DIVISION VII-MENTAL HYGIENE TEAM WORK IN MENTAL HYGIENE A STATE MENTAL HYGIENE PROGRAM, Homer Folks, Secretary, State Charities Aid Association, New York The general subject of this Conference is the fundamental basis of social work. Asking myself what is the fundamental basis of the mental hygiene program, it has occurred to me that the historical origin as well as the underlying justification of a mental hygiene program is to be found in one of the most important, even revolutionary, statutes ever enacted-revolutionary at least in its implications, and comparable in its significance to the first public school law and the first law for universal military training -the Poor Law of Queen Elizabeth. Under this law the state underwrote human misfortune; it made itself the residuary legatee of all uncared-for poverty. It crystallized into statutory form and placed the coercive and taxing power of the state behind the principle of human solidarity, the underlying basis of all great religions. The obvious corollary of the assumption by the state of ultimate responsibility for relief, is the duty of the state, for prudential reasons if for no other, to take all practicable steps to control the causes, and reduce the volume of, that poverty for the relief of which the state became responsible. It was, in fact, the effort of the state to act on this corollary that gave birth to the now far-reaching public health law and administration. The secretary of the Poor Law Authorities in London could not see why his department should continue to assume support of thousands of orphans whose parents died in epidemics without doing something to control such epidemics. He crystallized this suggestion in statutory form and tried to place the public health function in the Poor Law Authorities. But the old bottles refused the new wine, and a separate public health authority was created, of which this enterprising secretary logically became the first executive. Mental hygiene, in truth a branch of public health, seems to me to have the same logical and chronological origin. The state carries the burden, direct and indirect, caused by mental deficiency and mental disturbance. Mental deficiency and mental disturbance create more dependents than all other causes put together. Why should it content itself with simply caring for the end results? It must inevitably push back farther and farther along the chain of cause and effect, and seek in earlier and still earlier age periods an opportunity to control, if possible at a hopeful stage, these departures from the normal. Such is the underlying basis of a mental hygiene program. If the state is to provide the increasing sums necessary for adequate programs of education, recreation, health, and for social well-being generally, it must at least try to find a way of diminishing its expenditures for support of the insane and the feebleminded. t how early an age is it possible to begin? The question inevitably arises, can gin at the beginning? Is it possible to reduce the numbers of those who are to e the feebleminded and the insane? Something may be done in this line, but bly not as much as we hoped a few years ago. We do not know who are going to ebleminded. Dr. Fernald states that, as he and his assistants see the parents and iers and sisters of the children in his institution, they seem to fairly represent all es of the people of the state. He is of the opinion that in the majority of cases the tal deficiency which comes to his notice does not seem to be hereditary. There are, of course, the hereditary types, the families in which mental defect and -social factors predominate. There is a large place for segregation as a definite cy for denying parenthood to these types of the feebleminded—a larger place than yet been filled in any state. Recognizing that custodial care does not play so large art as we once thought, it would still be a most deplorable error to fail to exert every >rt to secure adequate custodial provision for the hereditary types. If the number is : as large as we once feared, that simply makes the problem a more manageable one, d makes possible the realization of our objective at an earlier date. Custodial care as an indirect control of hereditary mental defect is the more impornt since no more direct method of preventing parenthood on the part of such persons ems likely to meet general approval or to become a practical program. Sterilization nores all the evils flowing from mental defect, other than inheritance. It offends the ntiments of very large numbers of persons whose wishes we are bound to respect. It as yet to commend itself to the courts and the administrative authorities. There is, however, another factor from which definite and appreciable results in he control of the inheritance of mental defect may be expected-the supervision of the eebleminded in the late period of childhood in their homes by the aid of visiting eachers, social workers, probation officers, or others trained therefor. It seems clear hat there are many instances in which the advice and help which such workers could >ring to the parents of feebleminded children might aid sufficiently to turn the scale from disaster to stability during those most trying years after which character and habit would be more stable. There are distinct preventive possibilities from the standpoint of mental hygiene in the better protection of maternity and infancy. I have no doubt that we shall reap considerable benefits in the mental hygiene field from the work for maternity and infancy now being undertaken by many states under the Sheppard-Towner Law or as a direct result of the enactment of that law. New York state, for instance, while not accepting the provisions of the Sheppard-Towner Act, has increased the appropriation for its Bureau of Child Hygiene from $35,000 to $160,000 per year and includes in its scope the subject of maternity. The number of cases of mental disturbance following complications at child-birth should be appreciably reduced, and also the amount of impairment of brain development of infants in cases of difficult