, July, 1950
WHAT IS CHILD GUIDANCE ? * By A. A. E. NEWTH, M.B., D.P.H.,
Senior School Medical Officer, City of Nottingham T h e Handicapped Pupils and School Health Service Regulations, 1945, require local education authorities to establish a School Health Service and to appoint school medical officers to look after the health and well-being of the children. This was not, of course, a new idea. School medical officers had been caring for the health and well-being of school children for many years. T h e service was established because it was found at the beginning of this century that children were not being cared for properly, and its history has been characterised by a widening of its interests as advances were made. Sir George Newman, the Chief Medical Officer of the then Board of Education, in one of his earlier reports foreshadowed an organic development of the service and its concern in child guidance is an example of this. T h e history of the child guidance movement was given in the " H e a l t h of the School Child " for 1939-45. It started with the work of Dr. William Healy on juvenile delinquents in Chicago, and spread rapidly throughout America, being introduced into England through the generosity of the Commonwealth Fund of America. Dr. Ralph Crowley, of the Board of Education, who took such a keen interest in the less fortunate children, visited America and, after carefully weighing up its merits, repeatedly recommended it to school medical officers in successive issues of the " Health of the School Child." It was taken up by Emmanuel Miller, William Moodie, and other doctors in connection with voluntary clinics, by Shrubshall and Letitia Fairfield, of the L.C.C., by Robert Hughes, S.M.O., of Stoke-on-Trent, and Auden, S.M.O., of Birmingham, and by certain mental hospital doctors such as Kimber and Evelyn Lucas. Local education authorities became interested to an increasing extent, and Circular 29 mentioned child guidance as one o f the several forms of treatment to be developed to implement the requirements of the Education Act, 1944. Some educational psychologists were interested, particularly Sir Cyril Burt, Prof. Cattell, Susan Isaac.s and Lucy Fildes, but the expansion of the work was due chiefly to the initiative of various medical men and women. It is not easy to define what is meant by child guidance. Earlier reports of the Child Guidance Council said that it was primarily to advise parents--but it is more than this. Others said that it was for the elucidation of behaviour p r o b l em s- - b u t many child guidance cases show no behaviour problems. " T h e Health of the School Child " for 1939--45 speaks of the child who is mentally disturbed or emotionally deranged. These phrases are not very satisfying. I myself like the term maladjusted. T h e tendency of a child to become maladjusted may be likened to that of a motor car engine. Certain kinds of engine may be designed for ordinary use by everyday owner-drivers; others for rough agricultural w o r k ; others again for high speed racing in the hands of skilled mechhnics. Cars of any one of these classes may leave the works in perfect adjustment but will vary in their tendency to get out of adjustment. A car badly designed and constructed from poor material will break down under ordinary conditions, while those of sturdy make may work well for a long time without needing much attention, provided they are not mishandled. There are some persons who seem inherently unable to manage any mechanical contrivance without damaging it. One thing is certain--the car will run inefficiently, it will be a nuisance to its driver and possibly a danger to others, and it will suffer serious and permanent damage unless the necessary adjustments are made. Some adjustments are easy to carry out, particularly if tackled in the early stages; others call for the skilled attention of an experienced technician. T h e harm that may be done by the amateur or semi-efficient mechanic, is incalculable. Children may become maladjusted to themselves, to their parents or guardians, to other children or to society. Gener# Presidential Address to the School Health Service Group, Society of Medical Officers of Health.
193 ally the child will be found to be maladjusted in more ways than one. T h e symptoms are often multiple and vary from time to time. T h e symptom complained of in the first instance may not be the one that is causing the greatest anxiety. For these reasons it is difficult to classify the reasons for which children are referred to a clinic, but the Child Guidance Council have suggested a classification which is useful, although of no great scientific value : CLASSIFICATIONOF PROBLEMS 1. Nervous Disorders : i. Fears--anxiety, phobias, timidity, oversensitivity. ii. Seclusiveness--unsociability, solitariness. iii. Depression--brooding, melancholy periods. iv. Excitability--over-activity. v. Apathyqlethargy, unresponsiveness, no interests. vi. Obsessions--rituals and compulsions. 2. Habit Disorders : i. Speech--stammering, speech defects, aphonia. ii. Sleep--night terrors, sleep-walking or talking. iii. Movement--twitching, tics, head-banging, nail-biting. iv. Feeding--food fads, nervous vomiting, putting things into mouth. v. Excretory---enuresis, faecal incontinence. vi. Nervous pains and paralysis--headaches, deafness, etc. vii. Fits--epilepsy, hysterical fits, loss of memory. viii. Physical allergic disorders, asthma. 3. Behaviour Disorders : i. Unmanageable--defiance, disobedience, refusal to go to work or school. ii. Temper. iii. Aggressivenessqbullying, destructiveness, cruelty. iv. Jealous behaviour. v. Demanding attention. vi. Stealing--begging. vii. Lying and romancing. viii. Truancy--wandering, staying out late. ix. Sex difficulty--masturbation, sex play, homosexuality. 4. Psychotic Behaviour--hallucinations, delusions, extreme withdrawal, bizarre symptoms, violence. 5. Educational and Vocational Difficulties : i. Backwardness--mental retardation, school failure. ii. Inability to concentrate--day-dreaming, inattention. iii. Inability to keep jobs. iv. Special disabilities--high-frequency deafness, etc. 6. For Special Examination : i. Psychological examinations. ii. Educational advice. iii. Vocational advice. iv. Court examinations. v. Admission to special homes or hostels. vi. Placement in foster homes. vii. Adoption. 7. Unclassified. T h e symptoms often bear no obvious relation to the cause of the upset and may give little indication of the seriousness of the trouble. T h e quiet model child may be the subject of deep-seated psychological disturbance, while another child showing distressing behaviour may be found to be suffering from only superficial disturbance. All children behave badly or get emotionally upset from time to time and the wise parent or teacher can generally deal with the trouble successfully by symptomatic treatment. Such cases should not get to the child guidance clinic. I t is only when the ordinary treatment is found to fail that the clinic need be consulted with the object of trying to find out the cause of maladjustment and to suggest a way of putting it right. T h e causes of maladjustment in children are innumerable, involving social, educational, psychological, medico-psychological and medical factors interwoven very closely. So complex are these factors that it is now accepted that the work must be undertaken by a team of workers, consisting of a psychiatrist, educational psychologist and psychiatric social worker. This is the essential foundation on which child guidance was built up in America, and although individual workers have had success by other methods of approach at times it can hardly be called child guidance.
194 Child guidance work having been started by medical pioneers in children's hospitals, general hospitals, mental hospitals, universities and the School Health Service, tended after 1936 or 1937 to be taken up more and more by education authorities through their school health services. T h e troubles with evacuated children and the distressing increase of juvenile delinquency gave an urge to the work although the difficulty of getting staff proved a severe handicap. The Faversham Report
T h e Feversham Report on the Voluntary Mental Hospital Services published in 1939, was drawn up by a well-balanced committee of persons qualified by experience to express levelheaded opinions. They advocated the appointment of educational psychologists by education authorities to advise upon backward children and difficult problems of behaviour and education. Suitable cases were to be referred to child guidance clinics for further investigation and advice. At the same time they recommended the appointment of a full- or parttime psychiatrist to whom special cases of mental defect or behaviour disorders might be referred. They considered that child guidance should be a normal service of an education authority but were insistent that the clinic should be properly staffed and should be under the charge of a psychiatrist. While they seem to have favoured the clinic being run in connection with a general hospital, they would not lay down any hard and fast rules, observing that in some districts a school clinic or welfare centre might meet all requirements. (In 1948, out of 96 clinics in England, excluding London, in one instance only the clinic was in connection with a university, one was. voluntary, eight were in connection with hospitals, and 86 were local authority or county council clinics.) T h e Feversham Report was followed in 1941 by the report of a committee of the B.M.A. advocating a mental health service in each authority for all mentally sick persons, the appendix containing a scheme for child guidance approved by the Child Guidance Council. In the Supplement of the B.M..7. for June 16th, 1945, there appeared the plans for a psychiatric service drawn up by a joint committee of the B.M.A., the Royal College of Physicians and the Royal Psychological Society. This committee on which the mental hospital services were strongly represented, recommended the establishment of mental health services which, with appropriato statutory powers, were to be responsible for all aspects of mental health work, including child guidance, all mentally defectives, adult and children, educable or ineducable, and the curable and incurable insane. This was given an excellent press in The Times of June 30th, 1945. On February 21st, 1946, Dr. Blacker published his book on " Neurosis and the Mental Health Services," with a foreword by Sir Wilson Jameson, urging the development of treatment for neurotics and borderline psychotics. Although evidence was not collected from child guidance clinics, there were some child guidance clinic personnel connected with the enquiry, and the author, a mental hospital physician, made certain recommendations as to child guidance work. Very briefly, these were to the effect that there should be child guidance centres under the education authorities, and child guidance or psychiatric clinics incorporated in the Health Service. The difference between the two types of set-ups lay in the latter being under the direction of a medical psychiatrist, whereas the former were to be under a non-medical psychologist. The Times of the same day had a long and important article by its medical correspondence warmly advocating the scheme ; the wording of the article almost suggested that it was already a fait accompli. The same idea was put forward by Sir Laurence Brock, Chairman of the Board of Control, in an article in the Lancet of March 6th, 1946, and received further support in 1947 in the Nuffield Provincial Hospitals' T r u s t Report in an appendix on the planning of hospital services in the Berks, Bucks and Oxon region. It was not surprising that in 1945 the Association of Education Committees, whose secretary was at one time a psychologist of note, published a report giving the plans of a child guidance service as part of the education service with the
