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children in some of the work which we are doing in Chicago. Our work in this connection has included cooperation with United Charities in the continuous health supervision of their allowance families, and with the juvenile court in connection with the children of pensioned mothers. It is also included active cooperation with the Day Nursery Association in health supervision in regard to day nurseries.

In the case of Rose A. the findings were as follows: three carious teeth; tonsils large and cryptic; anterior cervical glands; nutrition fair. The recommendations were: dental care; watch throat; more milk; cereal for breakfast; stop tea and coffee; sleep with windows open.

It is evident that such notations on the part of the physician indicate that from his point of view a knowledge of the program relating to diet, sleep, fresh air, and exercise is an important factor in the diagnosis, and the correction of details in the program essential to the proper care of the case. Since this is true, it seems highly desirable that as a factor in this continuous health supervision the mother should be present at the physical examination, since it provides a most excellent means of education for her in the care of her child. This standard once established in her mind will then be re-emphasized by the nutrition worker or nurse, who follows through on the suggestions made by the physician.

Besides the first examination with its complete record of the social history, stock-taking of the habits of the child and of the family, and thorough physical history, there should be periodic examinations, which will probably take far less time, to indicate whether corrections have been made and whether progress is being made. Since it is now generally conceded that the growth record, especially relating to weight and height, is an important index of the child's physical condition, no program of health supervision can be considered complete which does not note regularly growth progress. A continuous record of a child with reference to weight and height should be a part of the physical record, and failure to make normal progress deserves attention.

This type of supervision, which is aiming at the normal child, depends upon very complete cooperation of all individuals who touch the life of the child. The child itself, of course, must be interested; the mother must cooperate on the program suggested; the physician's contribution has already been noted, and the nutrition worker or nurse provides the educational stimulus to both child and mother to carry out the suggestions. In addition, the social worker making contact with the family must be in spirit a health worker who cooperates closely with the physician and nutrition worker in re-emphasizing to the mother in the home the value of the advice given.

Our method in working with the agencies already mentioned is not to duplicate social visits to the home, but to expect the mother to attend the monthly or weekly meetings with the children. In the majority of cases the social worker is also present. If she is not, the nutrition worker and the social worker later communicate in regard to the essentials in the program to be followed

out, and the social worker then makes the necessary contact with the family. For the family agency, health supervision includes not merely the child whose condition indicates the need of special attention, but a regular health inventory of the entire child population.

THE USE OF CENTRAL CLINICS FOR CHILD

CARING AGENCIES

Alice H. Walker, Chief, Social Service Department,
Harper Hospital, Detroit

Wide variations are found in the policies of child caring agencies regarding the most effective and economical plan of providing physical examination and medical supervision for their wards. The establishment of a small clinic within the department seems to be the most common plan. While highly commendable if no better service can be obtained, such a clinic is wholly inadequate when compared with the well-organized out-patient department of a hospital, made up of eighteen or twenty clinics representing all branches of medical service, and with the most complete modern equipment providing for all patients scientific examination and skilled treatment.

Outstanding physicians of recognized ability and wide experience are in charge of the clinics. The entire dispensary service is correlated, physician consulting with physician, and with a central record system assembling all records, laboratory and X-ray reports in one folder, this unified study passing finally into the hands of one physician for interpretation, final diagnosis, and recommendation for treatment. The facilities for making this study possible are under one roof, with hospital beds at hand for the acutely ill or for those who should remain under observation. The appointment system insures for each person sufficient time for an unhurried, complete examination.

It is extremely difficult to obtain the right type of well-trained, progressive physician to serve in an independent clinic, since hospital connection is of such vital importance to him. Furthermore, few physicians working alone in a meagerly equipped clinic, without X-ray, laboratory facilities, or opportunity for consultation, are competent to make an accurate diagnosis of illness in the early preventable or readily remedial stages, particularly if the symptoms are somewhat obscure.

Nor should the examination cover the mere physical condition alone. For the child caring agency it is essential that the personality of the child in the light of his past history and his present mental and social make-up should be studied if he is to be placed in the community to best advantage. A psychological study is particularly imperative for the difficult child who presents a behavior problem, in order that wise social treatment and proper community adjustment may be effected.

Psychiatrists, psychologists, nurses, social workers, dietitians, dentists, physiotherapists as members of the hospital staff stand ready to give their professional services.

The health conservation clinic should invariably be an integral department of the hospital dispensary, thereby insuring the maximum scientific medical service at a minimum expenditure of funds.

WORK WITH CHILDREN PRESENTING SPECIAL
PHYSICAL PROBLEMS

Jacob Kepecs, Jewish Home Finding Society, Chicago

The physically handicapped child is rarely accepted by children's agencies because of its handicap. The handicap is usually discovered at the time of admission or afterward. There are, of course, exceptions to this rule, and as the facilities of the children's agencies develop for the care of the physically handicapped, their number will increase. The time may come when children's agencies will concentrate upon handicapped children as a special piece of work, not as incidental.

