Clinical Organization

Home , Child Guidance, School social worker

CLINICALORGANIZATION FOR CHILDGUIDANCEWITHIN THESCHOOLS

By ELISE H.MARTENS Senior Specialistin the Education ofExceptionalawry=

46.

BULLETIN1939, No. 15

UNWED STATESDIPAITIEWO TRZINTERIOR Harold L. Ickes,Secretary OmanOrEDUCATION s .. s J W. Studebaker,Commissioner

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Pate FOREWORD V CHAPTER I. THE PLACEOF CLINICAL SERVICEIN THE SCHOOL PROGRAM___ 1 Growth of the clinicalpoint of viewin educationTypesof clinical

e. organizationThe clinicalstaffThelarger functionsof clinical service. CHAPTER II. SOME STATEANDCOUNTYPROGRAMS______9 The Stateprogramin MassachusettaTheOregonplanThe Cali- fornia planThe MarylandStateprogram organizedon a county basisA tax-supportedcounty guidanceclinioAcountyprogram in CaliforniaOtherState andcounty plans. 411 CHAPTER III. THERESOURCESOFSMALL CITIES 25 A city serviceCityand universitycooperationCityand county orState cooperation-7-Aplan of jointcity servicewith countyor StatecooperationGeneralcommentsonsmall cityprograms. CHAPTER IV. PROGRAM/IINCITIESOFMODERATE SIZE 34 Psychiatric servicefrom the StatePsychiatricservice froma com- munityagencyPsychiatricservice withinthe schoolsystem Generalcommenta. , CHAPTER V. THZOPPORTUNITYOF THELARGE CITY _ _ 45 Providence, R. I.Portland,Oreg.Jersey City,N. J.Rochester, N. Y.Newark,N.J.Minneapolis,Minn.Detroit,Mich. New York, N.Y.Generalcomments. CHAPTER VI.A CONFERENCEAND A SUMMARY 68 SELECTEDREFERENCES 74 A GUIDETOSTATES, COUNTIES,CITIES,ANDCLINICALAGENCIES REFERRED TO IN THIS BULLETIN 77 FOREWORD There is nò communityservice which ha's showna morephenomenal growth during thepast quarter ofacentury than the organization of clinical facilities forthe adjustmentof ,behavior and personality problems of children.Theterms "child-guidance clinic," "psychiatric clinic," "behaviorclinic," "mental-health Clinic,"and other termshavingasimilar connotationarefamiliarto all who have anyresponsibility for thediagnosis andtreatment of children's difficulties.In 1896 the fitstpsychologicalclinic in the United States wasestablishedat the University ofPennsylvania, and theyear 1909sawthe first psychiatricclinic for childrenorganized in Chi- cago.Since that time thenumber of communitiesserved bypsy- chiatric child-guidanceclinics has reachedamark that probablylies somewhere between650 and 700. Amongthe interested agenciesare, ofcourse,the schools,the guidancefunction of which . is outstanding. Yet the limitations of budgets,both in school andcommunity administration, have alltoo often seemedtoprohibit thedevelopment of a programwhich hasbeen recognizedasdesirable. In May 1988 the Commission&of Education invitedto Washing- tona groupof specialists whowereactivelfiengagedin work ofa clinicalnature, with particular rilationto child-guidanceprograms in schoolsystems. Thepurposesand findings ofthat conferenceare presented in chapterVI of this bulletin.Among the serviceswhich the confereeesrequested that theOffice of Education takieundercon- siderationwasthe Keparation ofmaterial for publicationdescrib- ing thetypes of clidical organizationfor child guidanceunderway in communitiesand schoolsystems of various sizes: Suchapublica- tion, itwasthought, mightstimulate schooladministrators andother Civic leaders,in tommunities inwhichnodefinite fòrmof clinical organizationasyet exists, to seek possibilities for iervioein this field.Moreover, by showingtrends of organizationto date,one maypointout the direction which futuredevelopment islikely to take. -# This bulletin isanattempt tomeet therequest of the conference. It doesnot purport to makeacompletesurveyof clinical organist- dons in operation, butrather 'topresent illustrative practice, folind insomeof the States, counties,and cities in whichthe principlesof child guidancehave taken deeproot. It reflects the deliberations of v A e

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4 . A ,/,t :" . *4 I 4 4.; . ._ .Vv.i4'e 4, 4, ;1"1 v A". 4.,140r.. 4_, 1 S.; : Jerte 410`_. VI FOREWORD the confereesaswellasthe dataassembledby theOffice ofEduca- tion &roughtheuseofinquiryforms. Itshows,first, certainor- ganizationplansfollowedon aState-wideor a county-widebasis; then proceedsto the effortsbeing made insmallcommunities;next, to programsin cities ofmoderate size;and,finally,toa consideration oftheopportuniti..: ofalarge city.There hasbeennointent to describein detailmethodsofprocedureor types of diagnosisand treatment. Thesearetheresponsibilityof thespecialists incharge of the localprogramafter itis organized,and itis assumedthat those appointedwill becapable ofdischargingthatresponsibility. Only the broadlines oforganization andrelationshipsare sketched, in orderthat those whoareinterestedmay see howafoundationcan be laid forthedevelopment ofaneffectiveprogram. To all who havesuppliedinformationthroughconferences,re- sponseto inquiry forms,or correspondence, theOffice ofEducation extends gratefulappreciation. The citie's,counties, andStatesré-, ferredto in the successivechaptersconstitute onlyasmallpropor- tion of the total number-ofcommunitiesin whichclinicalservice for children is underway.It isbelieved,towever, thatthepro- gramspresentedareillustrative ofthe varioustypes thatarebeing operated withadirect relationshipto the schools ofthecommunity. BREI8 GOODYKOONTZI AssistantCommissionerofEducation.

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CLINICALORGANIZATIONFORCHILD GUIDANCEWITHINTHESCHOOLS CHAPTERF

THE PLACEOFCLINICALSERVICEIN THE SCHOOL PROGRAM HE TERMS"clinic" and"clinical"focusimmediateattention Tuponthe individualand hisproblem.Originallyappliedto medicine, theyhavenowbecome identified*withnumerousother fields in which effectiveservice isdependentupon aclose diagnosticrela- tionship betweenclient and theperson orpersonsqualifiedto give him expert advice. Thesuccessivesteps involved ingivingfull clinical servicetoanyindividualareexamination,diagnosis,andtreatment,- with thenecessaryfollow-upto check andto insure results.

GROWTH OPTHE CLINICALPOINT OFVIIM INEDUCATION In theschools theemphasisuponclinicalservicehasemerged asthe result ofanumber ofinterlockingfactors.Alwayspresentto acertainextent inaconstructiverelationshipbetweenteacherand pupil, ithas receiveditsgreatest impetus duringthepastquarter of acentury. The inaugurationof theuseof mentaltests, the attendant discovery of thewiderangeand diversityof capacitiesamongschool children, and theintensive effortsto provide forindividualdifferences- and needshave inthemselvespartakenlargely ofthe clinicalap- proach ineducation.The widespreademphasisuponintelligentand sympatheticpupilguidanceas amajorfunction oftheschoolhas .contributedsubstantiallyto the furtheranceof clinicalmeasures. Theacceptance of theconcept of the "wholechild"asthe objectof attention, withall itsinextricablyinterwovenimplications,hasneces- skatedaclinical studyof individualcases.Classroomteachers have becomemoreconscious ofthe need ofmalcingadjustmentsfor specific pupils. teachers andspecialclassteacherstiave beenap- pointedto handle serious instrudionaldifficulties.Sc/Wolcounselors, visitingcounselors, andvisitingteachers withexperience hiboth education and socialwork havefoundaplace inthe schoolsystemto study andto assist inadjustingpupil problemswithparticularatten- tionto the interrelationshipof community,school,and home.Health lind medicalspepiaiiita,psychometrists,and psychologistshave been -4 "C' t* . 11 -4 (JS *": , . r . 4,-4*4 1"t1.71: 4.271" 'rt. 'k44411Aqift -s, r VW f.. *. }_ 1'4 .:14_*4 °'''41: _jef741410r- ; t..i.4**1 .4i4$4,¡Zi 2 CLINICALORGANIZATION FORCHILDGUIDANCE

addedto the school staff.The servicesof allthese peoplehavebeen indicative ofthe increasingimportance placeduponthe clirOcal aspects of the educationalprogram. Situations arisingoutside theelementary andsecondaryschools have likewisebeen responsible for'the growthof clinicalassistanceto cihildren ofschoolage,and these havehad theirpart in stimulating dieschoolsto further action.dommunity,State, andnationalproj- ects have been undertakenwhicharedirectedtoward theprevention of crimeand psychosis.Widely publicizedresearch findingshave pointedto maladjustmentsin childhoodas,forerunners ofserious delinquenCyand personalitydisturbance&Authorities inmental, hygiene haveemphasized theimportance ofdetecting andadjusting incipientpropems ofbehavior and ofthus obviatingthe dangerof theirbecomingacute.Teacher-trairiinginstitutionshave begunto makestudents recognizethe importanceof mentalhealth jntheirown experiencesand in the livesof thitirpupils.Privateenterprisehas .subsidized clinicalprogramsin demonstrationcenters,some ona temporary basis, othersascontinuingagencies. Thus, coming h&c'both withinand withoutthe educationalranks, significant influenceshave beenat work toconcentrate attentionupon the clinical'point of viewsliduponclifficalpractice inthe schools. It isnotsurprising,therefore, thatschool administratOrsshould be lookingforwaysandmeans tomake betteruseof the Possibilitiesfor clinical servicewhich theymayalready havein theirmidstandto addto them other services inan ory:nized fashion.