PUBLIC HEALTH, July, 1950 educational psychologist as the key person. He or she was to have the organisation of this service and was to have on the staff a member of the school medical service and a medical psychiatrist. It should be observed, however, that in the previous year the Council of the B.M.A. had decided to oppose the principle of psychiatrists working in clinics under the direction of lay psychologists. (Supplement of the B.M.ff., May 13th, 1944.) T h e Society, it will be recalled, challenged this scheme of the A.E.C. very vigorously. It emphasised the " medicopsychological character of the large majority of child guidance cases in contrast to the educational. It feels that it would be as ill-advised to entrust this work and its organisation to an educational psychologist as it would be to entrust an orthopaedic scheme to a physical training inspector." The Lancet of December 6th, 1947, in a leading article, stated very clearly that the Child Guidance Council was opposed to the Blacker plan. ' " I n applying the ominous political device of partition (the scheme) depends for success on a mutual tolerance not always evident except where the working bond is close, and 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 modem psychiatric practice, retreats once more to his clinical castle." In July, 1948, Prof. Moncrieff, Secretary of the British Paediahic Association, and Dr. Soddy, Medical Director of the National Association for Mental Health, sent a letter to Directors of Education expressing concern at the organisation in some areas whereby a psychologist without medical qualifications could be entrusted with the ascertainment and in some cases even the diagnosis and treatment of disorders in childhood. Ministry of Education Circular 179
I n spite of these protests, the Ministry of Education in August, 1948, published its famous Circular 179, suggesting that the needs of most maladjusted children could be met by social and educational adjustments, and that consequently much of the child guidance work could be carried out in schools by educational psychologists and specially qualified social workers. Those children who were found to need psychiatric treatment should normally be referred to clinics which were to be provided in due course by the regional hospital boards, and which in some instances, were already available. At about the same time the Ministry of Health were advocating similar principles. Short-term cases were to be treated in child guidance centres of local education authorities and long-term cases in child psychiatric clinics of the regional hospital boards. T h e Council of the Group were alarmed at these suggestions. I n their experience, few cases responded to simple social and educational adjustments. They could not understand the ~distinction between long-term and short-term treatment cases ; children requiring educational treatment generally needed it for a long time, whereas some seriously disturbed cases might respond rapidly to suitable psychiatric treatment by a psychiatrist. I n any case, in child guidance work it was often impossible to distinguish between diagnosis and treatment, and attempts to separate the two would lead to a dichotomy which would destroy the whole basis of child guidance work. Sir Allen Daley led a deputation to the Ministry of Education, and we put our ease to Mr. Marris, the Under-secretary, Dr. Rees Thomas, of the Board of Control, Dr. Underwood and others. Our sincerity carried weight. We were told that the Ministry did not want to prescribe the precise set up of the child guidance eentres provided they were run on reasonable lines, and Dr. Rees Thomas said that psychiatric treatment clinics might be set up within an education authority's child guidance centre, the services of the psychiatrist being provided by the regional hospital board. Mr. Marris asked that we should try out the scheme for six months and then come back to him. This was in October, 1948. It is difficult to make out what is happening in the child guidance world. The Child Guidance Council arranged an
PUBLIC HEALTH, July, 1950 Interclinic Conference in D e c e m b e r last in an attempt to learn how things were going. T h e report has not yet been published, but I was left with the impression that workers had not been u n d u l y disturbed, although there were certain aspects which were causing dissatisfaction. O n e of the m o s t striking points that arose was, although that the large majority of the representatives were lay persons, opinion was practically unanimous in wanting the work to be u n d e r the control of doctors. Form 2 H.P. T h i s came as somewhat of a surprise to some of us because there had been reason to fear that we doctors had been losing the confidence of laymen in respect of psychological work. T h e A.E.C. scheme tried to delegate doctors to the position of assistants to educational psychologists. Circular 146 of the M i n i s t r y of Education, published in June, 1947, gave timely warning about the selection of school medical officers for duties in connection with educationally subnormal children, but it provoked educational psychologists to claim greater share in the completion of F o r m 2 H.P., the suggestion being that they were more capable of doing this than medical officers, w i t h the result that a new f o r m had to be drawn up. A t the British Association meeting in 1948 Prof. Rex K n i g h t claimed that Burt's Y o u n g D e l i n q u e n t was the fons et origo of child guidance in this country, and he omitted to mention the medical pioneers. Prof. Valentine took the opportunity of his presidential address to the British Medico-Psychological Society (British ffournal of Educational Psychology, N o v e m b e r , 1948) to attack doctors as advisers in children's psychology. Sir Cyril Burt, in the issue of the same journal of February, 1949, laid about him with even greater vigour, attacking not only school medical officers, but even F r e u d h i m s e l f - - a remarkable article well worth reading, but a surprising one from a psychologist of the standing of the author. It m u s t be acknowledged that the ordinary curriculum of the medical student does not encourage great interest in psychiatry or psychology, a n d m a n y doctors start their careers with a greater faith in the physical than in the psychological aspects of medicine. S o m e retain this attitude and not a few doctors look u p o n child guidance with suspicion and even tend to build up a sort of cordon sanitaire round the psychiatrist. At the Interclinic Conference already referred to, some of the delegates alleged with some bitterness that certain administrative school medical officers assumed the responsibility of diverting cases from the child guidance clinic without taking any intimate part in the work of the clinic. The Child Guidance Team Nevertheless, there is no doubt that the medical training affords an essential foundation u p o n which further education in psychological medicine can be built if the doctor happens to be attracted to this branch of his profession. N o one w o u l d entrust the medico-psychological problems of adults to anyone b u t a medical man, and although the psychological difficulties of children m a y differ in certain important respects f r o m those of adults, no one with an intimate knowledge of child guidance w o r k would entrust the supervision of the eases to other than a medical man. O n the other hand, a training in psychological medicine does not necessarily fit a doctor to understand the maladjustm e n t s of children, and it is essential that the child guidance doctor should have special training in child psychiatry. I n addition, he should have a lively interest in the w o r k of the schools and of the school health service. I n order to conserve the time of the psychiatrist for his technical work, a school medical officer of senior rank w i t h a special interest in child guidance m i g h t well be entrusted with the administration of the clinic. H e should also act as physician to the centre. I n this way it w o u l d be possible to ensure the necessary liaison between the physical and psychological aspects of the work. T h e other m e m b e r s of the team, the educational psychologist and the psychiatric social worker, will fall naturally into their places, s u p p l y i n g their own highly valuable technical help to the team w h i c h is the true basis of child guidance work. Each
195 m e m b e r of the team, if fully trained, will have sufficient faith in the importance of his own line of approach to urge h i m to follow it faithfully and not to impinge on the w o r k of his colleagues, although to a varying degree according to the nature of the particular case u n d e r discussion any one m e m b e r m a y take a m o r e p r e d o m i n a n t place. A team m u s t have a leader and it will be for the psychiatrist, after considering the various reports in consultation w i t h his colleagues at the case conference, to give cohesion to the various reports. H e should be able to c o m m a n d their confidence while at the same time he should be willing to hand over to t h e m for further action such aspects of the work that m a y seem advisable. With regard to the qualifications of the various m e m b e r s of the team, it is obvious that they should have had adequate training and experience. F o r some m o n t h s m y authority has been trying to get an educational psychologist to replace one who on marriage was unable to give enough time to the work, and I have been amazed at the n u m b e r of people w h o consider themselves capable of undertaking this branch of the work although not possessing suitable qualifications or experience. It is to be h o p e d that education authorities will not be tempted to make unsuitable appointments in their anxiety t o complete their staffs and that each professional body concerned will do its best to maintain a high standard of efficiency amongst its m e m b e r s so that its work does not fall into disrepute. F r o m time to time one reads of comparisons b e i n g m a d e between child guidance clinics run by the school health service, by childrens' hospitals or the childrens' departments of general hospitals or by mental hospitals. Some years ago the Child Guidance Council was strongly in favour of the voluntary clinics and opposed to the idea of clinics run by local education authorities, but by 1938 t h e y had modified its ideas very considerably and, as already mentioned, in 1947 it expressed itself definitely in favour of the clinic run by the school health service of the L.E.A. T h i s is gratifying to the school medical officer, and he could adduce m a n y reasons for showing the wisdom of the change of policy. Nevertheless, w h e n he attends interclinic conferences he finds that workers in other types of clinics are equally convinced of the soundness of their own organisations and are sceptical about the efficiency of others. N o doubt the truth is that different types of clinics have somewhat different aims and are p r o b a b l y dealing with a somewhat different type of maladjusted children. It is difficult to prove this statistically, because, unfortunately, various clinics report on their cases u n d e r differing classifications, but T a b l e s I, I I and I I I , drawn up f r o m figures given in reports of certain clinics, support this view. A - - L.E.A. clinic of a large county borough in the Midlands. B - - L.E.A. clinic of a county council ba the Midlands. (A and B have the same psychiatrist although they are run quite separately.) C - - Clinic of a mental health authority of a large county borougla. D - - Clinic of a large children's hospital in London. E - - L.E.A. clinic of a large C.B. in the Midlands. In 1941 it was under a part-time psychiatrist. There was a change in the organisation between then and 1943 when it was under the educational psychologist. F - - Clinic of the children's department of a county hospital TABLE I CLASSIFICATION OF CASES. 1948
Nature of cases
A
B
C
D
Nervous ......... Habit . . . . . . . . . . . . Behaviour ......... Psychotic behaviour . . . . . . Educational and vocational ... Special : Court cases, etc . . . . Other . . . . . . . . . . . .
25"4 29.4 29.7 1.0 6.0 7.3 1.0
19.3 21.0 26.1 -11.8 21-8 --
11.0 20.4 24.7 0.3 10-7 32.5 0.3
7.2 39.9 23.5 2,0 20.8 3.4 3.3
Number of cases
299
238
308
446
......
PUBLIC HEALTH, July, 1950
196 In A, the children's hospital has its own psychiatrist. Also, the educational and vocational cases do not include 275 eases examined by the educational psychologist--secondary school placements, nonreaders for educational therapy, and partially-deaf and partiallysighted pupils. TABLE II CLASSIFICATION OF CASES IN E
Nature of cases Nervous ......... Habit . . . ..... . . . . Behaviour and court cases Intellectual . . . . . . . . . Other . . . . . . . . . . . . N u m b e r of cases
...
