In all this we see little that we may call treatment process. Our concern has been far more with some of the fundamental attitudes of mind in ourselves which may make possible the development of social treatment in the future. There is, first of all, a humility which one may call the scientific attitude in the face of facts. The facts are all around us in the lives of people who do constantly, and more or less successfully, adjust themselves to life. Let us learn to observe far more accurately and thoughtfully these common manifestations which we tend to pass by in favor of our own activities. This implies also a certain faith that the process of adjustment is, after all, a natural process which we may, by scientific understanding, help, but not control to any great extent by our techniques and manipulations. Finally, perhaps most important, is the attitude of respect for the possibilities in our clients. In this faith, out of real knowledge of them and their capacities, limited though they may be, we may help them to build out of their experience not only a shelter from disaster, but something of worth to themselves and their community.

TYPES OF CLINICAL SERVICE AVAILABLE TO
CHILDREN'S AGENCIES

Bruce B. Robinson, Director, Department of Child Guidance
Board of Education, Newark, New Jersey

The type of psychiatric clinic most commonly available for the use of a children's agency is that which is operated in connection with the out-patient department of a general hospital. The staff generally includes a psychiatrist, a psychologist, and a social worker. Often all of the personnel are on part time. Especially is the psychiatrist likely to be on part time with the clinic. Often this psychiatrist is engaged in the private practice of neurology and psychiatry among adults. The number of cases handled by such a clinic makes it necessary to give only a short time to each case. Findings must be based on too short an interview, and there is no opportunity for a discussion of the case by the various members of the staff and the agency worker. There is usually too much reliance placed upon the psychiatric interview, and the psychiatrist, who ordinarily is working with adults who have sought his aid in treatment, is unable to adjust to a situation where his patient has been brought to him because of misconduct, a patient who resents examination, feels he is "on the carpet," and who has been scolded for the conduct which the psychiatrist discusses with him. The psychiatrist usually has had little contact with social workers and psychologists and has no training or experience in either of these specialties. He usually has neither the time nor the experience to discuss social treatment with the agency visitor. The large number of cases to be handled, the briefness of the examination, and the lack of familiarity on the part of the psychiatrist with social treatment limits

the usefulness of such a clinic to the recognition and treatment of gross mental defect. Such a clinic usually cannot handle cases needing treatment of the parents by the psychiatrist because of the time involved. It cannot handle the personality and emotional problems of children, especially of the adolescent, because such work requires long, and sometimes repeated, interviews. Almost all mild behavior problems, especially those of the preschool child, are outside the experience of such a psychiatrist, and specific advice regarding treatment of such conditions cannot be given to the referring agencies. This lack of familiarity with modern beliefs in child training makes it difficult for such a psychiatrist to recognize, in his recommendations for young children, what part is based on psychiatric judgment and how much is folk-lore, which the psychiatrist still accepts. Thus we find psychiatrists saying that the parents must be "more severe" with the child; that the child is "inherently bad"; and we find psychiatrists seriously discussing the conditions under which a child needs to be spanked. The development of such psychiatric service is sometimes accomplished through the education of the psychiatrist, but usually more adequate service can be secured only by the addition to the staff of a broadly trained psychiatric social worker who is able to talk over the cases with the visitor on the basis of the clinic study.

Psychiatric service of a type similar to that just mentioned is being given by an increasing number of clinics through the out-patient clinics of the state hospitals. The personnel of such a clinic would be a psychiatrist from the hospital staff, and perhaps a psychologist, and, occasionally, a psychiatric social worker, also from the hospital staff. It is possible that such a clinic is more limited in its usefulness to children's agencies than is the psychiatric clinic operated with a private physician as psychiatrist. The psychiatrist in private practice sees many borderline cases: adults who are mildly nervous, and those who are emotionally unstable, these being the conditions which are so regularly found among the parents of our problem children. The psychiatrist in private practice treats patients in their homes; he aids to a better adjustment in the community and at work. The state hospital physician, on the other hand, in his treatment of children referred by social agencies, contrasts to his usual work (which is the treatment of the adult insane in an institution which is usually isolated from the community) a study of a pre-adolescent who has been impertinent to his parents, or a four-year-old girl who has temper tantrums. The state hospital physician who is given charge of such an out-patient clinic usually has been on the staff of the institution for five to ten years before receiving this opportunity to engage in extramural work. During these years he has developed the institutional point of view toward psychiatry; he is accustomed to make a diagnosis and to fit his cases into a statewide system of classification; his experience in treatment is that of individuals apart from their natural environment. His isolation in the institution has usually prevented familiarity with community organization in social work; what he knows of case work methods and stand