birth. There are, of course, many other mental hygiene aspects of maternity and infancy, but here are at least two definite factors in which the public health movement is coming to the aid of our mental hygiene program. What are the possibilities of mental hygiene in the pre-school period? I believe that they are very great and that here, too, they are materially to be realized through the broad public health movement rather than through a mental hygiene effort as such. Certain it is that the period from birth to six years of age is of vital importance in the development of the personality of the child-possibly of greater importance than any later equal period. An extremely interesting article on the psychology of the pre-school period by Dr. Arnold Gesell, director of the Yale Psycho-Clinic, appeared recently in the Public Health Nurse. In this article, Dr. Gesell calls attention to the great influence of infancy in character formation. In the pre-school period, he says, the child is acquiring on every level of behavior both healthful and unhealthful habits of activity and though he may not learn to read during these years, he is, nevertheless, mastering the alphabet of life. Thus, every opportunity should be seized to see that in this early period right habits and right attitudes are cultivated, and undesirable ones eliminated, if possible, at their first appearance. It is easily predictable that a great majority of the children of the community are soon to be brought within the ken of the health authorities. The definite aim of the maternity programs is to reach all those who otherwise would not seek and secure early and adequate attention. The children, born under the most favorable circumstances which voluntary and public health agencies can provide, naturally are taken to the Well Baby Clinics, the definite aim of which is to reach a large majority of all the children of the community. It is no longer an open question that the benefits of the Well Baby Clinic should not come to an abrupt stop at the age of two, and it is not a rash prediction to suggest that their activities will be extended through the entire pre-school age, so that the benefits of public health activities will be reasonably continuous and reasonably universal from birth to school age. It is to this organized series of health agencies that we must look chiefly for our mental hygiene work in these years, rather than to any new and separate mental hygiene agencies. One can already see the emergence of various factors: 1. It will certainly very soon be the case that the new generation of parents has had some definite training in child care. Such facts as are stated in the concise leaflet by Professor William H. Burnham entitled "Mental Health for Normal Children" should be made known to all high-school pupils. We should not overemphasize the change that is needed from present home and school practice. Parents are not without ideas as to the training of children, nor have they made 100 per cent failure heretofore, even from the point of view of mental hygiene. Definite information, however, as to the mental development of normal children will naturally give them greater assurance and greater ability to deal with trying and exceptional situations. 2. The public health nurses, who are so large a part of the Well Baby Clinic operations, should receive some training in mental hygiene. It is very significant that the admirable paper of Professor Gesell appeared, not in Mental Hygiene, but in the Public Health Nurse. It carries no mental hygiene label, but is actually an extremely significant mental hygiene document. 3. Equally suggestive and prophetic is the establishment in Boston, at the request of the Baby Hygiene Association, of a pre-school Habit Clinic. These undesirable habits in the process of formation are divided by Dr. Thom, its director, roughly into three groups: bad health habits, bad mental habits, and bad habits of motor control. Under a complete system of supervision by public health nurses with some mental hygiene training, it is believed that a very large part of all cases of mental deficiency will be discovered before the age of six. How far the trend of their development and of the development of bad mental habits which might result later on in definite mental disturbance, can be affected by medical and nursing supervision through such clinics and agencies, only actual experiment can disclose. When this comprehensive health supervision of pre-school children becomes a he child will enter school not as an unknown X, but with a pretty complete stateof his individual capacities and difficulties, and there need be no break in continuthe efforts to secure his best physical and mental development. The school period, however, is that in which immediate and large results in the al hygiene of childhood are to be expected, for here we already have a well-de>ed agency of great prestige dealing with practically all the children of the commuwhile for the pre-school period we see only the beginnings and sketches in outline ich agencies. The public school for a long time will be the great sifting place. ‣ the various types and forms of mental deficiency, and of incipient mental disturb, will be brought to light. The special class for backward children is so thoroughly established in principle I need only indicate three points as to which consensus of opinion and united action ain to be worked out, such as: first, whether the state itself should subsidize such ses; second, how an adequate number of teachers, specially qualified for such ses, are to be secured; third, how the special class plan can be adapted to rural and irural communities. An interesting experiment in this direction is now under coneration in Beaver County, Pennsylvania. It is elementary that a special class produces almost as many kinds of problems as re are children. Since temperament and aptitude vary among deficient children as ll as normal children, the successful teacher of such classes should make her curricun flexible. There is substantial agreement as to some factors of special class