1941
1943
1948
13.8 9.0 49.5 27.7 0.0
7.3 3.7 30.3 55.5 3.1
12.6 7.4 36-1 43.5 0.4
99
193
269
......
" Intellectual difficulties " comprise educational retardation, special disabilities and educational guidance. T h e shifting of interest to the intellectual when the clinic came under the organisation of the educational psychologist is very clear. TABLE I I I SOURCES OF REFERRAL. 1948
Referred from
A
B
C
F
School . . . . . . . . . . . . Parent . . . . . . . . . . . . School M.O . . . . . . . . . . Private doctor ...... Hospital ......... Clinic staff ... Probation officer and"S.A.l)i Others . . . . . . . . . . . .
31.0 9"0 21-0 13.0 * 7"0 12.0 7.0
14-7 7.5 27.8 11-3 --21-4 17.2
14.6 13.6 14-6 12.0 2-6 6"5 33-4 2-6
15.0 --64.0 17"0
N u m b e r of cases
299
238
308
100
......
4.0 --
* Local children's hospital has its own psychiatrist. It is known that in A and B the referrals classed under " school " came often in the first place from the parent who had asked the head teacher to refer the case to the child guidance clinics. With regard to court cases, in area A there is close co-operation with the probation officer, the S.A.D. and the children's officer ; information is given about a large n u m b e r of cases before the case comes into court and full child guidance examination is done only when essential. T h e r e is n o d o u b t t h a t m a n y of t h e difficulties m e t w i t h in l a t e r c h i l d h o o d c a n b e traced b a c k to causative factors d a t i n g f r o m v e r y early years. M e l a n i e K l e i n has s h o w n t h a t it is possible to a p p l y psychoanalytic m e t h o d s to v e r y y o u n g children, a n d Bowlby, in his b o o k " F o r t y - F o u r J u v e n i l e T h i e v e s , " lays stress o n affectionless c h i l d r e n a n d claims t h a t t h e i r c o n d i t i o n can b e d i a g n o s e d at t h r e e years of age. I t is t e m p t i n g , therefore, to envy t h e c h i l d r e n ' s hospital w h i c h seems to get h o l d of cases m u c h earlier t h a n t h e school h e a l t h service clinic as is s h o w n in T a b l e I V : TABLE i V PERCENTAGE OF CASES IN AcE GROUPS (Children up to 12 years of age only) Clinic C.B. school health clinic. A ... E ... Children's Hospital, Lond. o n . D
U n d e r 2-4 5-6 7-12 Cases 2years years years years --4"0
9.0 5.0 34.0
13.5 19.0 23.0
77.5 76.0 39,0
250 216 ?
T a b l e s I a n d I I have s h o a l s t h a t t h e c h i l d r e n ' s h o s p i t a l deals w i t h a h i g h e r p r o p o r t i o n of h a b i t cases as m i g h t b e expected. W e do n o t k n o w w h e t h e r t h e t r e a t m e n t of t h e s e h a b i t disorders results in less b e h a v i o u r t r o u b l e s in later years.
T h o s e of u s w h o h a v e b e e n a c c u s t o m e d to deal w i t h s o m e . w h a t older c h i l d r e n m a y w o n d e r h o w m u c h c a n b e d o n e at s u c h early ages unless t h e b e h a v i o u r is causing great anxiety or unless t h e h o m e factors are s u c h as to b e a m e n a b l e to adjustm e n t . M y o w n e x p e r i e n c e has b e e n t h a t n o t a few of the v e r y y o u n g ones r e f e r r e d t o h a v e b e e n a l m o s t certainly of low intelligence, while o t h e r s c o u l d b e dealt w i t h satisfactorily b y t h e simple e x p e d i e n t of a d m i s s i o n to a n u r s e r y class. S o m e , however, have b e e n i m p o r t a n t cases a n d t h e r e is n o d o u b t t h a t a l t h o u g h we m a y feel t h a t t h e r e is p l e n t y of m a t e r i a l in t h e schools to keep t h e clinic staff busy, we s h o u l d b e always p r e p a r e d to give help to c h i l d r e n of all ages w h e n called u p o n to do so. T h e E d u c a t i o n A c t gives power, in fact a duty, to deal w i t h m a l a d j u s t e d c h i l d r e n w h e t h e r at school or n o t f r o m t h e age of two years. Delinquents S o m e w h a t at t h e o t h e r e n d of t h e scale are t h e d e l i n q u e n t s . I t has b e e n f r e q u e n t l y r e c o m m e n d e d t h a t all child d e l i n q u e n t s s h o u l d b e s u b m i t t e d to child g u i d a n c e e x a m i n a t i o n , a n d it m a y b e p l e a s a n t to p r o b a t i o n a n d c h i l d r e n ' s officers to b e able to p r e s e n t a full r e p o r t f r o m a child g u i d a n c e clinic. B u t it is t i m e - c o n s u m i n g w o r k a n d unless we feel t h a t we h a v e useful advice to give we m a y b e wise to c o n s e r v e o u r limited s t r e n g t h to m o r e p r o m i s i n g work. I t is n o t e v e r y m a g i s t r a t e w h o wishes to h e a r t h e views of t h e p s y c h i a t r i s t a n d his colleagues, b u t I h a v e f o u n d it to b e acceptable w h e n it is g i v e n c i r c u m s p e c t l y - - c l e a r l y a n d authoritatively, w i t h all deference to t h e prestige of t h e court. I t is i m p o r t a n t t h a t p r o b a t i o n officers a n d c h i l d r e n ' s officers s h o u l d u n d e r s t a n d t h e a p p r o a c h of t h e child g u i d a n c e clinic so t h a t m a g i s t r a t e s are advised b y t h e m n o t to p u t u p o n t h e clinic impossible tasks s u c h as t h e t r e a t m e n t of q u i t e u n s u i t a b l e cases or m a k i n g t r e a t m e n t at a clinic a c o n d i t i o n of p r o b a t i o n . I d o n o t p r o p o s e to say m u c h a b o u t t r e a t m e n t because this I believe to b e h i g h l y t e c h n i c a l w o r k to b e a r r a n g e d or carried o u t b y t h e p s y c h i a t r i s t himself. I f t r e a t m e n t of t h e child is e n t r u s t e d to a lay p s y c h o t h e r a p i s t t h e latter s h o u l d b e allowed to carry on w i t h o u t i n t e r f e r e n c e b u t w i t h t h e k n o w l e d g e t h a t w h e n u n u s u a l difficulty is e x p e r i e n c e d the psychiatrist is r e a d y to give advice. T r e a t m e n t ~ H o m e or Hospital ? W h e n e v e r possible t r e a t m e n t s h o u l d b e carried o u t w h i l e t h e c h i l d is living i n his o w n h o m e , b u t t h e r e are certain cases in w h i c h t r a n s f e r to a hostel is essential. T h i s q u e s t i o n of hostel t r e a t m e n t is a big one a n d I shall confine m y s e l f to o b s e r v i n g t h a t residence i n a hostel is a f o r m of medical t r e a t m e n t to b e r e s e r v e d for those w h o are definitely in n e e d of it a n d able to benefit f r o m it. A d m i s s i o n s a n d discharges a n d the c o n d u c t of t h e hostel are m e d i c a l m a t t e r s over w h i c h t h e p s y c h i a t r i s t s h o u l d h a v e clear control, s u p p o r t e d b y t h e school m e d i c a l officer acting as a liaison w i t h t h e lay e d u c a t i o n officer w h o is u l t i m a t e l y r e s p o n s i b l e to t h e authority. A firm s t a n d s h o u l d b e t a k e n against t h e hostel b e i n g u s e d as a m e r e d u m p ing g r o u n d for c h i l d r e n w h o are a n u i s a n c e elsewhere or as a hotel for t h e t e m p o r a r y a c c o m m o d a t i o n of n o r m a l o r delinq u e n t c h i l d r e n . T h e flow of a d m i s s i o n s s h o u l d b e r e g u l a t e d a c c o r d i n g to t h e capabilities of t h e staff to a b s o r b t h e m , a n d c o m m i t t e e s s h o u l d n o t interfere w h e n , owing to shortage of staff or o t h e r difficulties, t h e n u m b e r of cases has to b e c u t d o w n r e s u l t i n g in an a l a r m i n g b u t u n a v o i d a b l e excess of o v e r h e a d charges. T h e r u s h i n g of fences to please c o m m i t t e e s m a y lead to c h a o s a n d m a y p r o v e as h a r m f u l as t h e a d m i s s i o n of a case of infectious disease to t h e o r d i n a r y w a r d of a hospital. I h a v e h a d n o e x p e r i e n c e of day schools or classes for m a l a d j u s t e d c h i l d r e n , b u t h a v e f o u n d c e r t a i n selected cases t o do well in s p e c i a l b o a r d i n g schools for difficult children. I t s h o u l d b e p a r t of t h e o r d i n a r y w o r k of t h e authority, p r e f e r a b l y w i t h t h e close c o - o p e r a t i o n of t h e school m e d i c a l officer, to see t h a t suitable e d u c a t i o n a l p l a c e m e n t is effected f o r e v e r y child. T h o s e w i t h severe e d u c a t i o n a l s u b n o r m a l i t y s h o u l d have b e e n t r a n s f e r r e d to day or residential special school a n d s h o u l d n o t r e a c h t h e c h i l d g u i d a n c e clinic. Less seriously r e t a r d e d c h i l d r e n s h o u l d already h a v e b e e n p o t in