TYPES ,01? CLINICAL'ORGANIZATION

The desireforanorganized planof workhas ledtoavarietyof .. programs designed specificallyto adjust behaviorproblem§ ofpupils andmoregenerallyto help teachersto apply the principlesofmental hygiene in theclassroom.Yet, iinmediatelyoneis facedwithques- tions ofdefinitions andrelationships.-What isa,"behaviorproblem"? When tioeed&kieducational probl viIleabehavior problemiH.ow, isaparticular child'sbehavior relatedto his physical condition!To his mentalcapacityorschool achievenientiTo hts homesituationor ether environmental faitorsI Canaclinicalprogramfor behavior problems bedivorced fromthe total schoolguidanceprogram! Or . . . tromthe totalpro, r Y or health? "-Nn.16spe- ci013tsmust be I:1,yedtoe cariyon'a I 1 progiainI theseand other questions'love caused mica)coiy: s to school administrators who aregeariinely interested'develop 1' anelectiveclinical.service, t h : . is andno oneknows ,the findanswers to s- Thei *tryinganswers that have beengivens:5o wellasthe financialresources athanfIL-ari. reflectedIli'die 7734.: varyingtym of prganistionipetup,ranging from 0. et . ,. . ) !it

%r, ' k0. 'I, 1. .;0 N : J. - CLINICAL ORGNIZATIONFORCHILDGUIDANCE 3 the simplest planof erationamong alimitedpersonneltoafuil clinical staffof speciali ,In small8chool8y8t1718.---Insomecases one school psychologistor asocially mindeda.7.ndanceworkermayofferthe onlyhope of clinical assistancewthinthe schoolsystem, andhence theresponsi- bility for thepro mdevolvesuponhim.In othercasesitmaybe aschool counsel or avisitingteacher;in stillothersaschool physician whohhadpsychiatrictraining;and inothers theschool mayhaveto 1 entirelytoanoutsidecooperatingagencyforspe- cialized servicedependingupon members of itsregular stafffor the moregeneralnalysis oftheproblem.Thus,withoutcomplicated organization,one or two qualifiedpersons may, at leastinasmall school .systerii,initiatea program that Willmakeasignificantcon- *, tributionto the clinicaladjustmentof pupilproble.sis,includingthose of behavior. In citia ofmoderatosize.----Virhenexistingfacilitiespermita some- what moreextensivestaff,problemsoforganizationloomlarger,and they becomeincreasinglycomplexwith theincreasingsize ofthe city. A clinicalunitmay beestablishedin thedivisionofguidance,orift the department of pupilpersonnel,orin thechild-stiidydepartment., orin the psychological division,orin thehealthservice,orinthe division of special'education,oritmayexistas aseParateentity its director with responsibleimmediatelyto the suPerintendentor toan assistant superintendentin chargeofa group of relatedfunctions. Mere isno pattern of organizationwhich,;anbe offeredas a model for allcommunities. So far as canbe ascertainedat thepresent' timelhowever,the larg- est number- ofclinicalunitsorganizedwithinschoolsystems of moderatesize have been madeintegralparts of thetotalguidance prográmof the school.In suchcasesguidanceisinterpreted,not in thenarrowsense ofvocationalcounselingbutas abroadservicefor thepersonal adjustmentof alltypes of individualproblemswithinthe scópeof school consideration.Problemsofbehaviororsocial adjus4nent mal- coxistituteonlyoneof thesetypes. Thedirectorof guidancein theschoolsystem ofacity ofsome 86,000 inhabitants out that the points guidancemovement "developedout of theneedto help the adjustmentof theindividualchildwithinthelarge-scale, ardized stand- system of education.Problemsofeducationaladjustment, problemsofattendanceandbehavior,and finallyvarious lems tie socialprob- the sphereof the guidancebureauorclinicactivity."1 Repro- sontative of thispoint ofview,wefindvariouslynameddivisions the school of system dischargingalliedfunctionsofguidanceandclinical

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... ; : : , i : : -. ;,"t,...... -': 4 :i'...t- : . , . -;', . . tx.---",.. ".4... ..te.:. . .. . -1--* ».)- .!i ::12.11:Jo? . ,is..-'...«): .,-4' ,-,71 .-- .".. 1 ' -,, i:* :Pr .11bZar4".. '...... *it 0... 1;$1-,,v7 y-4#.,44.,,,A :'.-:i .;:i.:1'-r._ ... - - .e...: .4, v-, 4.'.5%,:-. t. :..,..-.... 4; 7;CAA : - :, ...- ..4, r . _,....1-11,441. iv : . lir:V4 ,:4. !Wei',.0.cifi'.. ., ,..ti, ,.._ r....-5e. , __. ..?,...... rite CLINICAL ORGANIZATIONFOR CHILDGUIDANCt a service.Among the titlesusedtiredivisionof guidance,placement, and personnel;attendance and guidancedepartment;guidancecom- mittee;department of pupiladjustment;department ofchildaccount- ing and adjustment;department of pupilpersonnel. In largeschool systems.--Inthe largestschoolsystems of thecoun- tryone mayexpect to findatendencyto perform the respectiveguid- ancefunctions indicatedhere through sepat;t:ebureaus, withan °attemptto coordinate services throughadministrativerelationships. One schoolsystem, for example, inacity ofmorethan300,000 inhabitants, carriesonits individualguidanceservices throughsix coordinate divisions ofthe superintendent'soffice staff,namely,(1) the visiting teacherdepartment; (2) thechild studyand special educationdepartment;(3rthedepartment ofeducational andvocational guidance;(4) the attendancedepartment; (5)theparent education andchilddevelopmentdepartment; and (6)the physicaleducation department. In cities of this sizethe clinicalservices for behaviorproblemsmay still be considered a part oflargerprogramof studyfor all children. 6011 With suchan arrangementthe "child studydepartment"orthe "psychological clinic" whichservesthe entire schoolpopulationserves also through intensivestudy the seriouscasesof maladjustment.It reservesthe rightto determine the nature andtheextent of the exami- nationto be made and the treatmentto be given in accordance withthe need of the child.Thereasonfor suchan,arrangement is basedupon the close interactionof educationaland socialmaladjustmentsand uponthe imperceptiblegradation in the relativeseriousness ofbehavior problem& Somanyfactors contribiltetoor areassociated with so-called "behaviorproblems" that it isimpossibleto isolate them as a groupuntil they havebecome rather pronounced.Through its wider applicationto all the children of theschoolsystem,adepart- ment of child study has the opportunityto exerciseapreventive influ- enformanyandaremedial effect- forthecomparativay few who need intensivemeasures. 4bi In keeping with Wsbroad conceptionof the clinicalfunction of the schoolprogram,the Educational PoliciesCommission ofthe National Education Associationdescribes theactivities ofthe "child- . guidance clinic"ufollows:2 The child-guidanceclinic bringstogether theteacher, parent,attendance worker, psychologist,and physicianfor consultationregarding thechild with problem& Thegenteel; ofa psychiatrist Okay also beneededpn occasion. The clinic ',Wilesthe child from all fteisReich* todiscover the roots ofhis [1 realties wbetkurthey lie isabnormalithpoor 'health: mentalmiadjustment,emotional conflicts,bid homeor school conditions, e; I-ç e Tb ttecational Pond.*Comtioéess.44dal emics. aut tbeallehsolat Washington, si4' D. C., NatiostalEducatiso Aartiedsos.P. OS.

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k t -e 4.? 1 ` , . 2e .4 r # -+ 11; -* ?fr., 4, 7. - ' -*/ -4 I . . -- ' ' ;. 4. .4 ; c¡ - 'VP - ;" ' 71 -t "' -. .` -4; bt. ' r " s!'g '4% . ..).; , 44- :1, % A47-At-Yr.,: " kt14- ( S 7 4-1P.?.!1:- z CLINICALORGANIZATIONFOR CHILDGUIDANCE 5 unwholesome friendships,or unfavorablecommunityenvironment.When thecausesof troubleare identified thetreatment isprescribedand the case followed up through theappropriateagencies ofcorrection. ()litheother hand,inafew of thelargestschoolsystems, also, the organization knownas a"child-guidanceclinic"limitsits major services to childrenofat least normalorapproximatelynormal intelligence who havedisplayeddefinitesymptoms ofadisturbed personalityorbehaviormaladjustment.This isin keepingwith the general conceptionof theefunctionsof suchaclinicasheld bythe National Co ittee forMentalHygiene.Aleadingrepresentative of thisorga tion hasdefinedachild-guidanceclinicas a"psychiatric clinic that -0-4cl psychologistsandpsychiatricsocialworkers; it isaclinic tha ..;:primárilywith behaviorproblems ofchildren ranging fairlynormallyin distribution;it isas arulecommunity- wide inscope;its servicesareof varying,degreesof intensiveness, but characteristicallyit is equippedto dovetailpsychiatric,psychological, andsocial servicesintoasingle diagnosticstatement anda single plan of treatment."I There isnoreal conflictbetween thetwo points ofviewpresented .here. TI1 differenceappears tobe largelyoneofterminology.Edu- cators and psychologists,ontheonehand, andmedicalmental hygienistsonthe otherhand,areunanimous inadvocatingclinical guidance for allschool children,withpsychiatricassistancewhen needed. Theformerarelikelyto define "childguidance"interms . of varioustypes of adjustmentprocedures foralltypes of problems foundamongschoolchildren. Thelatter tendto restrict itto psychiatric andassociatedtechniquesused forthe adjustmentof behaviororpersonalityproblems. Indescribingin thisbulletin the programsin operationin specificlocalities, theterm will bedeedas it is employedlocally. avio THE CLINICALSTAFF Whatever the planof organizationusedorthe situationinto which the clinicalunit for theadjustment ofbehaviorproblemsmust fit, therearewell-definedstandards withregardto desirablepersonnel. These havealreadv been impliedin theforegoingdiscussion,and they have beendetermined byananalysis ofthe influencesacting upon the child's 'behavior,which ingeneralmaybe classifiedas physiological, mentaland educational,emotional,andsocialor environmental. The physicianand the psycholog'ist.---Formanyschoolsystems, Atpoint ofdeparture in developingaclinical piogramin whichall or :. mortmar mow%, rob. 7 +fa t 1 ettvonson,Oierg0& Communityclinksas training oaten forpsychiatrists.Men- toil hygiene,18: , 03481, July 1934.