ards is usually confined to the procedures employed by the psychiatric social worker supervising patients on parole from the hospital. He usually has little knowledge of modern standards in child training. These limitations usually make it necessary for the clinic to give only a "gross defect" service. This recognition and treatment of the more obvious psychiatric problems of childhood is a necessary and valuable function, and calls for the service of a psychiatrist who is well trained and who has experience in this field. Some degree of this type of service is needed, but such cases as can be handled by this type of clinic represent a small proportion of the problem cases which a children's agency would like to refer for study. Aside from the qualifications of the psychiatrist, these clinics are limited further in their usefulness by the fact that both adults and children usually are handled in the same clinic, and that the effort to handle a large number of cases without limitation of intake and without appointments makes necessary such superficial examination that the more complex problems cannot be reached. The infrequency of the service to a particular community is also a handicap which would be less of an interference if the psychiatric social worker could be assigned to the community and thus be available for consultation and follow-up service. A further handicap of this extramural state hospital service is that the psychiatric social worker attached to the clinic, who might be of such great aid as liaison between the clinic and the children's agency, is herself handicapped by the fact that the greater part of her time is devoted to the supervision of adults on parole from the hospital, and also by her lack of familiarity with the work of the children's agencies.

Several states have developed state-wide extramural clinics, and are making available to smaller communities the much-needed psychiatric service in the examination of those cases where a brief survey and a diagnosis are adequate. Such clinics are creating a demand for more complete service and laying a basis for the development of an independent clinic in each community.

A very hopeful development in two states is the establishment of a traveling clinic service, where the clinic personnel is not attached to a state hospital, but consists of specialists in the treatment of problem children, with training and experience in children's clinics, and giving full-time service to problem children. These clinics are able to give complete service to children's agencies because of the professional qualifications of the members of the staff. Such traveling clinics usually have several stations which they visit at regular intervals, examining children by appointment, with the social history developed by local agency workers under the supervision of the clinic staff. The assignment of a clinic social worker to full-time service in a particular community increases the efficiency of clinic service to that community. It is possible that where a clinic must cover a wide area (a county, or part of a state) this establishment of stations with a social worker, and perhaps a psychologist, on full time at each station is better than maintaining a central station to which visitors and patients must come from a distance. The psychiatric social worker becomes more familiar with

community resources and with the individuals with whom she deals, and is available for conferences, treatment interviews, and educational work. A psychologist at a substation has an opportunity for more complete study, for followup study, and may increase the service of the clinic to the community by the psychological examination of school children who are not behavior problems. It would seem that children's agencies could be much better served by the subdivision of a state into areas with traveling clinics rather than by the effort to extend state hospital service to the study of problem children.

Several large agencies and some scattered communities have met their need for study of problem children by the organization of clearing houses where a complete study of the child can be made in one building. The clearing house staff includes specialists in many branches of medical work: pediatricians; specialists in eye, ear, nose, and throat; dentists; orthopedists; psychologists; psychiatrists; and social workers. Such a centralized service seems to be a very desirable development, since it insures more complete routine study, better coordination in the study, and probably a better understanding between the clinic group and the case workers than where the various specialists are scattered through different clinics and are not associated closely with the work of the agencies. The New England Home for Little Wanderers is the best known example of such clearing house service. An interesting development of this idea is represented by the children's clinic in Richmond, Virginia, where a psychiatrist is a full-time member of the clinic staff.

The Massachusetts Society for Mental Hygiene is trying out a new type of psychiatric service to social agencies through what is called the visiting psychiatrist. Dr. Elizabeth Sullivan, a psychiatrist experienced in cooperation with social agencies, will visit the central offices of the referring agencies or the homes of the clients in making her examinations. A modification of this service has been tried in Cleveland, and is being developed in Newark through the use of the psychiatrist as a consultant to a social agency. No cases are examined by the psychiatrist, but on the basis of the summary of the agency record there is a case discussion with supervisor and visitor. An extension of such psychiatric service would be the addition to the staff of a social agency of a psychiatrist on a full-time basis: part of his time would be given to this consultant service, and part to examination of cases, as in the case of the visiting psychiatrist mentioned above.

Habit clinics were organized a few years ago in Boston by Dr. D. A. Thom, and have been continued, under his supervision, on a state-wide basis by the State Division of Mental Hygiene. Through the publications of the Children's Bureau at Washington, the organization and operation of these habit clinics has become fairly well known. The efficacy of these clinics would seem to depend very much upon having as the psychiatrist to the clinic a specialist with problem children, and one who had particular experience with the preschool child. These clinics handle children between the ages of two and six. It is a question

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 problems 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 children 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 increased throughout the country by the program for the development of child guidance clinics. Almost all agency executives are familiar with this development through the publications of the Joint Committee on Methods of Preventing Delinquency. The work of these child guidance clinics is characterized by the complete, coordinated study of a problem child. Restricted intake, examination 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