PUBLIC HEALTH, July, 1950 'special classes if of a p p r o p r i a t e ages. T h e r e m a y be, h o w e v e r , a c e r t a i n n u m b e r of i n t e l l i g e n t c h i l d r e n w i t h specific e d u c a tional difficulties for w h o m e d u c a t i o n a l t h e r a p y w i t h o r w i t h o u t o t h e r p s y c h o t h e r a p e u t i c t r e a t m e n t m a y b e g i v e n in t h e child g u i d a n c e clinic or i n o t h e r c e n t r e s t h r o u g h o u t t h e area. B y s u c h m e a n s t h e e d u c a t i o n a l psychologist m a y give i n v a l u able h e l p to m a n y c h i l d r e n , b u t i n m y e x p e r i e n c e t h e t r a n s f e r of m a l a d j u s t e d c h i l d r e n f r o m o n e school to a n o t h e r b e c a u s e of alleged difficulties w i t h t h e staff or o t h e r c h i l d r e n h a s b e e n generally e m b a r r a s s i n g a n d s e l d o m effective. T h e p s y c h i a t r i c social w o r k e r can o f t e n give t h e m o s t v a l u able g u i d a n c e to t h e p a r e n t w h i c h m a y alter t h e w h o l e aspect o f t h e case, b u t too often little c a n b e d o n e e x c e p t to s u p p o r t t h e p a r e n t t h r o u g h difficult times. S o m e p a r e n t s benefit b y i n d i v i d u a l h e l p a n d o t h e r s b y g r o u p discussions d u r i n g w h i c h t h e p a r e n t s s e e m to h e l p one a n o t h e r w i t h o n l y t h e m o s t s u p e r ficial g u i d a n c e a n d f r o m t h e p s y c h i a t r i c social worker. P a t e n t l y n e u r o t i c or b o r d e r l i n e p s y c h o t i c p a r e n t s s h o u l d b e r e f e r r e d to t h e m e n t a l hospital p h y s i c i a n w i t h t h e c o n c u r r e n c e of t h e p r i v a t e doctor. T h e r e m a y b e m a n y ways o f t r e a t i n g m a l a d j u s t e d c h i l d r e n , b u t n o t all are a c c e p t e d b y t h e p a r e n t s or c h i l d r e n a n d in a n y case o w i n g to shortage of t r a i n e d workers t h e waiting lists s e e m always hopelessly long. F o r t u n a t e l y , n a t u r e is often k i n d to us, a n d it is f o u n d t h a t a n u m b e r of the cases settle d o w n w i t h o u t a n y v e r y special t r e a t m e n t . I t is s o m e t i m e s difficult to u n d e r s t a n d h o w this occurs, b u t p e r h a p s it is t h a t we h a v e p r e s e n t e d to t h e c h i l d t h e p a r e n t a n d t h e t e a c h e r a different aspect of t h e case a n d t h e y h a v e f o u n d for t h e m s e l v e s a way of tackling t h e difficulty. N o p a p e r o n child g u i d a n c e s h o u l d b e c o m p l e t e d w i t h o u t p a y i n g a t r i b u t e to t h e teachers. T h e i r influence for good is e n o r m o u s , s e c o n d only to t h a t of t h e m o t h e r . B u t t h e y w o r k u n d e r v e r y different c o n d i t i o n s w i t h t h e i r large classes a n d necessarily pedagogic a p p r o a c h . I t w o u l d b e n o m o r e possible ~ir desirable for teachers to deal w i t h a case o n c h i l d g u i d a n c e n e s t h a n it w o u l d b e for a m e m b e r of t h e child g u i d a n c e staff to take a class in school, b u t close c o - o p e r a t i o n of t h e child g u i d a n c e w o r k e r w i t h t h e t e a c h e r will r e s u l t in t h e g r e a t e s t benefit to t h e m o t h e r a n d child. T h e p r i v a t e d o c t o r is u n f o r t u n a t e l y too o f t e n so p r e o c c u p i e d w i t h t h e physical t r o u b l e s of his p a t i e n t s t h a t he has little t i m e to go into t h e psychological difficulties of t h e family. B u t h e is g e n e r a l l y well aware of t h e m a n d possesses a m o r e i n t i m a t e k n o w l e d g e of f a m i l y c i r c u m s t a n c e s t h a n t h e c h i l d g u i d a n c e worker, a n d I h a v e f o u n d h i m to be m o s t c o - o p e r a t i v e w h e n h e realises w h a t we are t r y i n g to do. U n l e s s for a n y r e a s o n t h e p a r e n t expressively forbids t h e child g u i d a n c e staff to c o m m u n i c a t e w i t h t h e p r i v a t e doctor, I c o n s i d e r it is m y d u t y to let h i m have a r e p o r t o n t h e case w h e t h e r h e has r e f e r r e d to it or n o t . C h i l d g u i d a n c e w o r k is expensive a n d it is n o t u n r e a s o n a b l e for c o m m i t t e e s to ask occasionally w h e t h e r it is w o r t h while. I d o u b t if it is possible to s h o w t h e results of t h e work statistically. I a m n o t sure e v e n w h e t h e r it is wise to q u o t e the occasional d r a m a t i c a l l y successful case. Personally, w h e n t h u s c h a l l e n g e d , I q u o t e s o m e p a r t i c u l a r l y difficult a n d p a t h e t i c case a n d ask w h a t alternative t r e a t m e n t is possible. T h i s will g e n e r a l l y result in t h e s o u n d c o m m o m s e n s e of t h e c o m m i t t e e o v e r r i d i n g q u e r r u l o u s criticism. Under no circumstances s h o u l d we b e t e m p t e d to p r o d u c e o v e r - o p t i m i s t i c r e p o r t s w h i c h m a y b e m o s t misleading. Conelusioa
I n conclusion, I w o u l d r e m i n d you again of o u r d u t y to to h e l p t h e e d u c a t i o n a u t h o r i t y to care for t h e h e a l t h a n d wellb e i n g of t h e c h i l d r e n . T h e school h e a l t h service can n o m o r e escape its obligations t o w a r d s psychological h e a l t h t h a n it can towards physical health, i t is difficult w o r k w i t h far too m a n y failures a n d too few c o m p l e t e successes, b u t it is i n d i s p e n s a b l e a n d calls for all t h e skill a n d a c u m e n w h i c h t h e s c h o o l m e d i c a l Officer s h o u l d possess. T o b e effective we m u s t m a i n rain a k e e n a n d b a l a n c e d o u t l o o k a n d t h u s keep this n e w activity at a h i g h level a n d e n s u r e t h e greatest assistance to the c h i l d r e n .
197 OBITUARY ROBERT MENZIES GALLOWAY, M.D. (RDIN.), D.P.H.
W e announce with deep regret that Dr. R. M. Galloway, Medical Officer of Health of the County Borough of BoRon since 1932, died at the Townleys Hospital on Monday, June 5th, 1950, at the early age of 51, after a long illness from which it was recently hoped that he was recovering. W e are indebted to Drs. J o h n Yule and V. T . Thierens, and Mr. H. Moorhouse, his chief clerk, for the following tribute : Born in Birkenhead, he received his early education in England but went to E d i n b u r g h for his medical education, whence he graduated with honours in 1020, after a distinguished academic career interrupted by service as a surgeon probationer in the First World War. He spent his first five post-graduate years in various hospital appointments and thus laid a solid foundation for his future career. He took his D.P.H. in Manchester in 1923, and two years later proceeded to his M.D. with commendation at Edinburgh. Possessed of a broad humanitarian outlook, it was not surprising that Galloway should devote himself to Public Health. His apprenticeship in that service was by way of assistant posts in BoRon and with the Lancashire County Council under two pioneers, the late Paget Moffat and Butterworth. In 1929 he became Medical Officer of Health of Dewsbury, and at the commencement of 1932 proceeded to BoRon as medical officer of health. H e was a sound doctor and at the same time an administrator of no mean ability and acumen. For these reasons, quite apart from his worth as a man, he was held in the highest esteem not only by his authority b u t also by his colleagues and those members of the Public Health Service who were privileged to enjoy his friendship. His fondness for children and young people found expression in his work for the Bolton Lads' Club, of which he was a m e m b e r of the committee and honorary medical advisor. He had received many honours in Public Health. H e was a Fellow and Examiner of the Royal Sanitary Institute, of which body he was also a M e m b e r of the Council. He was a Fellow of the Society of Medical Officers of Health and had been President of the North-Western Branch. Only last year, as President of the County Borough Group, he met his fellow members in a delightful and memorable week-end at Windermere. As recently as 1948 he was appointed Lecturer in Public Health at Manchester University. T h e influence of his education in Scotland, where he spent many of his early holidays, was reflected in a pawky yet kindly and whimsical humour. As a raconteur, he was in great demand. His intimate knowledge and understanding of his fellow men could be expressed with equal fluency in the Lancashire dialect, broad Scots, Welsh or even Irish. Both as a m a n and as an outstanding medical officer of health, he will be mourned by all, particularly so by his widow and four children, to w h o m our deepest sympathy goes out in their grievous loss. His elder daughter is due to qualify soon at Edinburgh while his elder son is in his second year at Cambridge. We know that it would have brought great joy and pride had he b e e n ' p e r m i t t e d to see two of his children at least in the profession to which he had devoted his life. It was not to be. He has passed beyond our ken to the bourne from which no traveller returns, b u t we shall ever treasure his memory. Another friend writes : - " As one of the Society's deputation to the Ministry of Health which led to the ultimate passing of the Nurseries and ChildMinders Regulation Act, 1048, I was particularly impressed by the humane, forceful yet courteous way in which Galloway made the case for some power of control over the private enterprise nurseries being r u n by industry, especially in this area, sometimes to the detriment of the children. In doing so he seemed to me to show the very qualities that a medical officer of health should possess---a sense of proportion tempered with vigilance for the health of his population." BENJAMIN ALFRED PETERS~ ]~.A.j M.D.~ CANTAB.~D.P.H.