The obligation of the children's agency to the physically handicapped child is chiefly in the nature of social treatment. The medical side naturally is attended to in the clinic. There is some danger that social workers may neglect social treatment and emphasize medical care, accepting the purely medical point of view. The fundamental needs of physically handicapped children are identical with those of all children. Growth and development require nutrition, play, education, religion, and so on, and the difference in treatment lies in the emphasis of certain factors, such as rest for the cardiac, special food for the tubercular, etc.

The most important factor in treatment of the handicapped is education. It is not sufficient merely to treat a child for a certain period of time without educating him for the future in habits, hygiene, and the mode of living applicable to his particular handicap.

To be effective the agency must develop a special method in enlisting the cooperation of the child, the foster mother, the doctor, the school, and the child's own parents. Contact with special clinic or specialists is a matter of course and must be followed up by the social worker. The question is, should a social agency employ a special health worker for this or should it be left to the regular visitor? Placement of the physically handicapped child should be made so that contact with the clinic can be convenient and close supervision possible during treatment. Country placements where clinical facilities are poor or non-existent are hardly desirable.

Children counted as specially handicapped are the cardiac, tubercular,

malnourished, enuretic, and those suffering from skin conditions, vaginitis, post-encephalitis, and the various deformities. General children's institutions are out of consideration, as they are entirely unsuitable for the care of these classes. Private home placements, hospitalization, or special institutions are the only facilities to be considered. The question arises as to which is the most desirable and effective mode of care. There are those who claim that the physically handicapped child, if permitted to be cared for in a normal environment, will develop an inferiority feeling on account of his handicap. On the other hand, there are those who hold that segregation in hospital or sanatorium or specialized institution makes the adjustment of the child in the community after the period of treatment so much more difficult.

Of all the classes mentioned the one most difficult to deal with is vaginitis. Opinion as to its nature, effect, treatment, cure, and prevention varies so greatly that a consistent policy is impossible or not even desirable. The claim is made by some physicians that vaginitis results in sterility, while others discount its seriousness and claim it disappears at the age of puberty without harm. There is also a difference of opinion in regard to method of treatment, and the only unanimity that exists is as to contagion. It is a question in my mind if any single children's organization can ever cope with vaginitis successfully until the medical profession itself comes to some decision in the matter. I wonder whether a social agency especially organized for the accumulation of material would not be the most effective way of getting to the bottom of the whole problem. Perhaps such an organization as the Elizabeth McCormick Foundation, of Chicago, which has done an unusual piece of health work for children, would undertake the care and treatment of children suffering from vaginitis for the purpose of such a study.

A practical medical arrangement for a children's agency, it seems to me, would be to tie up with a clinic of good standing; to include on its staff paid physicians, part or full time according to the extent of the work and the resources of the organization. Such a physician should have the responsibility of the first and recurrent general examinations, the supervision and check-up on refers to special clinics, and arrangements for consultations, etc. The board of directors should have one or more physicians to constitute a medical advisory board. In addition, if the organization is large enough, the responsibility for supervision of the work with the physically handicapped should be placed with one person.

Quality, rather than quantity, should be the keynote of the private children's agency. The physically normal child can well be left to the usual community resources and public agencies. If the private organization used better judgment in intake and discharge its population would decrease to a considerable extent, thus liberating funds for the more intensive work with the physically handicapped child.

THE SCHOOL AND SOCIAL PROBLEMS

(SUMMARY OF MEETING)

Jane F. Culbert, Executive Secretary, National Committee
on Visiting Teachers, New York

What social workers should know about the school.-Dr. Jesse H. Newlon, superintendent of Denver schools and president of the National Education Association, said that any worker from outside the school should study the present-day report system so as to know what the curricula and other activities are offering before attempting to propose any worth-while program from outside. He spoke of the fact that not infrequently people wished to introduce work through an outside agency because they believed the schools have not met some particular problem, when, as a matter of fact, they are basing their theories on no more recent knowledge than that acquired in their own school days. The schools are constantly changing and developing, said Dr. Newlon, and there is a strong tendency toward socialization and an increased realization that the school is for the child. Teachers, he said, will be found to be interested and ready to cooperate for a child in practical plans which are clearly set before them. Social workers should learn what services are offered in the school by its various departments, and through which of these departments inquiries regarding a child can be made. Assuming that the social worker is a trained person with a liberal education, particularly in the social sciences and psychology, Dr. Newlon feels that she is, and should be, a welcome contributor to the school services. The effort should be toward the integration of the educational and social forces in the school.

The problem of the outside social worker's reaching the right source of information in the school.-In discussion, the opinion was expressed by some that the social worker often feels unwelcome in the school and finds it difficult to obtain information, about a child, which is necessary to her plans. It was also suggested that sometimes the schools found it hard to give time for interviews with these outside workers. The general conclusion seemed to be that the social worker should obtain as detailed information as possible from a department or a central bureau in the school, such as a guidance department, or any other special service department. After that she should consult with both teacher and principal, but should remember that the school's time is budgeted, and should therefore have very clearly in mind what she needs to say or ask, and keep clearly to the point. In response to a question as to just how or through whom a more complete cooperation of educational and social forces can best be brought about, how their purposes are to be best united toward the educational aim, the visiting teacher was designated as the school functionary who, with experience in teachîng as well as in social work, is able to blend the two professions in a manner to increase the school's efficiency in its own field of education through introduction of social work methods.

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