: ' - .. : : CLINICAL ORGANIZATIOlsiFOR CHILDGUIDANCE

these influencesareconsideredlies intheuseof thetime ofschool physicians and schoolpsychologists.The, schoolphysicianmakesa physical examination;thepsychologistadministersamentaltest. studies thechild'seducationalprogress,and, ifheis.qualifiedin- the broader aspects of clinicalpsychology,hemay go further inthe alkalysis of the child'sabilitiesandpersonalityasfactorsinmental health and socialadjustment.Thefindings ofthesetwopersons alonemay throwsignificantlightupontheproblem Fidpointthe way to effective treatment throughcurriculumadjustment,medical service,orothermeans. Thecase tworke4--A thirdtype of serviceis alsoimportant, namely, that representedbyavisitingteacher,psychiatricsocial worker,* or person withequivalentresponsibilities.Contactsmay needto be made with thehome, thehomesituationmodified,community influencesandresourcesstudied,the child'senvironmental problemsinterpretedto theteacher. Apsychiatric or a socialworker visitingteacher,who hashadtrainingandexperiencebothin classroom serviceand insocialservice,is wellequippedforsuch participationinatlinicalprogram.In theabsenceof suchaworker, certain schoolsystems makeanefforttosecurethesamegeneraltype of service throughspecialpart-timeassignmentsto regularteachers as"school counselors"or"visitingcounselors"whoarefittedbyper- sonality and some trainingtocarry onwork ofthiskind.Reports frommany placesindicategratifyingresultsundersucharrange- . ment, although one cannot, ofcourse, expect thefamiliaritywith socialserv.icetechniquesdisplayedbyaspecialist. The poohiatrist.---Thefourthtype of service\whichisessential for 'acomplete clinicalorganizationis thatof thepsychiatrist,with emphasisupon theapplicationofpsychiatrytothelivesofchildren. The science of "childpsychiatry"or"childguidance,"astheterm is used,by psychiatrists,hasevolvedas an importahtbrtiichofa fieldwhichoriginallywaslargelylimited to the studyandtreatment la ofmental diseaseampng adults.Thepsychiatristisaphysician who has: spe'cialiteduponthestudy oftheindividualusatotal functioningorganism, with älltheintricaciesofrelationshipamong ' physiologicaland emotionalfactors.The"ohildpsychiatrist". psychiatrist isa who appliesthisspedaltyto children.The tremendòus grows#4 Ofcommunity child guidancecliiiiesduringthepast 25years has'teS44dto the need - and, itis hoped,to the effectivenessofsuch 813*.-rvice. ":

4.& I "psychiatricmetalworker"isa socialworkerwho teehtdolebut without has hadtrainingLs psychiatric the'polleepreparstioaot thspsychiatrist. IA asdietern isneed hiMabullettáljv "Askingteacher," pormiswho,withbodkinssootiest%bUe r-111104041111 ththemodal 'lentof pupilproblem :

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THE LARGERFUNCTIONS OFCLINICAL SERVICE The immediateassistanceto individual children whopresent prob- emsof adjustment isnot thedailyfunction of theclinical organization, and if it limits itsprogram tothis the clinicwill fall farshort of its possibilitiesfor service."Tlievalue ofaclinictoaschool system," says onespecialist,/ "liesless in the benefitto the individual child studied than in helping teachersto understand andtreat all probleta children ina moreconstructive manner."Another' considersit "important that the clinic shall befpgardednotas aplaceto get rid of

s The NadonaleCommittee for Mental Hygienetitspublisheda Directory of PeyoMetris Clinics 1st the MAW&Stet,as et 1938, *lading those operatingunder the auspice:se Boards a Education. %ran, W.Carson.Mental Wankthree* aducatios. NewYork, The Commonwealth AO taste MI& Pp. 205-208. !Wawa', H. W. Themows of child.goldases adaptedto a public-schoolprogram Mental *ilea% 18: 8112412,July 1934. *. s Robinson, Brew B. Tbsplace of the *IA;Wanes disk in mentalOgles& 8111.p. eitienal Method, 14: 1110--188,January 1931. I

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aproblem, butas aplace whereadditionalunderstandingandhelp maybe receivedsothat theresponsibleperson cancarry on his workmoresuccessfully." From thereport of the directing psyciatristofachild-guidance clinic organizedwithinalarge cityschoolsygemcomesthestatement that "theclinicoperatestoremoveobsticles(withinorwithoutthe child's personality)to education.It also hasaneducationalfunction in helpingparents and teachersto understand anddeal withchildren ip wiserways.It hasthe functionof learningfromtheindividual cases seenwhatarethe majorsourcesofstress in the 'schoolsystem and aidingin removingormodifyingthese forimprovementof the mentalhealth of theaveragechild."a Followingout the implicationsof thesestatements,weconcludethat the clinicorclinicalservice,to be most effective,must be intimately -relatedto activities in theschooladministrativeoffices, inthe classroom,andonthe playground.Schoolorganizationcanbe madeto contributeto mental health ofboth pupilsandteachers, butitcan also contributeto their mental illhealth.Classraimproceduresmky either helporhinder theprogramof mentalhygiene.Principalsand teacherscanreinforce theclinicalserviceortheymaythroughlack of understandingundo all the clinichasaccomplished. Itseems mostessential,therefore,thatthesepersons should be brought into theclinicalprogramandprogressivelylearrihowto applyto school and classroomsituationswhat theclinic isattempting to do with individualcases.Theymaybe giventhe%pportunityto participate inclinicalconferences,to enroll inprofessionalcourses ordiscussiongroupstreating theapplicationofmental hygieneto education,to consult the psychiatristpersonallyuponindividualpupil problems, andtosecureaid inadjustingsomeof theirownproblems. In 'these andotherwaysthe influenbeof theclinicmaybe extended directlyorindirectlyto all the childrenin theschoolsystem.Prin- cipals and teacherswill thusbecomeincreasinglyableto handlesuc- cessfullyanumber of themilderproblemsoccurring,leavingthespe- cialized seivice ofthe clinicfor themoreseriouscasesand forthe evor-continuingprogramofparent and teachereducation.When this happens, mental hygienewill reallyfunctionin education,for it will constituteanintrinsic'part ofeveryteacher'sequipmentfor service.

Statementcontributedby theChildStudyDepartment,Public Schools, Minn. Minneapolis,

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SOME STATEANDCOUNTY PROGRAMS Inarecentarticle by George S. Stevenson,atthat time Director of the Division of Community Clinics of the National Committee for Mental Hygiene, it is pointedout that"approximately80 percent of the service offered by child guidance clinics is offeredto communities withmorethan 150,000 population, whereas the smallercommunity, the type that holds 75 percent of the population of the United States, has had but 20 percent of the total service.Furthermore,this 20 percent hasbeen conducted for themost part inarather planlessway. This fact is crucial to the planning of State services kcause itdefines the unmet need towhich the Statemayrespond?" The significance of this statement is obvious.If the childrenin rural school districts and in small towns and citiesare tohave the benefit of expert guidance services which will recognize andtreat the problems of personal maladjustment, such services will inmost casesneed tocomefromalarger unit than that representedby the school district in which the child is enrolled.Thereareseveral bases uponwhich this larger unitcanbe organized.In the first place, several neighboringdistrictscanjoin forces ill establishingaclinical program,thus sharing both theexpenseincurred and thetime available.In the second place,acountyprogram maybe organized, designed toserve everyschool districtwitlathecounty.In the third place, the Statemayacceptthe responsibility,asStevensonsuggests, for developingaState-wide system of child guidance clinics which mayextend their influence intoevery cornerof its territory.As the State isthe major unit for educational provision,soitmaylikewise become the unit for specializedchild-guidance serviceto those whom it would educate. All three bf theseprocedures have been used, with varyingplans of action and withvarying degrees ofsuccess.It istoo early to evaluateany oneof them in conwarison with the others, for the whole movement is still tooyoung.The goal of each of themmust be to reach the needs ofeverychild, whether in ruralarea orin crowded city.Some of the organized efforts being ktadeto do this

I* Stevenson, George S. Lines et development of child guidance clinics. Psychiatric quarterly supplement,1$:111-48, January 19110. 168114* ;: 2 9