The death of Dr. B. A. Peters was briefly reported in our last issue. He was born in 1885 a n d after graduating M.B., Ch.B., Cambridge, in 1910, he was appointed R.M.O. to Park Hill City Hospital, Liverpool. After service in the R.A.M.C. in the first war he joined the staff of H a m Green Hospital, Bristol, where he spent 28 years of his professional life and built up a national reputation in fevers. He was awarded the Welch Prize of the Society for the most original contribution to meetings of Branches in the session 1939-40, viz., his address " Some Unproven Assumptions in Epidemiology" published in Public Health, July, 1949, p. 215. His study of crossinfection over 40 years, which appeared in our contemporary T h e Medical OB~j~cer in 1946, was another typical contribution from his experience. He was a Fellow of the Society from 1911 and a well-
WHAT IS CHILD GUIDANCE ? * By A. A. E. NEWTH, M.B., D.P.H.,
Senior School Medical Officer, City of Nottingham T h e Handicapped Pupils and School Health Service Regulations, 1945, require local education authorities to establish a School Health Service and to appoint school medical officers to look after the health and well-being of the children. This was not, of course, a new idea. School medical officers had been caring for the health and well-being of school children for many years. T h e service was established because it was found at the beginning of this century that children were not being cared for properly, and its history has been characterised by a widening of its interests as advances were made. Sir George Newman, the Chief Medical Officer of the then Board of Education, in one of his earlier reports foreshadowed an organic development of the service and its concern in child guidance is an example of this. T h e history of the child guidance movement was given in the " H e a l t h of the School Child " for 1939-45. It started with the work of Dr. William Healy on juvenile delinquents in Chicago, and spread rapidly throughout America, being introduced into England through the generosity of the Commonwealth Fund of America. Dr. Ralph Crowley, of the Board of Education, who took such a keen interest in the less fortunate children, visited America and, after carefully weighing up its merits, repeatedly recommended it to school medical officers in successive issues of the " Health of the School Child." It was taken up by Emmanuel Miller, William Moodie, and other doctors in connection with voluntary clinics, by Shrubshall and Letitia Fairfield, of the L.C.C., by Robert Hughes, S.M.O., of Stoke-on-Trent, and Auden, S.M.O., of Birmingham, and by certain mental hospital doctors such as Kimber and Evelyn Lucas. Local education authorities became interested to an increasing extent, and Circular 29 mentioned child guidance as one o f the several forms of treatment to be developed to implement the requirements of the Education Act, 1944. Some educational psychologists were interested, particularly Sir Cyril Burt, Prof. Cattell, Susan Isaac.s and Lucy Fildes, but the expansion of the work was due chiefly to the initiative of various medical men and women. It is not easy to define what is meant by child guidance. Earlier reports of the Child Guidance Council said that it was primarily to advise parents--but it is more than this. Others said that it was for the elucidation of behaviour p r o b l em s- - b u t many child guidance cases show no behaviour problems. " T h e Health of the School Child " for 1939--45 speaks of the child who is mentally disturbed or emotionally deranged. These phrases are not very satisfying. I myself like the term maladjusted. T h e tendency of a child to become maladjusted may be likened to that of a motor car engine. Certain kinds of engine may be designed for ordinary use by everyday owner-drivers; others for rough agricultural w o r k ; others again for high speed racing in the hands of skilled mechhnics. Cars of any one of these classes may leave the works in perfect adjustment but will vary in their tendency to get out of adjustment. A car badly designed and constructed from poor material will break down under ordinary conditions, while those of sturdy make may work well for a long time without needing much attention, provided they are not mishandled. There are some persons who seem inherently unable to manage any mechanical contrivance without damaging it. One thing is certain--the car will run inefficiently, it will be a nuisance to its driver and possibly a danger to others, and it will suffer serious and permanent damage unless the necessary adjustments are made. Some adjustments are easy to carry out, particularly if tackled in the early stages; others call for the skilled attention of an experienced technician. T h e harm that may be done by the amateur or semi-efficient mechanic, is incalculable. Children may become maladjusted to themselves, to their parents or guardians, to other children or to society. Gener# Presidential Address to the School Health Service Group, Society of Medical Officers of Health.
193 ally the child will be found to be maladjusted in more ways than one. T h e symptoms are often multiple and vary from time to time. T h e symptom complained of in the first instance may not be the one that is causing the greatest anxiety. For these reasons it is difficult to classify the reasons for which children are referred to a clinic, but the Child Guidance Council have suggested a classification which is useful, although of no great scientific value : CLASSIFICATIONOF PROBLEMS 1. Nervous Disorders : i. Fears--anxiety, phobias, timidity, oversensitivity. ii. Seclusiveness--unsociability, solitariness. iii. Depression--brooding, melancholy periods. iv. Excitability--over-activity. v. Apathyqlethargy, unresponsiveness, no interests. vi. Obsessions--rituals and compulsions. 2. Habit Disorders : i. Speech--stammering, speech defects, aphonia. ii. Sleep--night terrors, sleep-walking or talking. iii. Movement--twitching, tics, head-banging, nail-biting. iv. Feeding--food fads, nervous vomiting, putting things into mouth. v. Excretory---enuresis, faecal incontinence. vi. Nervous pains and paralysis--headaches, deafness, etc. vii. Fits--epilepsy, hysterical fits, loss of memory. viii. Physical allergic disorders, asthma. 3. Behaviour Disorders : i. Unmanageable--defiance, disobedience, refusal to go to work or school. ii. Temper. iii. Aggressivenessqbullying, destructiveness, cruelty. iv. Jealous behaviour. v. Demanding attention. vi. Stealing--begging. vii. Lying and romancing. viii. Truancy--wandering, staying out late. ix. Sex difficulty--masturbation, sex play, homosexuality. 4. Psychotic Behaviour--hallucinations, delusions, extreme withdrawal, bizarre symptoms, violence. 5. Educational and Vocational Difficulties : i. Backwardness--mental retardation, school failure. ii. Inability to concentrate--day-dreaming, inattention. iii. Inability to keep jobs. iv. Special disabilities--high-frequency deafness, etc. 6. For Special Examination : i. Psychological examinations. ii. Educational advice. iii. Vocational advice. iv. Court examinations. v. Admission to special homes or hostels. vi. Placement in foster homes. vii. Adoption. 7. Unclassified. T h e symptoms often bear no obvious relation to the cause of the upset and may give little indication of the seriousness of the trouble. T h e quiet model child may be the subject of deep-seated psychological disturbance, while another child showing distressing behaviour may be found to be suffering from only superficial disturbance. All children behave badly or get emotionally upset from time to time and the wise parent or teacher can generally deal with the trouble successfully by symptomatic treatment. Such cases should not get to the child guidance clinic. I t is only when the ordinary treatment is found to fail that the clinic need be consulted with the object of trying to find out the cause of maladjustment and to suggest a way of putting it right. T h e causes of maladjustment in children are innumerable, involving social, educational, psychological, medico-psychological and medical factors interwoven very closely. So complex are these factors that it is now accepted that the work must be undertaken by a team of workers, consisting of a psychiatrist, educational psychologist and psychiatric social worker. This is the essential foundation on which child guidance was built up in America, and although individual workers have had success by other methods of approach at times it can hardly be called child guidance.
194 Child guidance work having been started by medical pioneers in children's hospitals, general hospitals, mental hospitals, universities and the School Health Service, tended after 1936 or 1937 to be taken up more and more by education authorities through their school health services. T h e troubles with evacuated children and the distressing increase of juvenile delinquency gave an urge to the work although the difficulty of getting staff proved a severe handicap. The Faversham Report
T h e Feversham Report on the Voluntary Mental Hospital Services published in 1939, was drawn up by a well-balanced committee of persons qualified by experience to express levelheaded opinions. They advocated the appointment of educational psychologists by education authorities to advise upon backward children and difficult problems of behaviour and education. Suitable cases were to be referred to child guidance clinics for further investigation and advice. At the same time they recommended the appointment of a full- or parttime psychiatrist to whom special cases of mental defect or behaviour disorders might be referred. They considered that child guidance should be a normal service of an education authority but were insistent that the clinic should be properly staffed and should be under the charge of a psychiatrist. While they seem to have favoured the clinic being run in connection with a general hospital, they would not lay down any hard and fast rules, observing that in some districts a school clinic or welfare centre might meet all requirements. (In 1948, out of 96 clinics in England, excluding London, in one instance only the clinic was in connection with a university, one was. voluntary, eight were in connection with hospitals, and 86 were local authority or county council clinics.) T h e Feversham Report was followed in 1941 by the report of a committee of the B.M.A. advocating a mental health service in each authority for all mentally sick persons, the appendix containing a scheme for child guidance approved by the Child Guidance Council. In the Supplement of the B.M..7. for June 16th, 1945, there appeared the plans for a psychiatric service drawn up by a joint committee of the B.M.A., the Royal College of Physicians and the Royal Psychological Society. This committee on which the mental hospital services were strongly represented, recommended the establishment of mental health services which, with appropriato statutory powers, were to be responsible for all aspects of mental health work, including child guidance, all mentally defectives, adult and children, educable or ineducable, and the curable and incurable insane. This was given an excellent press in The Times of June 30th, 1945. On February 21st, 1946, Dr. Blacker published his book on " Neurosis and the Mental Health Services," with a foreword by Sir Wilson Jameson, urging the development of treatment for neurotics and borderline psychotics. Although evidence was not collected from child guidance clinics, there were some child guidance clinic personnel connected with the enquiry, and the author, a mental hospital physician, made certain recommendations as to child guidance work. Very briefly, these were to the effect that there should be child guidance centres under the education authorities, and child guidance or psychiatric clinics incorporated in the Health Service. The difference between the two types of set-ups lay in the latter being under the direction of a medical psychiatrist, whereas the former were to be under a non-medical psychologist. The Times of the same day had a long and important article by its medical correspondence warmly advocating the scheme ; the wording of the article almost suggested that it was already a fait accompli. The same idea was put forward by Sir Laurence Brock, Chairman of the Board of Control, in an article in the Lancet of March 6th, 1946, and received further support in 1947 in the Nuffield Provincial Hospitals' T r u s t Report in an appendix on the planning of hospital services in the Berks, Bucks and Oxon region. It was not surprising that in 1945 the Association of Education Committees, whose secretary was at one time a psychologist of note, published a report giving the plans of a child guidance service as part of the education service with the
