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whether at present they can be of much use to the average children's agencies
because the problems of the preschool child usually are not recognized as prob-
lems by the visitor, or are not regarded as needing treatment. The time of the
agency visitor is usually so much taken up with the consideration of older chil-
dren who are acute problems that she overlooks the preschool child unless he
becomes considerable of a nuisance. Development of habit clinic work, separate
or as a part of a community clinic, seems to depend upon the education of the
agencies as to the needs of the preschool child.

Interest in well-rounded studies of problem children has been much in-
creased throughout the country by the program for the development of child
guidance clinics. Almost all agency executives are familiar with this develop-
ment through the publications of the Joint Committee on Methods of Prevent-
ing Delinquency. The work of these child guidance clinics is characterized by
the complete, coordinated study of a problem child. Restricted intake, examina-
tion by appointment, examination of children only, are some of the means by
which the high quality of work is maintained.

In connection with adequate clinic study of problem children by a group of specialists organized into a clinic, we must emphasize the fact that a special social study is essential, and that the visitor preparing the social history must know the social data needed in the clinic study of that particular problem. The visitor cooperating with such a clinic must have special training to carry out the social treatment. Considerable time is required in the social study, in the complete study at the clinic, and in the carrying out of recommendations for treatment. All of these considerations bring out the point that clinic facilities for the examination of problem children must match community resources and the ability of agency workers. The completeness of the study must not exceed the opportunity for treatment. It must be possible to carry out in the community the usual recommendations of the clinic. Complete psychological and educational analysis of a school failure is of little use if there are no special classes in those schools, and if there is no grading of children according to learning ability. Simple determination of mental age will probably satisfy the needs of the social agency in such a community. Careful analysis of a problem, with recommendations regarding the occupation of leisure time, is hardly worth while in a community which is decidedly lacking in recreational facilities. Vocational guidance based upon psychological and psychiatric study is of little use in a community where there is a lack of prevocational and vocational training. Little is gained by a complete study which points out the necessity of treatment of a problem child temporarily away from his home unless the children's agency supervising the child can arrange such temporary care. Psychiatric clinic service which brings out the need of a problem child for a brief period of institutional care is of little value to a social agency unless the proper institutional care can be provided. It may be possible for a children's agency to secure a complete clinic study, but complete clinic service is not available if the lack of community resources pre

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vent the carrying out of clinic recommendations. As has been said by one executive, "It's no use trying to put a fifty-dollar clinic in a five-dollar community." The lack of community resources in most towns and smaller cities require, for efficient service, no more than a clinic able to recognize and treat gross defect. The out-patient clinics operated by state hospitals often are adequate for the communities in which they are located because they are as progressive and as complete in their work as the agencies in the community they serve.

In the treatment of young children a psychiatric clinic is too largely an educational agency when the visitor referring cases is unfamiliar with modern child training methods. A habit clinic operates with difficulty as long as the visitor supervising the child is certain that continued violent crying in a temper tantrum is likely to burst a blood vessel; that the child who masturbates is immoral; or that the annoying child needs a sound spanking.

As far as facilities for psychiatric study are concerned, their development will depend in large measure on the social agencies knowing what they need in the way of clinic service and being able to use efficiently better clinics than they have.



Ethel Taylor, Director, Department of Children's Case Work,
Child Welfare League of America, New York

To try to prescribe for all communities, with their manifold variations of development in child caring work, exactly the kind of mental hygiene service any of them might need would be a reckless undertaking. Communities and agencies, like individuals, have a way of differing from each other, not only in inherent native qualities but in stages of social growth, and, as with individuals, the stages of social growth are not always coincident with chronological age. We have organizations and communities that are thoroughly mature chronologically but that are functioning socially on a plane suitable to their chronological childhood. These are cases of arrested development, as real and as tragic as those of the individuals who weather their way through adult life on the basis of emotional mechanisms or intellectual development characteristic of childhood. On the other hand, we have organizations and communities that may be considered precocious; that, in spite of being relatively young chronologically, are functioning as well as present-day knowledge permits them to function. It is clear that organizations and communities, like people, are molded by the events of their lives, and are more or less products of the ideas and happenings that they have themselves produced or that have come to them from without. As these ideas and happenings are infinitely varied, the organizations and communities which they have produced are likewise infinitely varied; therefore to

determine, for instance, the kind of mental hygiene service they should have, they need individual study and advice shaped to their individual needs. They need, in other words, community case work. Because of this need of individualization of communities and organization this paper does not attempt to write a blanket prescription for a mental hygiene clinic service guaranteed safe for any of them, but rather seeks to determine a few fundamental principles by which we may be guided in the organization of such service.

At least one definition is needed, namely, What is a children's agency? Broadly speaking, a children's agency is any which is organized primarily to meet some need of childhood. Such a definition would include schools, recreation agencies, health agencies, and organizations conducting research and propaganda on behalf of children, as well as agencies serving individual children who present some specific economic, social, or personality problem. Tempting as it would be to pursue our subject into all of these fields, particularly into the realms of education and recreation, we are arbitrarily, for the purpose of this paper, limiting our definition to those agencies which deal with children on an individual basis and which are under the necessity, therefore, of using the technique known as social case work. This includes juvenile courts, child placing societies, societies to protect children from cruelty, institutions for children, juvenile protective societies helping actual boys and girls, and visiting teachers. These agencies, because they are up against the necessity of finding some practical solution to the pressing problems with which the children in their care every day confront them, are perhaps more eager for help from the mental hygiene field, and more deeply concerned about its development, than are agencies which have not the same imperative responsibility for individual lives.