Alm lo CLINICAL ORGANIZATIONFOR CHILDGUIDANCE

areworthy of closeexamination,eventhough resultsmaybeas yet admittedly inadequate.In this chapter,therefore, certainprograms will be describedillustrative of Stateandcounty projects.Con- sideration of city andjoint cityprogramswill bereserved forlater chapters. THE STATEPROGRAM IN MAkSACHUSETTS'

Probably themost extensive clinicalprogram onaState-widebasis has developedover aperiod ofyearsin Massachusetts.In theState department of mentaldiseases, whichhas generalsupervisionof all public andprivate institutionsfor the mentallyill, the mentallyde- fective, andepileptics, thereisadivision ofmental hygieneaswell as adivision ofmental deficiency.Each of thesemakesadistinct contributionto the clinicalprogramof the State,the formerwith referençeto behavior and personalityproblems ofintellectually normal childrenof preschool andearly elementaryage,*andthe latter with primaryreferenceto mental retardation andassociatedfactors. Eachoperatesaseries of clinicsfor which itdrawspsychiatricand other specializedassistance from theState hospitalsabd the State schools for thementally deficient.Some of theclinicsfunctionas integralparts of the hospitalprogram,othersarecarriedonin closely coordinatedrelationshipto the local schoolsystems.All of themservethe school childrenof thecommunity in whichthe clinic is held.Those operatedby the divisiönof mentalhygiene arecalled "habit clinics,"and those ofthe divisionof inental defi- ciencyare"traveling school clinics."In addition,certain ofthe State hospitalsoperate theirownchild eidance'clinicsas out- patient departments.In allcases,workingrelationshipsaredevel- opednot only with the schoolsystem but with othercommunityagen- cies concerned withthe child in question. Habit andchildguidant;ealinics..The habitclinics andthe childguidance clinics ofthe division of mentalhygieneoperate inconnection with11 institutionalcenters of the State. Thecommunitiesin which thesearelocatedrangein size fromtowns of less than10,000 populationto the city of Boston. Theprofessionalstaff providedby the hospitals includesspecialists inpsychiatric,psychological,medical, and social service.More thanathousand childrenareserved eachyear,most of -them receivingintensivestudyat the handsof physician, psychologist,psychiatricsocialworkers, andpsychiatrist, withrecurrent visits to the clinicoccurringover aperiodof time. The psychiatrist is the coordiiiatorof staffactivitiesand takesthe leadership in staff conferencesat which thecaseis reviewed,adiag- u Information concerning theNeeesehneettsprams has bees securedfrom(1)reports of thèStatedepartmentof sentniMeows;(2) Inquirytome fontto local school systems;( 11)- correspondenceandconference. t. .4 = CLINICAL ORGANIZATION FOR CHILD GUIDANCE 11 nosticsummarypresented, and plans fortreatment made.Physi- cians,teachers, social workers, and others interested inaparticular case areinvitedto the conference at which it is discussed.About one-third of thecasesstudiedarereferred by the schools, one-third by health agencies, and the other third by children's agencies, friends orrelatives,Physicians,orothersourcesof referral. Supplementary conferencesareheld by the clinicalstaff with! school officials and theseserve atwofoldpurpose:(1) To giveto principals and teachersabetter understanding of the psychological aspects ofchildren's problems andabroader understandirig ofthe aims of mental hygiene; and (2)to provide the clinic staff witha clearer appreciation of the school environment in all its implications. Thus each professionalgroup serves toenlighten the other in the interests of the best possible adjustment foreverychild.The clinics ; conceive their function in terms of the larger responsibilityof in- fluencinieducational procedure, and they have proveda sourceof vital assistance to the schools with which theyhave operating relationships. Sùchaclinicalprogramobviously demands adequatelytrained personnel.In commentinguponthismatter, the director of the division of mental hygienesaysinoneof his annualreports:1!. It has been demonstrated beyond all doubtthatwe cannot expect the State hospitals to operate these clinics with the byproductsof their hospital staff.The needs of these clinics for childrenare not those of the institution either in the interest, training, or experience of thepersonnel which makeupthe staff.If this type of service isto be rendered by the State to the various communities in which State institutionsarelocated, it is absolutely necessary that each institution be provided with fundswith which to secure adequately trainedpsychiatrists,powchologists, and social workers and that the clinic personnel _should not have dutiesconnected with the institution.Only in thisway can we expect to get wholehearted cooperation from the superintendents of the institutions inthe development of community activities.It is too muchto expectanalready overburdened hospital staff to embark upon these extrainstitutional d#mandswithany degree of enthusiasm evenif theywere trained and interested in this particular field ofpsychiatry. The psychiatricand psychological approachto the child is quite different from thatwhich is made to the adult.The social situationswhichcause us concernwith reference to the school child are not those in whichwewould be interested were wethinking of patients fromaState hospital.Both typesof work require specially trained and experienced personnel., . This statement exp the conviction ofcettain other child- guidanceworkers who . Pteto give to psychiatrists who have had training andexperience only in institutional work for adultsthe

al The Commonwealth of Massachusetts,Annual Report of the Commissioner of Mental Diseases, 1114,P. SO.(Public Document No, 117.)

_.J . .

*I. 12 CLINICAL ORGANIZATIONFOR CHILDGUIDANCE responsibility for clinical serviceto children.In orderto obviate the difficulties encountered,steps have been taken by professionalgroups to designate thetypeof training andexperience which willoffi- cially qualifynot only the psychiatrist but alsothe psychologist and the social worker forservice inachild-guidance clinic." Traveling school clinie8.Thereare15 psychiatric travelingschool

11 clinics in Massachusettsfunctioning underthe division ofmental deficiency, each of whichoperates fromagiven State hospitalor schoolas a centerand gives service directlyto the schools inthe surrounding territory.The responsibilityof these clinics ispri-

, marilyoneof diagnosis and recommendationfor educationalplace- ment of backward children, but otherproblems relatedto behavior orpersonalityareincreasingly demandingattention, andthesco of service renderedby the clinics is growingcorrespondingly bs :ir. From 8,000to 9,000 examinationsareconducted annuallyinm re

than 200 differenttowns of the State,manyof themOfadistin.3r. rural character.The personnel participatingin theprogram,on eitherafull-time,\orapart-time basis, intheyear193647 consisted of 20 psychiatrists,29 psychologists9rpsychometrists,and 16 social workers, with the additionof the social-servicestaff ofoneof the hospitals. The totalcost to the State of the operation ofthe clinics during thatyear was$46,255.40, theaverage cost perexamipation being $5.56. To supplement theservices provided by theState for thetraveling school clinics, the localschoolsystem assigns two membersof its ownstaff*to work with the clinic.Theseare(1) eitheraschool nurse or avisiting teacher, whoassists in preparingthe historyof the child and inmakingcontacts with the parents; and(2)ateacher who gives the educationaltests requested by the clinic.Sometimes the school physicianis alsoamember of the clinicalgroup,andsome of the largertowns furnish psychological serviceaswell.All forms to be filled inarefurnished by the Statedepartment.Througha well-organizedprogramscheduled inadvance of theclinic'scoming and providing the needed preparationfor its visit,aneffectiveserv- ice is builtup.The final recommendationsof the psychiatrist,who is in charge of the clinic,eónsidereducational,social, andphysical adjustiiients that should bemade, and actiononthecaseis leftwith the school authorities and theparents. our r. a Standards of trainingof professionalpersonnel in psychiatricclizaps.Recommenda- tions ofastudy by the New YorkCity CommitteeonMental Hygieneof the StateChari- ties AidAssociationand ilia Mental HygieneSection of the WelfareCouncil ofNew York at/.14p

. e . r., ". .1 . . r 1..t1; 1Z. tt 12:1;:t31:014;t:: -At-44 51_4%. I1 CLINICAL ORGANIZATIONFOR CHILD GUIDA4CE 13 4.

V.PERSONNELOF TRAVELINGSCHOOL CLINIC

(PSYC H A T R JST] (PSYCHO LO GIST Le------LSOCIAL WORKER

AIDS FROMLOCAL°SCHOOL SYSTEM

SCHOOLNURSE ASSIGNED TEACHER OR TO COMPLETE VISITING TEACH ER. SCH OOL TESTS.110

(PRELIMINARYPROCEDURE)

RETAR0ED CHILD R EN LIST SENT DATE 'SET LI STED B Y TO CLI N IC FOR VIS IT SCHOOL SUPER INT EN DENT PSYCHIATRIST. OF CLINIC. v f 411111111W

HISTORY AND TEST HISTORIE S SCHOOL TESTS FORMS FORWARDED COMPLET ED BY COMPLETED BY TO SCHOOL SOCIAL WORKER ASSIGNED SUPER INTENDENT. OR SCHOOL NURSE. TEACHER. J r

FINAL PROCEDURE ) _0_ TRAVELING CLI N IC EXAMINATIONS COMPLETED SUMMARY AND VISITSSCHOOL. BY CLINIC STAFF DIAGNOSIS BY (AV ERAG E6 PER DAY) PSYCHIATRIST. %Jr r o DETAI LED REPORT RECOMMENDATIONS OF PARENTSINTERVIEWED TO SCHOOL PSYCHIATRIST BY PSYCHIATRIST SUPERINTENDENT, EDUCATIONAL ; SOCIAL!PHYSICAL 4owboorwm...... r=111111111S1111111MIIIMMINIIMAIP

CHART. SHOWING PinecortNgt.ANDPROCIOMIIIIOVTsAVELING &MOM CLINIC.IN iimutscaverrrs. Reproduced by courtesy of the Massachusetbetite Department ofEdizcationand the Massachusetts State Departmenrof MentalDiseases.