PUBLIC HEALTH, July, 1950 educational psychologist as the key person. He or she was to have the organisation of this service and was to have on the staff a member of the school medical service and a medical psychiatrist. It should be observed, however, that in the previous year the Council of the B.M.A. had decided to oppose the principle of psychiatrists working in clinics under the direction of lay psychologists. (Supplement of the B.M.ff., May 13th, 1944.) T h e Society, it will be recalled, challenged this scheme of the A.E.C. very vigorously. It emphasised the " medicopsychological character of the large majority of child guidance cases in contrast to the educational. It feels that it would be as ill-advised to entrust this work and its organisation to an educational psychologist as it would be to entrust an orthopaedic scheme to a physical training inspector." The Lancet of December 6th, 1947, in a leading article, stated very clearly that the Child Guidance Council was opposed to the Blacker plan. ' " I n applying the ominous political device of partition (the scheme) depends for success on a mutual tolerance not always evident except where the working bond is close, and 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 modem psychiatric practice, retreats once more to his clinical castle." In July, 1948, Prof. Moncrieff, Secretary of the British Paediahic Association, and Dr. Soddy, Medical Director of the National Association for Mental Health, sent a letter to Directors of Education expressing concern at the organisation in some areas whereby a psychologist without medical qualifications could be entrusted with the ascertainment and in some cases even the diagnosis and treatment of disorders in childhood. Ministry of Education Circular 179
I n spite of these protests, the Ministry of Education in August, 1948, published its famous Circular 179, suggesting that the needs of most maladjusted children could be met by social and educational adjustments, and that consequently much of the child guidance work could be carried out in schools by educational psychologists and specially qualified social workers. Those children who were found to need psychiatric treatment should normally be referred to clinics which were to be provided in due course by the regional hospital boards, and which in some instances, were already available. At about the same time the Ministry of Health were advocating similar principles. Short-term cases were to be treated in child guidance centres of local education authorities and long-term cases in child psychiatric clinics of the regional hospital boards. T h e Council of the Group were alarmed at these suggestions. I n their experience, few cases responded to simple social and educational adjustments. They could not understand the ~distinction between long-term and short-term treatment cases ; children requiring educational treatment generally needed it for a long time, whereas some seriously disturbed cases might respond rapidly to suitable psychiatric treatment by a psychiatrist. I n any case, in child guidance work it was often impossible to distinguish between diagnosis and treatment, and attempts to separate the two would lead to a dichotomy which would destroy the whole basis of child guidance work. Sir Allen Daley led a deputation to the Ministry of Education, and we put our ease to Mr. Marris, the Under-secretary, Dr. Rees Thomas, of the Board of Control, Dr. Underwood and others. Our sincerity carried weight. We were told that the Ministry did not want to prescribe the precise set up of the child guidance eentres provided they were run on reasonable lines, and Dr. Rees Thomas said that psychiatric treatment clinics might be set up within an education authority's child guidance centre, the services of the psychiatrist being provided by the regional hospital board. Mr. Marris asked that we should try out the scheme for six months and then come back to him. This was in October, 1948. It is difficult to make out what is happening in the child guidance world. The Child Guidance Council arranged an
PUBLIC HEALTH, July, 1950 Interclinic Conference in D e c e m b e r last in an attempt to learn how things were going. T h e report has not yet been published, but I was left with the impression that workers had not been u n d u l y disturbed, although there were certain aspects which were causing dissatisfaction. O n e of the m o s t striking points that arose was, although that the large majority of the representatives were lay persons, opinion was practically unanimous in wanting the work to be u n d e r the control of doctors. Form 2 H.P. T h i s came as somewhat of a surprise to some of us because there had been reason to fear that we doctors had been losing the confidence of laymen in respect of psychological work. T h e A.E.C. scheme tried to delegate doctors to the position of assistants to educational psychologists. Circular 146 of the M i n i s t r y of Education, published in June, 1947, gave timely warning about the selection of school medical officers for duties in connection with educationally subnormal children, but it provoked educational psychologists to claim greater share in the completion of F o r m 2 H.P., the suggestion being that they were more capable of doing this than medical officers, w i t h the result that a new f o r m had to be drawn up. A t the British Association meeting in 1948 Prof. Rex K n i g h t claimed that Burt's Y o u n g D e l i n q u e n t was the fons et origo of child guidance in this country, and he omitted to mention the medical pioneers. Prof. Valentine took the opportunity of his presidential address to the British Medico-Psychological Society (British ffournal of Educational Psychology, N o v e m b e r , 1948) to attack doctors as advisers in children's psychology. Sir Cyril Burt, in the issue of the same journal of February, 1949, laid about him with even greater vigour, attacking not only school medical officers, but even F r e u d h i m s e l f - - a remarkable article well worth reading, but a surprising one from a psychologist of the standing of the author. It m u s t be acknowledged that the ordinary curriculum of the medical student does not encourage great interest in psychiatry or psychology, a n d m a n y doctors start their careers with a greater faith in the physical than in the psychological aspects of medicine. S o m e retain this attitude and not a few doctors look u p o n child guidance with suspicion and even tend to build up a sort of cordon sanitaire round the psychiatrist. At the Interclinic Conference already referred to, some of the delegates alleged with some bitterness that certain administrative school medical officers assumed the responsibility of diverting cases from the child guidance clinic without taking any intimate part in the work of the clinic. The Child Guidance Team Nevertheless, there is no doubt that the medical training affords an essential foundation u p o n which further education in psychological medicine can be built if the doctor happens to be attracted to this branch of his profession. N o one w o u l d entrust the medico-psychological problems of adults to anyone b u t a medical man, and although the psychological difficulties of children m a y differ in certain important respects f r o m those of adults, no one with an intimate knowledge of child guidance w o r k would entrust the supervision of the eases to other than a medical man. O n the other hand, a training in psychological medicine does not necessarily fit a doctor to understand the maladjustm e n t s of children, and it is essential that the child guidance doctor should have special training in child psychiatry. I n addition, he should have a lively interest in the w o r k of the schools and of the school health service. I n order to conserve the time of the psychiatrist for his technical work, a school medical officer of senior rank w i t h a special interest in child guidance m i g h t well be entrusted with the administration of the clinic. H e should also act as physician to the centre. I n this way it w o u l d be possible to ensure the necessary liaison between the physical and psychological aspects of the work. T h e other m e m b e r s of the team, the educational psychologist and the psychiatric social worker, will fall naturally into their places, s u p p l y i n g their own highly valuable technical help to the team w h i c h is the true basis of child guidance work. Each
195 m e m b e r of the team, if fully trained, will have sufficient faith in the importance of his own line of approach to urge h i m to follow it faithfully and not to impinge on the w o r k of his colleagues, although to a varying degree according to the nature of the particular case u n d e r discussion any one m e m b e r m a y take a m o r e p r e d o m i n a n t place. A team m u s t have a leader and it will be for the psychiatrist, after considering the various reports in consultation w i t h his colleagues at the case conference, to give cohesion to the various reports. H e should be able to c o m m a n d their confidence while at the same time he should be willing to hand over to t h e m for further action such aspects of the work that m a y seem advisable. With regard to the qualifications of the various m e m b e r s of the team, it is obvious that they should have had adequate training and experience. F o r some m o n t h s m y authority has been trying to get an educational psychologist to replace one who on marriage was unable to give enough time to the work, and I have been amazed at the n u m b e r of people w h o consider themselves capable of undertaking this branch of the work although not possessing suitable qualifications or experience. It is to be h o p e d that education authorities will not be tempted to make unsuitable appointments in their anxiety t o complete their staffs and that each professional body concerned will do its best to maintain a high standard of efficiency amongst its m e m b e r s so that its work does not fall into disrepute. F r o m time to time one reads of comparisons b e i n g m a d e between child guidance clinics run by the school health service, by childrens' hospitals or the childrens' departments of general hospitals or by mental hospitals. Some years ago the Child Guidance Council was strongly in favour of the voluntary clinics and opposed to the idea of clinics run by local education authorities, but by 1938 t h e y had modified its ideas very considerably and, as already mentioned, in 1947 it expressed itself definitely in favour of the clinic run by the school health service of the L.E.A. T h i s is gratifying to the school medical officer, and he could adduce m a n y reasons for showing the wisdom of the change of policy. Nevertheless, w h e n he attends interclinic conferences he finds that workers in other types of clinics are equally convinced of the soundness of their own organisations and are sceptical about the efficiency of others. N o doubt the truth is that different types of clinics have somewhat different aims and are p r o b a b l y dealing with a somewhat different type of maladjusted children. It is difficult to prove this statistically, because, unfortunately, various clinics report on their cases u n d e r differing classifications, but T a b l e s I, I I and I I I , drawn up f r o m figures given in reports of certain clinics, support this view. A - - L.E.A. clinic of a large county borough in the Midlands. B - - L.E.A. clinic of a county council ba the Midlands. (A and B have the same psychiatrist although they are run quite separately.) C - - Clinic of a mental health authority of a large county borougla. D - - Clinic of a large children's hospital in London. E - - L.E.A. clinic of a large C.B. in the Midlands. In 1941 it was under a part-time psychiatrist. There was a change in the organisation between then and 1943 when it was under the educational psychologist. F - - Clinic of the children's department of a county hospital TABLE I CLASSIFICATION OF CASES. 1948
Nature of cases
A
B
C
D
Nervous ......... Habit . . . . . . . . . . . . Behaviour ......... Psychotic behaviour . . . . . . Educational and vocational ... Special : Court cases, etc . . . . Other . . . . . . . . . . . .
25"4 29.4 29.7 1.0 6.0 7.3 1.0
19.3 21.0 26.1 -11.8 21-8 --
11.0 20.4 24.7 0.3 10-7 32.5 0.3
7.2 39.9 23.5 2,0 20.8 3.4 3.3
Number of cases
299
238
308
446
......
PUBLIC HEALTH, July, 1950
196 In A, the children's hospital has its own psychiatrist. Also, the educational and vocational cases do not include 275 eases examined by the educational psychologist--secondary school placements, nonreaders for educational therapy, and partially-deaf and partiallysighted pupils. TABLE II CLASSIFICATION OF CASES IN E
Nature of cases Nervous ......... Habit . . . ..... . . . . Behaviour and court cases Intellectual . . . . . . . . . Other . . . . . . . . . . . . N u m b e r of cases
...
1941
1943
1948
13.8 9.0 49.5 27.7 0.0
7.3 3.7 30.3 55.5 3.1
12.6 7.4 36-1 43.5 0.4
99
193
269
......