In considering the kind of clinic service these caseworking agencies need, we are forced to the more fundamental consideration of the relationship that should prevail between social case work and psychiatry. From its earliest beginning, case work at its best has emphasized personality and has sought to give individuals opportunity for self-expression and for balanced living. It has constantly used the specific need of the individual that brought him to its door as a sort of diagnostic and treatment springboard from which it dove beneath the surface of complaints and explored the depths of contributing causes. Among these contributing causes it frequently saw conflict between members of families, inadequate ideals of conduct, conflict between the desires of the individual and the standards of the group, inability on the part of the individuals to face the realities of their lives, or to grapple with them effectively even when they did face them. All of these disabilities case work has struggled with valiantly, and sometimes with brilliant success. For the vagaries of human nature it developed tolerance, and for erring or ineffective people themselves, an attitude that on the whole was non-condemnatory, sympathetic, judicial, and objective. For its insight into the character forces of its clients, however, it had to rely mainly on the evidence of overt behavior, lighted by such practical understanding as intui

tion, imagination, and past experience could give. As fast as other fields, such as medicine and psychology, were able to give definite help, case workers used doctors and psychologists as consultants. Within the past decade, moreover, a light has begun to shine at another point on the horizon, and this new light, modern psychiatry, the case worker sees illuminating many of the corners and subterranean channels of personality that hitherto have been too dark for her to see. In her elation at the revelation she has sometimes become a little giddy, a little too prone to act as if the new light were by itself sufficient to cure her most perplexing problems. Sometimes, too, have not the psychiatrists, through whom the light is disseminated, like other pioneers in the first flush of accomplishment, tended to accept responsibility a little too generously? Now, however, that the somewhat tipsy joy of discovery on the part of the case worker and of initial achievement on the part of the psychiatrist is sobering into a more realistic understanding of each other's functions, each is viewing the other with honest inquiry as to what their relationship should be. The answer to their common question will be expressed concretely in the kind of clinic service the psychiatrist will give.

We are all aware that with the recognition of the mutual value of psychiatry and case work to each other, a movement has developed to give some knowledge of psychiatry to case workers. The workers who received this education have been called psychiatric case workers, and most of them at first became attached to clinics, state hospitals, or other forms of service clearly recognized as having a mental health function. When clinics began dealing with behavior problems of children, however, they entered a field where case workers were already active. Immediately there arose a question as to the type of mental hygiene clinic service the case workers should have. When a clinic staff consisted only of psychiatrist or psychologist it was obvious that only consultation service could be offered; that they themselves had to give the psychiatrist sufficient history to enable him to see the problem; and that they had to utilize his interpretation or diagnosis in their treatment. But when clinic staffs consisted of psychiatrist, psychologist, and a member of the new species, a psychiatric case worker, the issue became confused. In some instances the non-psychiatric workers themselves felt that cases presenting acute conduct problems should be laid, like abandoned babies, upon the doorstep of the clinic to be dealt with as the clinic saw fit. They were willing to withdraw from these cases entirely except in so far as their oversight might be necessary for such practical matters as payment of bills. When clinics and psychiatric social workers were willing to accept the inclusive responsibility thus trustfully laid upon them, it is possible that the immediate results in the small number of cases that they could so absorb were better than they would have been had the non-psychiatric case workers struggled to gather pertinent diagnostic data and to apply ill-digested psychiatric advice. The long-time result upon the work of the social agency and the nonpsychiatric case worker, however, seems not to be so good. To relinquish a diffi

cult problem is to lose the educational effect that comes from an attempt to solve it. Vicarious experience may have some educational value, but not as real and lasting value as direct experience. Furthermore, when the top layer of most troublesome problems is drawn off, there appears underneath a great number of minor or incipient problems that the non-psychiatric worker must still deal with on a pragmatic basis. There is an educational connection between these minor, less-advanced problems and the major, well-advanced ones, but when a psychiatric worker is handling the well-advanced problems the non-psychiatric worker has little opportunity to understand their development through just the stages which some of her other cases are exhibiting. She therefore misses the insight she might develop, fails to evaluate correctly the small signs of maladjustment shown by her less advanced cases, and therefore, unless accident intervenes, is likely to permit their development to the stage which qualifies them for the service of the clinic and the psychiatric worker.

As mental hygiene itself develops more knowledge of prevention it confirms the idea held by some case workers that there is no sharp distinction between a problem and a non-problem case. It formerly was the policy of one child placing agency to accept from the court, schools, parents, or other sources children who exhibited antisocial behavior of various kinds, and were, therefore, labeled problems. But it was the experience of this agency that many children who came to it for other reasons were just as real problems. A baby who comes into care because his mother has to go to a hospital for an operation tries to tyrannize over the adults about him by screaming till he exhausts their endurance. A girl of seven in the care of the agency for two years because of the death of her mother suddenly and unaccountably begins to steal. A boy of twelve who must leave an orphanage because he has reached their age limit is a persistent bed wetter and no physical cause can be found for his malady. Are not these problems? Will the case worker in the children's agency help them as effectively as she might if she had some understanding of their psychological basis?

Because there is no sharp line between problem and non-problem cases, because every children's agency is dealing with both children and adults who exhibit unhealthy personality trends in every stage of development, it would appear that there is no clearly defined group of cases that may be turned over completely to a clinic staff. It would appear, in other words, that a children's agency has no group of cases that plainly requires psychiatric case work, and another group that can get along with non-psychiatric case work. Going still farther, it would appear that no new type of case work was discovered when the term "psychiatric case work" was coined, but rather that all case work is essentially the same in content and method, and that psychiatry gives to all case work new knowledge enabling it to deal with its problems with greater precision.

Translating this conclusion into practical service to a children's agency from a mental hygiene clinic, it would appear that in the main the children's agency should avail itself only of consultation service. Its case workers should provide

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