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iktia 14 CLINICALORGANIZATIONFOR CHILDGUIDANCE

These travelingschool clinicsarethe outgrowthofaplan ofco- operation,recognizedby law,between theStatedepartmentofedu- cation andthe Statedepartment ofmental diseases.They havebeen developed insucha way as to meet the varying needsof theschool systems involved andhave provedadefinite stimulusto the organization ofspecialclasses forretarded pupilsthroughoutthe State. Because their Contactwith eachchild is limitedin 'mostcases toa singleinterview inthecourseof,a year,theirwork withbehavior problemsmust necessarily beless intensivethan thatcarriedonby the habitclinicsorthe child-guidanceclinics oftheseparate hospitals.. Onthe otherhand, theyarereachingamuch largerterri- tory, and forproblems ofmentalretardationnot seriouslycompli- cated withbehaviordifficultiesasingle interviewwithdiagnosis andrecommendationsis usuallyall thatis needed.There isno doubt thatthe servicethus rendereato rural districtsand small townscanbe ofimmeasurable valuein preventingthe socialmalad- justment thatsooften resultsfrom schoolfailure. Localattitude towardthe clinicg.Theschoot,people inMassachu- »setts havecome tolookupontheclinics--particularlythetraveling school clinicsasa partof the totalprogramprovidedby theState for theadjustment ofthe problemsof schoolchildren.Mostof those whohave commenteduponthe planbelieve thatthe cooperative arrangement isonthe wholesatisfactory.They pointout that the clinic "bringsawealth ofsuggestionsfrom othercommunities"which it hasvisited;thatparents lookuponitas animpartialagencycorn- ing fromwithout thehAmediatecommunityan4 thattheyare re- peatedly seekingthe helpitcangive.Certain-:..ationsaremade however, andthese referprimarilyto the limitationsof serviceavail- able andtothe:inadequateunderstanding,onthepart ofsomeof the visitingclinicalstaff, ofthe localeducationalsituation."Too litnitedaclinical force,""neededimprovementinextent andquality of service,""infrequentcontacts,""too littlefollow-up,"and "im- practicalrecommendationsof thepsychiatrist"are some of the obser- vitions made.One schooladministratorfeels thatthepsychiatrists insomehospitals "candoagreat deal ofharm."Thisstatement bearsuponthe,matter alreadydiscussedwithregardto desirable qualificationsorwychiatristsassignedto work withchildren.As Stevenson pointsout 14' One of themost importantdeterminationsofa successful Stateprogram is its personnel.Proficiency Ischild psychiatryis nota byproductof hos- . pital psychiatry,although thisIs importantas a foundation.Moreand more, aswo critically evaluateour training for thisfield,are we finding it necessary to strengthencertainaspectsageneralknowledgeof child

11,411. 16Stvonson, pompS. Optit.,p.

Om.

I ! _ , .4 ; : .. , di t e 4,44Viadr.; 4r..L3;.-3124Q43144-giiit.litZ V.414SU1 CLINICAL ORGANIZATION FOR CHILD GUIDANeE 15 development, a knowledge of community fupctions and how communitiesare organized to perform the functions particularly of education,protection, health and welfare, how they affect child behavior, and howto collaborate with them.Knowing the difference betweencommon-sense advice and a specific psychiatric knowledge of therapeutic procedures withchildren,ap- preciating the need for joint efforton caseswith psychologists and psychiatric social workers,aknowledge of standards of perRonneland training inthese fieldsis all-important toclinic staff inunderstanding their functions. THE OREGON PLAN is In OregonaState child-guidance clinic has been developed, with the medical school of the University of Oregonasthe nucleus of clinical activities which extend through traveling units into various sections of the State.Members of the faculty of the department of psychiatry in the medical school comprise t4 medicalstaff of the central unit, direct the organization of local units, and offer the necessarypsychiatric service.In 1938 the State Legislature made anappropriation of $12,000per yeartothe medical schoolto be applied toward theexpensesinvolved in carryingontheprogram which had hitherto been operating withoutanyspecial State aid. Asaresultsomeextension of service became possible.In May cd thatyearitwasreported that "10 clinic units have beenestablished and 5morewill probably be institutedat the beginning of thenew school year." 16All units have been establishedas aresult of interest coming from within the community rather thanas animposition of service from without. In additionto thepsychiatric assistance providedby the medical school, the central unit furnishes also the social servicesnecessary to maintain contacts with the local units.The local district isexpected to makeavailable the time of educational, social, and healthworkers neededto complete theclinical service for both diagnosisandtreatment.It is thought, however, that thecost of operating the local unitscantoalarge extent be met through mobilization ofthe facilities already available from various types of agencies withinthe district.The general plan of organization and functionalrelation- , ships is shown by the .charton page17. The leders in thisprogramof work placegreat stressuponthe need of coopehtion and coordination of services.It is held that-- Child guidance issoclosely related to the general fields of medicine,education, social work, health, law enforcement, and general communitywel- fare that the pioblem of broad cooperation, both local and State,is acute. ( It is vital to the existence of suchaplan thatnosingleagency,represents.

0 Information concerning the Oregon plan has been securedfrom (1) reports of the" University of Oregon Medical School; (2) correspondence. 14 The Oregon child-guidanceprogram.The commonwealth review, 20:475-485, Maq 1938. .1 duma

...C11 4-.- se I 1- is . 1 4 :11 "4- 16 CLINICAL ORGANIZATIONFOR CHILDGUIDANCE

tive of onlyoneof these fieldsbe responsible forits operation. , Themain- tepance of this principle hasbeen difficult insomeinstantwes.Insome cases, community strifeamong those responsible in thevariousagencies has delayed initiationof the plan.In most cities,however, thisproblem hesnot been serious." It is alsoemphasizedthat-- Proper coordinationof centralizedState agencies isessential.Inasmuch as most local service is directedfrom Stateagencies, it isnecessary that overlapping andmisunderstanding beavoided bycoordinated Stateplan- ning. The mainproblem encounteredin thisrespectwas the lack ofunder- standingonthe part of the child-gutilanceclinic staff ofthe organizationand operation of otherState agencies.° Inat leastonecounty of the State,thechild-guidanceprogram is conceivedas anessentialpart ofagood public-healthprogram. It is pointedout that "the functioisofacounty public-healthunit would bedeficient ifa programfor the benefitofaproblemchild were notincluded.Likewise,aguidanceservice wouldseemincom- plete if it didnot makeuseofahealth unitfunctioningin thesame area." 28 Fromthiscounty it is reportedthat-- The travelingchild-.guidance clinicsarefillinga very definite needin the community. Thisneed hasbeen recognizedby the localmedicalsociety, the schoolsuperintendents, andthe local healthunit.Casesthat previously had beenneglected, becauseof lackof _qualifiedassistancein thecommunity,now are seen early enoughto preventcomplicationswhichlater might leadthe child intothe juvenilecourt. Weare learning torecognize abnormalities intheir earlyform, whichpreviously hadbeen allowedto develop intosometimel seriousconditions.Therelationshipof thechild- guidance clinicto thecounty health unitin WascoCountyisone of mutual cooperation forthe bettermentof the healthof thechildrenof thecommunity.° THECALIFORNIA PLAN. .0» itt Thenucleus of theMassachusettsand theOregonplans isthe , provisionof psychiatricclinicalservice, inthe formof eitherout- patientortraveling units,emanatingfrom Stateinstitutions.The California planhas developedsomewhatdifferently,althoughin the beginni* it,too,wascharacterized bythe Abrgiinizatioiofafull- time travelingclinicalunit, thepersonnel ofwhichconsistedofá psychiatrist,aclinicalpsycholoesandone or twopsychiatriiso- cial workers.Part-time unitswerelater established(in 1981)with the cooperationof Stateinstitutions;but withadrasticcurtailment of the budget2yearslater, allbut.oneof theclinicalunitshadto be abandonedand anothermediumofdevelopmentsought.How- Ibid.,p. 476. 26 Ibid..p. 482. wIbid.,p. 483. seInformationen the Californiaplan has been Bureau of secured fromreports of the(1) State Juvenile Research;(2) 'north/erne sentte local schoolsystems eorreepoadmeeaavi conteream ; ud (3)

01. CLINICAL ORGANIZATION FORCHILD GUIDANCE 17

too

STATE CHILDGUIDANCE CLINICPROGRAM UNIVERSITY OF OREGONMEDICAL SCHOOL

THE CHILDGUIDANCE CLINIC MEDICAL SCHOOL PARENT CLINIC AT M EDICAL SCH OOLEXTENSION PROGRAM

ADMINISTRATIVE t COMMITTEE i 4 i I EXTENSIONSTAFF r- MEDICAL SOCIAL-TEACHER

FACULTY OF DEPARTMENT CENTRAL OFFICEAND sp OF PSYCHIATRY PSYCH/AMC SUPERVISOR CONDUCTS TRAVELING CONTACTS UNITS CLINICS' "v. r

s 4 DISTRICT UNITS STATE STAFF (ORGANIZED LOCAL coNNITTE(S)

_70 SCHOOL',writer REPRESENTATIVE MEDICAL SOCIETY CONDUCTING PERIODIC CLINICS AND SU P E RVISINGPSYCHIATRIC di/DU COURT DOMESTICRELATIONS CASE WORK WITH TEACHERS AND SOCIAL WORKERS REPRESENTATIVE WELFARE AND HEALTH AGENCIES REPRESENTATIVE WOMEN'SAND SERVICE CLUSS

OTHERS INTERESTED pl ...sitle.