" Intellectual difficulties " comprise educational retardation, special disabilities and educational guidance. T h e shifting of interest to the intellectual when the clinic came under the organisation of the educational psychologist is very clear. TABLE I I I SOURCES OF REFERRAL. 1948
Referred from
A
B
C
F
School . . . . . . . . . . . . Parent . . . . . . . . . . . . School M.O . . . . . . . . . . Private doctor ...... Hospital ......... Clinic staff ... Probation officer and"S.A.l)i Others . . . . . . . . . . . .
31.0 9"0 21-0 13.0 * 7"0 12.0 7.0
14-7 7.5 27.8 11-3 --21-4 17.2
14.6 13.6 14-6 12.0 2-6 6"5 33-4 2-6
15.0 --64.0 17"0
N u m b e r of cases
299
238
308
100
......
4.0 --
* Local children's hospital has its own psychiatrist. It is known that in A and B the referrals classed under " school " came often in the first place from the parent who had asked the head teacher to refer the case to the child guidance clinics. With regard to court cases, in area A there is close co-operation with the probation officer, the S.A.D. and the children's officer ; information is given about a large n u m b e r of cases before the case comes into court and full child guidance examination is done only when essential. T h e r e is n o d o u b t t h a t m a n y of t h e difficulties m e t w i t h in l a t e r c h i l d h o o d c a n b e traced b a c k to causative factors d a t i n g f r o m v e r y early years. M e l a n i e K l e i n has s h o w n t h a t it is possible to a p p l y psychoanalytic m e t h o d s to v e r y y o u n g children, a n d Bowlby, in his b o o k " F o r t y - F o u r J u v e n i l e T h i e v e s , " lays stress o n affectionless c h i l d r e n a n d claims t h a t t h e i r c o n d i t i o n can b e d i a g n o s e d at t h r e e years of age. I t is t e m p t i n g , therefore, to envy t h e c h i l d r e n ' s hospital w h i c h seems to get h o l d of cases m u c h earlier t h a n t h e school h e a l t h service clinic as is s h o w n in T a b l e I V : TABLE i V PERCENTAGE OF CASES IN AcE GROUPS (Children up to 12 years of age only) Clinic C.B. school health clinic. A ... E ... Children's Hospital, Lond. o n . D
U n d e r 2-4 5-6 7-12 Cases 2years years years years --4"0
9.0 5.0 34.0
13.5 19.0 23.0
77.5 76.0 39,0
250 216 ?
T a b l e s I a n d I I have s h o a l s t h a t t h e c h i l d r e n ' s h o s p i t a l deals w i t h a h i g h e r p r o p o r t i o n of h a b i t cases as m i g h t b e expected. W e do n o t k n o w w h e t h e r t h e t r e a t m e n t of t h e s e h a b i t disorders results in less b e h a v i o u r t r o u b l e s in later years.
T h o s e of u s w h o h a v e b e e n a c c u s t o m e d to deal w i t h s o m e . w h a t older c h i l d r e n m a y w o n d e r h o w m u c h c a n b e d o n e at s u c h early ages unless t h e b e h a v i o u r is causing great anxiety or unless t h e h o m e factors are s u c h as to b e a m e n a b l e to adjustm e n t . M y o w n e x p e r i e n c e has b e e n t h a t n o t a few of the v e r y y o u n g ones r e f e r r e d t o h a v e b e e n a l m o s t certainly of low intelligence, while o t h e r s c o u l d b e dealt w i t h satisfactorily b y t h e simple e x p e d i e n t of a d m i s s i o n to a n u r s e r y class. S o m e , however, have b e e n i m p o r t a n t cases a n d t h e r e is n o d o u b t t h a t a l t h o u g h we m a y feel t h a t t h e r e is p l e n t y of m a t e r i a l in t h e schools to keep t h e clinic staff busy, we s h o u l d b e always p r e p a r e d to give help to c h i l d r e n of all ages w h e n called u p o n to do so. T h e E d u c a t i o n A c t gives power, in fact a duty, to deal w i t h m a l a d j u s t e d c h i l d r e n w h e t h e r at school or n o t f r o m t h e age of two years. Delinquents S o m e w h a t at t h e o t h e r e n d of t h e scale are t h e d e l i n q u e n t s . I t has b e e n f r e q u e n t l y r e c o m m e n d e d t h a t all child d e l i n q u e n t s s h o u l d b e s u b m i t t e d to child g u i d a n c e e x a m i n a t i o n , a n d it m a y b e p l e a s a n t to p r o b a t i o n a n d c h i l d r e n ' s officers to b e able to p r e s e n t a full r e p o r t f r o m a child g u i d a n c e clinic. B u t it is t i m e - c o n s u m i n g w o r k a n d unless we feel t h a t we h a v e useful advice to give we m a y b e wise to c o n s e r v e o u r limited s t r e n g t h to m o r e p r o m i s i n g work. I t is n o t e v e r y m a g i s t r a t e w h o wishes to h e a r t h e views of t h e p s y c h i a t r i s t a n d his colleagues, b u t I h a v e f o u n d it to b e acceptable w h e n it is g i v e n c i r c u m s p e c t l y - - c l e a r l y a n d authoritatively, w i t h all deference to t h e prestige of t h e court. I t is i m p o r t a n t t h a t p r o b a t i o n officers a n d c h i l d r e n ' s officers s h o u l d u n d e r s t a n d t h e a p p r o a c h of t h e child g u i d a n c e clinic so t h a t m a g i s t r a t e s are advised b y t h e m n o t to p u t u p o n t h e clinic impossible tasks s u c h as t h e t r e a t m e n t of q u i t e u n s u i t a b l e cases or m a k i n g t r e a t m e n t at a clinic a c o n d i t i o n of p r o b a t i o n . I d o n o t p r o p o s e to say m u c h a b o u t t r e a t m e n t because this I believe to b e h i g h l y t e c h n i c a l w o r k to b e a r r a n g e d or carried o u t b y t h e p s y c h i a t r i s t himself. I f t r e a t m e n t of t h e child is e n t r u s t e d to a lay p s y c h o t h e r a p i s t t h e latter s h o u l d b e allowed to carry on w i t h o u t i n t e r f e r e n c e b u t w i t h t h e k n o w l e d g e t h a t w h e n u n u s u a l difficulty is e x p e r i e n c e d the psychiatrist is r e a d y to give advice. T r e a t m e n t ~ H o m e or Hospital ? W h e n e v e r possible t r e a t m e n t s h o u l d b e carried o u t w h i l e t h e c h i l d is living i n his o w n h o m e , b u t t h e r e are certain cases in w h i c h t r a n s f e r to a hostel is essential. T h i s q u e s t i o n of hostel t r e a t m e n t is a big one a n d I shall confine m y s e l f to o b s e r v i n g t h a t residence i n a hostel is a f o r m of medical t r e a t m e n t to b e r e s e r v e d for those w h o are definitely in n e e d of it a n d able to benefit f r o m it. A d m i s s i o n s a n d discharges a n d the c o n d u c t of t h e hostel are m e d i c a l m a t t e r s over w h i c h t h e p s y c h i a t r i s t s h o u l d h a v e clear control, s u p p o r t e d b y t h e school m e d i c a l officer acting as a liaison w i t h t h e lay e d u c a t i o n officer w h o is u l t i m a t e l y r e s p o n s i b l e to t h e authority. A firm s t a n d s h o u l d b e t a k e n against t h e hostel b e i n g u s e d as a m e r e d u m p ing g r o u n d for c h i l d r e n w h o are a n u i s a n c e elsewhere or as a hotel for t h e t e m p o r a r y a c c o m m o d a t i o n of n o r m a l o r delinq u e n t c h i l d r e n . T h e flow of a d m i s s i o n s s h o u l d b e r e g u l a t e d a c c o r d i n g to t h e capabilities of t h e staff to a b s o r b t h e m , a n d c o m m i t t e e s s h o u l d n o t interfere w h e n , owing to shortage of staff or o t h e r difficulties, t h e n u m b e r of cases has to b e c u t d o w n r e s u l t i n g in an a l a r m i n g b u t u n a v o i d a b l e excess of o v e r h e a d charges. T h e r u s h i n g of fences to please c o m m i t t e e s m a y lead to c h a o s a n d m a y p r o v e as h a r m f u l as t h e a d m i s s i o n of a case of infectious disease to t h e o r d i n a r y w a r d of a hospital. I h a v e h a d n o e x p e r i e n c e of day schools or classes for m a l a d j u s t e d c h i l d r e n , b u t h a v e f o u n d c e r t a i n selected cases t o do well in s p e c i a l b o a r d i n g schools for difficult children. I t s h o u l d b e p a r t of t h e o r d i n a r y w o r k of t h e authority, p r e f e r a b l y w i t h t h e close c o - o p e r a t i o n of t h e school m e d i c a l officer, to see t h a t suitable e d u c a t i o n a l p l a c e m e n t is effected f o r e v e r y child. T h o s e w i t h severe e d u c a t i o n a l s u b n o r m a l i t y s h o u l d have b e e n t r a n s f e r r e d to day or residential special school a n d s h o u l d n o t r e a c h t h e c h i l d g u i d a n c e clinic. Less seriously r e t a r d e d c h i l d r e n s h o u l d already h a v e b e e n p o t in