teaching. first importance is training in proper personal habits, followed by sense training, ysical training, and the correction of speech defects where they exist. The so-called ademic subjects, the three R's, have limited usefulness; on the other hand, defective ildren as a class take readily to manual and industrial training, and it is to the developent of the child along these lines that the school years can be most advantageously evoted, with especial emphasis, in the years preceding graduation, on actual vocational aining in trades and industries. This latter phase of special-class teaching remains to e fully developed in order to make it of practical value from a wage-earning standpoint. The mental hygiene problem of the school has only begun when the special class or backward children has been established. The school system throughout should be ervaded by a mental hygiene atmosphere, and mental hygiene factors and point of view taken into consideration at every stage. This is especially important from the tandpoint of the difficult, nervous, or peculiar child, often of normal intelligence, whose unusual behavior indicates, perhaps, a psychopathic trend. Such children do not need, in most cases, to be transferred from the regular classes, but they do need on the part of the teacher an understanding of their individual problems in the light of the emotional and other factors involved. In the more pronounced cases, psychiatric counsel should be availed of. More or less marked departures from the normal in conduct may indicate the beginnings of serious mental disturbance. How early it is possible to recognize these departures from normal development of personality which lead to definite mental disorders, and how far, if recognized, they can be dealt with beneficially so as either to remove altogether the abnormal tendency, or to diminish its seriousness, or to postpone its further development, only experience will show. It is, however, a field of great and important promise. This mental hygiene program for backward and difficult children is broader than the school itself. The teacher becomes interested in the child not merely as a pupil but as a person, a member of a family. The teacher very soon sees that she can hardly understand, much less help, the child without the aid of the parents on the one hand, and on the other the aid of expert psychiatrists. Some benefit may be realized from visits by the parents to the school, but even this often makes more clear the necessity of a much more complete knowledge of the home and of the personalities therein for a real understanding of the child. Home supervision, then, emerges as the next great factor in a mental hygiene program for the school age; first, to understand the child as a pupil, and second, to secure reinforcements in dealing with the child's peculiarities during the hours when he is not in school. The home visitor, whether she be visiting teacher, psychiatric social worker, or other trained person, immediately finds, of course, that the home problem differs in each case. In some instances the parents need only a little fuller understanding of the child's difficulties to deal with him successfully. In others, either because of greater difficulties in the child himself or in the home, a very much more intensive and more continuous supervision is required, to secure anything like normal adjustment of the child to his home and school relations. In rural regions especially, this calls for an intensive supervision which cannot possibly be realized, if that were desirable, by a special service for such children only. All the resources of public health nursing, probation service, child welfare agents, family welfare agents, and other social agencies, working in the local area, must be utilized. On the other hand, of course, there must be also available for all such workers and for the teachers the best expert advice from psychiatrists of special training and experience. The mental hygiene program therefore calls for a mental hygiene point of view on the part of the public health and educational agencies dealing with all the children in the community, and for special agencies to deal with instances of mental peculiarity thus brought to light. This special training and home supervision should always be the least that will accomplish the desired result-the protection of the child, his family, and the community from serious evils. It should be made in each case more and more intensive, only as the need therefor becomes unmistakable. The largest degree of liberty and of normal freedom from supervision should be permitted which is consistent with safety. It will, of course, be found from time to time, particularly among the mentally defective children that even the utmost efforts of the special class and of the home visitor and all of the reinforcements which these agencies can bring into play, are insufficient to insure the child's welfare, either because of the strength of his anti-social tendencies or because of the weakness of the home. It is then only a slight step to the institution which, continuing all the special educational factors, adds a more complete control of the environment. The transition from the maximum of home supervision to institutional life when that becomes necessary should be easy, simple, and direct. The child is simply placed under the care of those who are presumably wiser, more experienced, and perhaps more dependable than his parents, and the risks and danger of the unsupervised hours out of school are removed. Even now we still have the possibilities, after a period of training, of parole to the child's own home, of parole to some other family, or perhaps a period of colony life under definite supervision but approaching normal economic and social conditions more nearly than the institution. We have thus in outline an elastic program, departing from the usual provision for all children as little as possible, step by step as the necessity therefor is shown, utilizing all existing agencies, flexible, adaptable, studying the individual, and faithfully cherish |