UNIT PROGRAMS mom is so ow. 41011111111111=11 PLANNING Of CLINICS COOPERATION IN THE TRAINING OP TEACWERS COORDINATION OF MEDICAL, EDUCATIONAL. COURT AND SOCIALWORK FACILITIES j CASE STUDIES WITH, $TATf PSYCHIATRIC SOCIAL WORKER OMER MASH Of LOCALPkOOR;IM PROGRAM LIMITED TOCHILDREN. UNDER 14 et Reproduced bycourtesy tbe University of Oregon Medico) School.

- , ; Is : ve-J4 .10 18 CLINICAL ORGANIZATIONFOR tHILDGUIDANCE

ever,the work alreadydone inmanycommunitiesservedas ademon- stration of child-guidanceprocedures whichhas been ofsignificant value in furtherprogress. The Stateagencysponsoring theclinical servicein Californiais the bureau ofjuvenile research,adivision of theState departmentof institutions.It is the convictionof thedirector ofthe bureauthat "any communitycanimprove its facilitiesfor childguidance,"regardless ofrestrictions ofbudget. Thebureau hasdevotedits resourcesto the demonstration ofpracticalwaysin which thiscanbe accomplished.It holds that'although childguidance hascome to signify, in thenarrow sense, professional interest inthe -mental health of childhoodand youth,it should, inthe largersense,desig- natethe interestsof allworkers in thepersonalitydevelopmentof children andadolescents."21 Two featuresin the prograiihave accordingly beengiven specialemphasis. Thefirst is theeducation of the teacher incapitalizing, inthe interests-ofthe mentalhealth of her pupils,her day-by-daycontacts with them.The secondis the need of activecooperationonthepart of all in the schoolandrom- munity whoareconcerned withthe individualpupil snd hisproblem. A.13aresult of thecontinuingemPhasisplaceduponthesetwo featuwe, therehas evolvedin Californiawhat is knownas"thechild- guidance conferenceplan." Thisis "essentiallythe gatheringto- gether ofa groupof schoolofficials fortht systèmaticandthoughtful study ofamaladjusted child.It followsthe generalform of.the child-guidance clinic,but it isadaptedto the facilities ofeachpar- ticular schoolorinstitution."22 Thismeansin short:Use what isat hand in theinosteffectiveway possible.Ifapsychiatrist isnot available inaparticular schoolsitu- ation,someoneelsemaylead in theanalysis ofcasesthatcome upfor considerationat the conferencesheld fromweekto weekorfrom monthto month. Itmaybe theschool principal,'a visitingteacher orpsychiatric socialwörker,aclinicalpsychologist,anattendance supervisor,or aschool comiselor,dependinguponthe trainingand aptitude of therespectivepersons.If available,aprivatepracti- tionermaybe calledinonsped&casesto give psychiatricadvice. Often representativesofcommunityagencies haveacontributionto make. The teacherorteacirrs ofagiven childarealwayspresent when hiscaseis beingdiscussed.Theconstant factor ofthe childguidance coliferenceis thesympatheticand intelligentparticipation of 'everybodyconcerned nith thechildand hisadjustment. 9 After thecurtailmentof fundsmade itimpossibleto maintainthe traveling clinicalservices ofthe Statebureau ofjurenileresearch,

. ft restei, Norman.State childguidance terriesin Californiacommunities.Bars- setito, Calif., themooniest ofdocuments, liftre XII. alMCpsSS.

1.1 : ; . . . *1, W ,t + 14 . k. *. <- ;-. .5, .?."!4.".41.1f #2- ?'4 '"t ;; ffr rs' 49' , :jit 2 ',fir*7'ArjOi -4r4-**Z18-. .1411' CLINICALORGANIZATI6NFOR CHILD GUIDANCE 19

and when practical necessity forced the developthent ofalessex- pensive technique, the child-guidance conference plan becamethe heartof clinical activity in the local schoolsystems of the State. EnCouragementand assistance in the organization ofchild guidance conferences have thus been acceptedas oneof the major functions of the bureau of juvenile research. Now "theultimate4bjectiveof the Bureauprogramis the development of local facilitiesfor child guidance rather than the establishment ofaState-wide network of clinic units." 23 Concerning the effectivéness of the plan, the director ofthe bureau

writes: 0N Sufficient trial has been given to the child guidance conference variety of school and community conditions to indicate thatunder adequate leadership it isavaluable method andanefficient administrativedevice. Timely, also, is the recognition of the fact that it costsvery little to intro- duce the child guidance conference, makingunnecessary the disturbing alternative of waiting foryears because school boards continue to consider the child guidance clinic, visiting teachers,orpsychologiststoo expensive to add to the budget.' A.1

a Inover2.00communities in California the initial demonstrationof the child-guidancecoide'rencehas been directed by clinical psychologistsof the California Bureau of Juvenile Research.After this demonstrationmiknya-. ,of the schools with adequate leadership and interest havebeen able te continue the plan under the tion ofsome person'intheirowngroup. In other States, wherenosuch bureau exists, the procedurecould be

, demonstrated initially by clinical iisychologists who mightbe members of university faculties, personnel of the Statedepartment of education,or otherpersons trained in childpsychiatry, clinical psychology,orpsychiatric social work.. 4 How the plan functionson acounty-wide basis is describedin the .! _- caseof Ventura Coinity,on page22. The plan of organization ina .V small city (Santa Barbara)i4discussedon -page26.In both of

these.`casesit is evident tkat the schoolsystem itself is thecenter of clinical activity and that, lacking themorehighly specialized facilities deemednecessaryforamedically recognized child-guidanceclinic, itcanstill make effectiveuseof the limitedresources atits disposal. -ta THEMARYLANDIPTATBPROGRAM ORGANIZED ON A COUNTY BASIS" In the State of Maryland thereare28 counties, which, with the exception of Baltimore County,arelargely rural in character.Ex- tensive child-guidance service is availablein Baltimore in connection il 1 n atd., 0, 9. .a Pm,P.83- Ibid.,1%.87- . 0 latermationon tbe Maryland program was secured from the Intgein of child tinkle . , otibi Oats departmentet health amid from ecbool aides it. leao r' 4 . s. t s 4I) ' ------.".0 - ; e. ryr;f 4 "... f k --z, J . P % , 1 0. A 1,47. : of ' AC: . ,4: -, v,:.:4:,¡?.%-: .1; t-t "11,- - 20 CLINICAL ORGANIZATIONFOR CHILDGUIDANCE

with Johns HopkinsUniversity Hospitaland the city-schoolsystem, but in therest of the State therearefew clinicalresourcesupon which the schoolscandraw.Recognizing fact,a group of psychiatrists representingboth State andprivate agencieshave de- velopedaplan for meeting theneedonthe basis ofcounty organization. The bureau of childhygiene in theState departmentof health is the official Stateagencysponsoring theprogram,and psychiatrists from various publicand privateinstitutions of theState donatetheir services in conducting mentalhygiene clinics. The State is dividedinto districts,each districtconsistingofone or _morecounties. The numberof clinicsper yearscheduledfor each district variesaccordingto circumstances.In 1936,63 clinics wereheld in19 counties andwereconducted by13 psychiatristsand their assistants.Theaveragenumber of patient'sseen per county was25, and the total for theyear was469, of whom321werebetween theagesof 6 and15,alarge majority ofthem being referred-by school teachers. County superintendentsof schools andcounty health officerswel- comed the comingof the clinicsasthe realizationofalong-feltneed. Since all service givenison avoluntary basisoris furnishedby the institution with whichthe psychiatrist isimmediatelyconnected,no &Tense is incurred by the schoolsystem. One countysuperintendent writes of theprogram asit relatesto the schools in hiscounty, which is strictly rural:" Whena"problem" develops,it is time forsomeone to get busy andstart studying not the problembut the situationthat causedthe problembf couree, the "problem" will need to bereadjusted andhelped.Iholdto the thesis thatan "ounce of prevention iswortha pound of curi," and, asschool administrators,it TO! isour job tosee that our schoolsare so organised that "problems"are reduced toa minimum. . These problemsare"picked up"or reported toour supervisors andat- tendance worker. Thenone of several thingsmay follow:. 1. Insome cases the child's schoolprogram ,is changed--bomeeco- nomicsorindustrial artsis added-a-contentsubjectsdropped.Here one must have complete understandingamong the teachersas to the pupils' difficulties.This is :1 ! ally effective forover-age pupils. 2. The childmaybe placedinaspecialgroup for temporaryreme- dial work-orfora continuedprogram adjusted to hisindividual needs. 8, A childmay be examinedatoneofour regular monthlyclinics. -.Theparentsare always interviewed and,wheneverpossible,attend the clinic. A trains&psychiatristI. presentand the Binettest Is given. A conference isheld at theend of the dayby theclassroom teacher, principal, and supervisorwith thepsychiatrist, aidrecommendations givenare carefully considered.Treatment followsaccording to the walla recommendation.

111Statement reproducedby courtesy ofRaymond BHypos,comity ouperiateadeat, Carroll DHOW,Md., frompaper gives at meatiag ofdepartment ofrural edseattoa,of the MaternalEducation Amodatioa,held la Clavelaadta rebruaryiNe. 13'

. .