PUBLIC HEALTH, July, 1950 'special classes if of a p p r o p r i a t e ages. T h e r e m a y be, h o w e v e r , a c e r t a i n n u m b e r of i n t e l l i g e n t c h i l d r e n w i t h specific e d u c a tional difficulties for w h o m e d u c a t i o n a l t h e r a p y w i t h o r w i t h o u t o t h e r p s y c h o t h e r a p e u t i c t r e a t m e n t m a y b e g i v e n in t h e child g u i d a n c e clinic or i n o t h e r c e n t r e s t h r o u g h o u t t h e area. B y s u c h m e a n s t h e e d u c a t i o n a l psychologist m a y give i n v a l u able h e l p to m a n y c h i l d r e n , b u t i n m y e x p e r i e n c e t h e t r a n s f e r of m a l a d j u s t e d c h i l d r e n f r o m o n e school to a n o t h e r b e c a u s e of alleged difficulties w i t h t h e staff or o t h e r c h i l d r e n h a s b e e n generally e m b a r r a s s i n g a n d s e l d o m effective. T h e p s y c h i a t r i c social w o r k e r can o f t e n give t h e m o s t v a l u able g u i d a n c e to t h e p a r e n t w h i c h m a y alter t h e w h o l e aspect o f t h e case, b u t too often little c a n b e d o n e e x c e p t to s u p p o r t t h e p a r e n t t h r o u g h difficult times. S o m e p a r e n t s benefit b y i n d i v i d u a l h e l p a n d o t h e r s b y g r o u p discussions d u r i n g w h i c h t h e p a r e n t s s e e m to h e l p one a n o t h e r w i t h o n l y t h e m o s t s u p e r ficial g u i d a n c e a n d f r o m t h e p s y c h i a t r i c social worker. P a t e n t l y n e u r o t i c or b o r d e r l i n e p s y c h o t i c p a r e n t s s h o u l d b e r e f e r r e d to t h e m e n t a l hospital p h y s i c i a n w i t h t h e c o n c u r r e n c e of t h e p r i v a t e doctor. T h e r e m a y b e m a n y ways o f t r e a t i n g m a l a d j u s t e d c h i l d r e n , b u t n o t all are a c c e p t e d b y t h e p a r e n t s or c h i l d r e n a n d in a n y case o w i n g to shortage of t r a i n e d workers t h e waiting lists s e e m always hopelessly long. F o r t u n a t e l y , n a t u r e is often k i n d to us, a n d it is f o u n d t h a t a n u m b e r of the cases settle d o w n w i t h o u t a n y v e r y special t r e a t m e n t . I t is s o m e t i m e s difficult to u n d e r s t a n d h o w this occurs, b u t p e r h a p s it is t h a t we h a v e p r e s e n t e d to t h e c h i l d t h e p a r e n t a n d t h e t e a c h e r a different aspect of t h e case a n d t h e y h a v e f o u n d for t h e m s e l v e s a way of tackling t h e difficulty. N o p a p e r o n child g u i d a n c e s h o u l d b e c o m p l e t e d w i t h o u t p a y i n g a t r i b u t e to t h e teachers. T h e i r influence for good is e n o r m o u s , s e c o n d only to t h a t of t h e m o t h e r . B u t t h e y w o r k u n d e r v e r y different c o n d i t i o n s w i t h t h e i r large classes a n d necessarily pedagogic a p p r o a c h . I t w o u l d b e n o m o r e possible ~ir desirable for teachers to deal w i t h a case o n c h i l d g u i d a n c e n e s t h a n it w o u l d b e for a m e m b e r of t h e child g u i d a n c e staff to take a class in school, b u t close c o - o p e r a t i o n of t h e child g u i d a n c e w o r k e r w i t h t h e t e a c h e r will r e s u l t in t h e g r e a t e s t benefit to t h e m o t h e r a n d child. T h e p r i v a t e d o c t o r is u n f o r t u n a t e l y too o f t e n so p r e o c c u p i e d w i t h t h e physical t r o u b l e s of his p a t i e n t s t h a t he has little t i m e to go into t h e psychological difficulties of t h e family. B u t h e is g e n e r a l l y well aware of t h e m a n d possesses a m o r e i n t i m a t e k n o w l e d g e of f a m i l y c i r c u m s t a n c e s t h a n t h e c h i l d g u i d a n c e worker, a n d I h a v e f o u n d h i m to be m o s t c o - o p e r a t i v e w h e n h e realises w h a t we are t r y i n g to do. U n l e s s for a n y r e a s o n t h e p a r e n t expressively forbids t h e child g u i d a n c e staff to c o m m u n i c a t e w i t h t h e p r i v a t e doctor, I c o n s i d e r it is m y d u t y to let h i m have a r e p o r t o n t h e case w h e t h e r h e has r e f e r r e d to it or n o t . C h i l d g u i d a n c e w o r k is expensive a n d it is n o t u n r e a s o n a b l e for c o m m i t t e e s to ask occasionally w h e t h e r it is w o r t h while. I d o u b t if it is possible to s h o w t h e results of t h e work statistically. I a m n o t sure e v e n w h e t h e r it is wise to q u o t e the occasional d r a m a t i c a l l y successful case. Personally, w h e n t h u s c h a l l e n g e d , I q u o t e s o m e p a r t i c u l a r l y difficult a n d p a t h e t i c case a n d ask w h a t alternative t r e a t m e n t is possible. T h i s will g e n e r a l l y result in t h e s o u n d c o m m o m s e n s e of t h e c o m m i t t e e o v e r r i d i n g q u e r r u l o u s criticism. Under no circumstances s h o u l d we b e t e m p t e d to p r o d u c e o v e r - o p t i m i s t i c r e p o r t s w h i c h m a y b e m o s t misleading. Conelusioa
I n conclusion, I w o u l d r e m i n d you again of o u r d u t y to to h e l p t h e e d u c a t i o n a u t h o r i t y to care for t h e h e a l t h a n d wellb e i n g of t h e c h i l d r e n . T h e school h e a l t h service can n o m o r e escape its obligations t o w a r d s psychological h e a l t h t h a n it can towards physical health, i t is difficult w o r k w i t h far too m a n y failures a n d too few c o m p l e t e successes, b u t it is i n d i s p e n s a b l e a n d calls for all t h e skill a n d a c u m e n w h i c h t h e s c h o o l m e d i c a l Officer s h o u l d possess. T o b e effective we m u s t m a i n rain a k e e n a n d b a l a n c e d o u t l o o k a n d t h u s keep this n e w activity at a h i g h level a n d e n s u r e t h e greatest assistance to the c h i l d r e n .
197 OBITUARY ROBERT MENZIES GALLOWAY, M.D. (RDIN.), D.P.H.
W e announce with deep regret that Dr. R. M. Galloway, Medical Officer of Health of the County Borough of BoRon since 1932, died at the Townleys Hospital on Monday, June 5th, 1950, at the early age of 51, after a long illness from which it was recently hoped that he was recovering. W e are indebted to Drs. J o h n Yule and V. T . Thierens, and Mr. H. Moorhouse, his chief clerk, for the following tribute : Born in Birkenhead, he received his early education in England but went to E d i n b u r g h for his medical education, whence he graduated with honours in 1020, after a distinguished academic career interrupted by service as a surgeon probationer in the First World War. He spent his first five post-graduate years in various hospital appointments and thus laid a solid foundation for his future career. He took his D.P.H. in Manchester in 1923, and two years later proceeded to his M.D. with commendation at Edinburgh. Possessed of a broad humanitarian outlook, it was not surprising that Galloway should devote himself to Public Health. His apprenticeship in that service was by way of assistant posts in BoRon and with the Lancashire County Council under two pioneers, the late Paget Moffat and Butterworth. In 1929 he became Medical Officer of Health of Dewsbury, and at the commencement of 1932 proceeded to BoRon as medical officer of health. H e was a sound doctor and at the same time an administrator of no mean ability and acumen. For these reasons, quite apart from his worth as a man, he was held in the highest esteem not only by his authority b u t also by his colleagues and those members of the Public Health Service who were privileged to enjoy his friendship. His fondness for children and young people found expression in his work for the Bolton Lads' Club, of which he was a m e m b e r of the committee and honorary medical advisor. He had received many honours in Public Health. H e was a Fellow and Examiner of the Royal Sanitary Institute, of which body he was also a M e m b e r of the Council. He was a Fellow of the Society of Medical Officers of Health and had been President of the North-Western Branch. Only last year, as President of the County Borough Group, he met his fellow members in a delightful and memorable week-end at Windermere. As recently as 1948 he was appointed Lecturer in Public Health at Manchester University. T h e influence of his education in Scotland, where he spent many of his early holidays, was reflected in a pawky yet kindly and whimsical humour. As a raconteur, he was in great demand. His intimate knowledge and understanding of his fellow men could be expressed with equal fluency in the Lancashire dialect, broad Scots, Welsh or even Irish. Both as a m a n and as an outstanding medical officer of health, he will be mourned by all, particularly so by his widow and four children, to w h o m our deepest sympathy goes out in their grievous loss. His elder daughter is due to qualify soon at Edinburgh while his elder son is in his second year at Cambridge. We know that it would have brought great joy and pride had he b e e n ' p e r m i t t e d to see two of his children at least in the profession to which he had devoted his life. It was not to be. He has passed beyond our ken to the bourne from which no traveller returns, b u t we shall ever treasure his memory. Another friend writes : - " As one of the Society's deputation to the Ministry of Health which led to the ultimate passing of the Nurseries and ChildMinders Regulation Act, 1048, I was particularly impressed by the humane, forceful yet courteous way in which Galloway made the case for some power of control over the private enterprise nurseries being r u n by industry, especially in this area, sometimes to the detriment of the children. In doing so he seemed to me to show the very qualities that a medical officer of health should possess---a sense of proportion tempered with vigilance for the health of his population." BENJAMIN ALFRED PETERS~ ]~.A.j M.D.~ CANTAB.~D.P.H.
The death of Dr. B. A. Peters was briefly reported in our last issue. He was born in 1885 a n d after graduating M.B., Ch.B., Cambridge, in 1910, he was appointed R.M.O. to Park Hill City Hospital, Liverpool. After service in the R.A.M.C. in the first war he joined the staff of H a m Green Hospital, Bristol, where he spent 28 years of his professional life and built up a national reputation in fevers. He was awarded the Welch Prize of the Society for the most original contribution to meetings of Branches in the session 1939-40, viz., his address " Some Unproven Assumptions in Epidemiology" published in Public Health, July, 1949, p. 215. His study of crossinfection over 40 years, which appeared in our contemporary T h e Medical OB~j~cer in 1946, was another typical contribution from his experience. He was a Fellow of the Society from 1911 and a well-