. , . ; $ 4,4. ' -*SW.,Cznit,' 01. %),10..1" .: ' CLINICALORGANIZATION FOR CHILDGUIDANCE 21 The growth of theprogramsince 1986 is evidentfrom the fact that in 1988the number of patientsseen was901, of whom 760rep- resentednew casesof children under21yearsofage.The referring agencies during thatyear,in the order_ of thenumber of caiesre- ferred,were:The schools, social agencies,health officeror nurse, parentsorrelatives,courts, and private physician&Both failure in school and conductorpersonality difficultiesaremajor reisons for referral, andaschool adjustmentprogramhasaprominent place amongthetypes of treatment recommended.

A TAX-SUPPORTED COUNTYGUIDANCE CLINIC 2$ The Milwaukee (Wis.) CountyGuidance Clinicwasestablished by thecounty board of supervisors in1926as atax-supported organization reporting directlyto themanagerofcounty institutions. The staff of -the clinic consistsoftwo psychiatrists,oneof whomacts asdirector,two psychologists, three psychiatric socialworkers, and three office assistants. All of thesepersonshold their positionsunder civil service andarechosen by competitiveexamination. Although the clinicwasfoundedas ageneral mental hygiene agencydesignedtoserveboth children andadults, it is reported that from 75 to 80percent of theeases seen arechildren.Referrals comefromavariety ofsources,including the juvenilecourt, social agencies, medical agencies, and theschools.The problems referred by the schools relateto disciplinary difficulties, retardation,over- activity,extreme shyness, and withdrawn personalities. Thecompre- hensiveness of the examination and of thetreatment given depends toalarge extentuponthetype of problem involved. In order that adequate studymaybe made ofeach patient in accordance with his needs, the number ofnew casesis strictly limited to about 20perweek. "Most patientsare seen onwhat is primarily aconsultative basis, with recommendations fortreatment being made by the clinic and reportedto the referringagency.Onlytitsmall proportionarecarried fortreatment by staff members." Cowl) tion with school officials from timeto time regarding theprogress ofachild sentto the clinic helps the clinical staffto evaluate its recommendations andto suggest possiblenewdirections of treatnient. Fromacity-school system utilizing the servicesof this cliniccomes the statement that "alltypes of maladjustments requiringpsycho- logicalorpsychiatrictreatmentmaybe considered for clinicalWen- don. A regular application blank is filled inandanappointmentis made. At leastoneparent attends the clinical conferencewith the child. Aidolconferenceonthecaseis heldonthesameday anda

_ . Viakeentjag theMilwaukeeCounty &MamaMalewufurnishedby Its dredge andby seboolMade =lag the sirvieeset the ask.

P. 22 CLINICAL ORGANIZATIONFOR CHILD - GUIDANCE report of thecaseis received bythe schooladayor twolater."This schoolsystem considers theassistance renderedby the clinicas most valuable in guidingand carryingout remedialmeasuresfor individualcases.The limited timeavailableto each schoolsystem, however, and theconsequentnecessarydelayin securingappointmentsare con- - sideredahindranceto the realization of themost effective serviceto the schools. A COUNTYPROGRAM INCALIFORNIA* Onadifferent basis,but with thesameultimate objective,have been developedseveralcountyprogramsin California.These follow general principlesof the child-guidanceconference planin that tstte,asalready described.Theprograminone countyis citedas illustrative of whatcanbe done withoutahighly developedclinical organization and itsattendantcost. Thecounty seat of Ventura County,Calif., is-Ventura,acity of about12,000 inhabitants. Thisis thelargest city in thecounty and thereareonlytwo others withapopulation of5,000or more. The educationalsystem of the county includesrural schoolsof varying sizes, city elementary and secondaryschools, andajuniorcollege. On the staff of thecounty superintendent ofschools isasupervisorof child welfare, guidance,and attendance,who has hadpsychological training and whoseresponsibilitiesareindicatedby his title.They include (1) childaccounting, (2) supervisionof childwelfareprob- lems, (3) formulationand evaluationof guidanceplans, (4)supervision of testing andadjustment ofindividualproblemcases. With the assistance ofthe State bureauof juvenileresearch,steps have been taken inVentura Countyto developto theutmost the service of the child guidanceconference,asdescribedon pages 16 to 19 of this bulletin.Thecounty superintendent tookthe firststep by announcing the ikvailabilityof the servicethrough hisbulletinsand by inviting schools wishingto makeuseof itto send inrequests. The schools which respondedtothis initialinvitationwereusedas the first clinicalcenters. For thecountyas awholeasteeringcom- mittee of teachers and administratorswasnamed,representingall levels of education in thecounty, and it inturn appointedasub- committee to study the problemsat hand andto advise withthe supervisor of guidance. The office of the principal ofeach schoolserves asaclearing house for allcasesreferredtothe child-guidanceconference,which ismany attended by the principal,classroo er,psychologistorguidatfte supervisor, andnurse.A State hoof 1located inthecountysup-

aInformationoathe Vesturecount/program was from thecountysapervisor of childwelfare,guidasee, and attendance,and froma oa of theprogram pub- lished hi theQs UremiaJournal of lillemestaryMica :00-44, August p. . 1988.

Ik.e: ''s .. . - ' .. . r, .' : i-li. . . '. If...a04,:. i0,0 ',..t 1 ..' 1. ' i'" vt''' "tdii...ts1 4 ....i.:_i_*<;Z..-q2_!;°Lf11`,IAVs. .1.1-ett47-41iattltid '-"11:41,tit.1:1;f*.t: :4r:-"..1s::.:6;4. ,....441tfA,31;,;;APG...C.Eiri,,;eLL..- CLINICAL ORGANIZATIONFOR CHILD GUIDANCE 23 plies psychiatric serviceasneeded. Communityagenciescooperate by furnishing information, referringcases,and givingassistance in adjustment. A follow-upprogramis outlinedfor eachcase,anda time is set for evaluating the results of themeasurestried. The supervisor of guidance is charged with theadministrationandarrange- mentsof both the child-guidance conferenceand the follow-up. Problems that have been consideredat the periodic sessions of childguidance conferences held in variousschool districtsof thecounty fall intooneof three general classesor somecombinationof these. The classificationsare: 1. Failure tocome upto expected standards ofschool work. 2. AntisocialorabnCrmalbehavior whichmarks the childas "different." 8. Problems in which healthappearsimpairedorhygieneques- tionsareinvolved. Since the organization and supervision ofchild-guidanceconfer- encesis onlyoneof the responsibilitiesof thecounty supervisor of child welfare, guidance, and attendance,, it isimpossibleto arriveat Ilbanyfigures of cost withrespect to this particular phase ofhis work The pregramserves as aclear example of howintimatelythe adjustmentof behavior problemsmaybe relatedto the total guidanceactivi- ties ofaschoolsystem.

OTHER STATE AND COUNTYPLAYS Inumber of other States and ofcovnties withinStates havea centralagencycharged with certaintypes of clinical functions.In Connecticut there is the bureau of mental hygieneof the Statedeptirt- ment of health;in Illinois, the institute ofjuvenile researchof the State de st of social welfare; in Michigan, theState welfare department and the Michiganchildguidance institute;in New Jersey, the State department of institutions andagencies;in New York, the division of prevention of the State departmentof mental hygiene; in Ohio, the bureau of juvenile researchof the State departmentof public welfare; in Pennsylvania, the bureauof mentalhealth of the State department of welfare; in Virginia,the bureau ofmental hygiene of the State department of public welfare; andin Wisconsin, the division of prevention of the State department ofmental hygiene. In universities, too,onefinds increasingevidence Of theacceptance of responsibility for service to the communitiesabout them.Refer- enceis made-in succeeding chapterstosomeof the plansunderway .in relation to city school systems, and othersarebeing developed,as, for maniple, in the newly organised department ofchild guidance of the University of Minnesota Medical School. 24 CLINICAL ORGANIZATION FOR CHILDGUIDANCE

County agencies furnishing the nucleus foraclinicalprogram. include welfare societies, healthboards, juvenilecourts, hospitals located within thecounty, and mental hygiene societies. Anyone or anycombination of thesemayoperate withorwithout the assistance of the communitychestThe tax-supported Milwaukee County Mental Hygiene Clinichas already been described.Essex County, N. J., hasajuvenile clinic organizedas acounty community project which givesextension serviceto school districts within the county. In Rockland County, N. Y.,is located the RocklandState Hospital, which functions under theState department of mentalhygiene and cooperates with the Rockland County schools incaring for the mental health needs of the children.Clinicsareheld in schools whichrangein size fromtwo tomany rooms.Concerning their

relationship with the schools, thedirectors-of the clinics writes:" One cannot have intelligentworking contact with educatorswithout

:makinganeffort to acquire thecurrent philosophies of education.Indeed it is futile to work inaschool without becoming familiarwith the educational procedures and problems.Failure to do this resultsina general lack of sympathy andunderstanding. Onecannot interpretachild's personality difilculty toateacher unless the teacher'spoint of viewis understood and toacertain extent shared.e *Certainly education is ready and willing forpsychiatry and theneed must bemet witha plan of action which isnot only scientific butpractical. Most of theprogramsunderway areunfortunatelysuffering from alack of adequate fundsto make the specialized clinidalservice really State-wideor evencounty-wide inextent. WhaNaure developments will bringno one canforetell, but it issafetosaythat everyintelligent plan of attackuponthe problemthat is beingmade today will contribute somethingto the pattern of clinical servicethat will ultimately evolve. Themost significant trend thathas appeared to date is perhaps the fact that the adjustmentof behaviorproblems is not oonsidered the jobofone or evenofafew specialists but rather the joint responsibilityof allpersonsand agencieshaving anythingto do with the child in question. Closelycoordinated effort capitalizing the knowledge andthe abilitiesof eachf these has demonstrated its worthasby far themost effective method ofpro- oedure.The important objectiveto be achieved is theutilization and the integration of all availableforceslocal,county, and State-- foraclinical organization thatwill showresults in thelives of children.

aTallman,TookF.Child guidance in schools.Psychiatricquarterly,9: 431-417, July 11015.

44,Jibe CHAPTERIII

THE RESOURCESOFSMALL CrrrEs31 What the Stateandcounty have to offer in clinical service is likely tohaveasignificant influenceupontheprogramsof small cities,most of which throughtheirownbudgetsareunableto provideeven a smallamount of specialized assistancefor the adjustment ofbehavior problemsamongthe childrenof their schools.Some, however, have founda way to,attack the problemat least inanelementaryway,and others have forgedahead withaconstructive clinicalprogram, sup- plementing theirown resourceswit of State,county,orprivate foundation.Certain organizationhpitssefunctioningin cities witha population ofless than 50,00032aredescribed hereasillustraiiveof present practices and trends in the smallerurban communities.

A CITY SERVICE Winnetka, Ill.So farasis known, the onlycity in this population groupemploying for itsschoolsystemafull-time psychiatristis Winnetka, IlLThe approximately13,000 inhabitants of thiscity showa rangeof economicstatusaswideasthat of almostanyother city of its size, but thedistribution issomewhat skewed towardthe upperend, withalarger proportionof people incomfortable circumstances thanonewould find inatypical community.The citypro- vides both psychologicaland psychiatricselvvices for the children enrolled in its schools. Apsychiatristisatthe head ofadepartment of educational .counsel ofthe schoolsystem. He takes the leadership incaseconferences and isresponsible forfollowingupthetreatment asrecommended. Problemsmaybe referredto him by teacher, principal,orparent, and he is likewiseopenfor conference withchildren whomaywishtocome tohim. Of thenature of the clinical activities, he writesasfollows: The teacheralways ,participatesincaseconferences. Thepsychiatrist confers with the teacherto advise in the handlingof specific problemand to keep her informed of theprogress he is making when working directly

a Except where otherwiseindicated, alldata reported In thischapter, including quoted statements,are taken from reports contributedin 1988 by local schoolofficials to the Office of Education. All populationfigures usedare uof estimates madeby tbe Bureau of the Census in 1938. s. 163734-39-3 25 26 *CLINICALORGANIZATION FOR CHILD GUIDANCE

witha case.Insomeinstances the teachermaydo all the work withthe child and with his parents under the direction of the psychiatrist. In addition, the psychiatrist works directly with parents and childrenfor &agnosticpurposes,both in order to gainabetter understanding ofthe casehimself and to give parents and childrenabetter understandingof

theirownemotional problems e ng onthecase.More time is spent with parents of.preadolescent childredi anwith tbe children themselves,because thisis felt to bemoreeffective in most instances.Types of problems handledare:Aggressive, troublesome behavior; shy,feirful,or a-social characteristics; special educationalorsubject-matter difficulties; andcases of mental retardation not accepted byparents. Discussion periods in schoolareled by the psychiatristonsuch subjects asmental hygiene, dreams,orinsanity, when the teacher desires himto supplement discussion she has already had with her class.Parentgroups likewise calluponthe psychiatrist for consideration of probleMs inchild development, and seminarsareheld with teachersonsimilar problems. It is apparent that the heart of the clinical program in thiscity of 13,000 inhabitants is the education ofparents and teachers in the application of the principles of mental hygienetotheir relationships with children. Psychiatric service isrecognizedasof such impQrtance that it is givenamajor placeamongneeded school facilities, andthe resourcesAvailablearedistributed accordingly.In the words of the Superintendent, "It isnotsomuchaquestion of havingresources as it isarecognition of the need of using theresourcesavailable for the most important services." Witha qua'1:4 child-guidance specialist atthe helm, there isnodoubt that the?.ts achieved froma pro- gramdevelopedonthis basiscanbe of untold valuetoeveryone ooncern9d. Banta Barbara, Calif.Applyingthe principles of the California plantoalocal situation,we mayciteas anexample the city of Santa Barbara, which, with its 86,000 inhabitantit,has organized in its school systemadepartment of child guidance.The director of this department has had training in psychological andotheraspects of child-guidance serviceapart from its psychiatric phases.Working inorin close cooperation with the guidance organizationare :One full-time visiting counselor, who has special home-visitingduties; oneschool counselor for each of the12 schools in thesystem, who has also part-time teaching responsibilities;onefull-time andone part-time school physician.Several psychiatristspracticing in the community have volunteered help in difficult caseiorfurnish assist- ancethrough thecourtesyof thecountychild welfare department. The child-guidance department of the schoolsystem works with all casesof maladjustment in the schools, includingthose relatingto educationalpro: personality, and behavior. Child-guidance conferencesarescheduled regularly(at leastonce a month) in each of the12 elementary and secondary schoolsof the CLINICAL ORGANIZATION FORCHILD GUIDANCE 27 ciV, at which the problems of individualchildrenareconsidered. The principal of the schoolactsaschairman of theconference.Pres- -entalsoarethe child's teacherorteachers, the schoolphysician, the school counselor, the director of childguidance, andoccasionallya familycaseworker, if the child isknowntoasocialagency.In the high school the dean of girls andthe boys' adviserareaddedto the group.The responsibility for followingupthecaseis assignedat the _conferenece to die individual whoseemsbest suitedtocarry outthe recommendations made. Because of its suggestive value thefollowingaè,ount of the specific procedure used in the SantaBarbara plan isgiven verbatim:" 11. The study ofthe individukil childpresents the most efficientmeansof dis- covering the mental healthneeds of children.In analysis ofthe problems of children isa sure indicator of the adequacy ofthe educationalpractices inuse.It shows whetheror not the school, the home, andthe community are meeting the needs and interests ofthe child.Whileno one will deny that this method ofstudy is the slowest,everyone must admit that it is the most certain to obtain thedesired resultsin the longrun. A request for sucha study maycomefrom teacher,parent,some outside socialagency, or from the child himself.Sucha request is madeasthe result of maladjustmentsomewhere in thechild's relationswith othersAs soon as a case is referred for study, itbecomes the dutyof thecounselorto collect the social, physicaCandschool history,all of whichnecessitates some contacts withpersons outside the school whoare interested in the individual child.Theremust beaphysical exAminationby theschool physician, withoutcost, and only with theconsent of theparent.The social history is obtainedthrough home visits,through checkingwithany religious agencies with which thechildor family is identified andwith thesocial service exchange for informationconcerning the familybackground,as well asthe record of the child.In additionto this, the interviewwith the child himself ismost important. Thisis done by boththe directorand thecoun- selor.This involves muchtime,asit usually requiresa carefully planned technique to gain fullconfidence of tbe childand thusestablishgood rapport. A Binettest is always given, andsuch othertestsas may be deemed necessary for thecase under study. Whenall°the dataare gathered, the director conductsaconference whichis attended bythe counselorand all the teachers ofthe child.When all dataare presented, suggestionsare made by variousmembers of thegroup.Out ofthiscome physical, social,and educationalrecommendations.Theserecommendationsare passedonto those whoare to put them into operation.There isseldomastudy madethat the help ofsome outside organization isnot enlisted. The directorof guidancerePorts that "themost significant value ofour programis that itbegan withschool personneland isessen- tiallypart ofanin-serviceprogramthrough whichteachersmay develop. Wearefeelingmost optimisticat present, sincealarge percentage ofcasesshowmost unexpected improvement.Our chief

a Johnston, OliveS.Guidanceas a factor in social interpretation.Education,58: 003-807. June1988. 28 CLINICAL ORGANIZATION FOR CHILDGUIDANCE

lack is the usual hickof personnel. We coulduseseveral full-time visiting teachersto good advantage and hopc&tohavesometimea regular consulting psychiatrist."

CITY AND UNIVERSITYCOOPERATION Eugene, Oreg.Theplan of the Universityof Oregon Medical School has been describedon pages15to17. From Eugene,Oreg.,a city of 20,000 inhabitants,comes a reportof how the clinicfunctions in that community.The fact that the StateUniversity is located there makes thearrangementa veryconvenientone,but it issomewhat typical ofwhat takes place in othersmall citiesof the State. Through the university medicalschool the Stateprovidesapsychi- atrist foraperiod of 2 daysevery2 months.Psychologicalservice is given by the StateUniversity through itspsychologydepartment. The local board ofeducation furnishesafull-time visitingteacher, parttime ofasocial worker andnurse,while thesuperintendentof schoolsactsasdirector of the clinic. Thepsychiatrist'sscheduled days for serviceto thelocal schoolsystemare set apartfor clinical conferences, attended by the superintendent ofschools, the university psychologist, the visiting teacher, social worker,nurse,andanylocal physician concerned with the particularcaseat hand.Sometimesthe teacher,too,is brought into th%caseconference. Concerning the general procedure used, thesuperintendentwrites: Applications for study ofcases are referred from the schoolsto the superintendent's office andarethen referredto the medical school ofthe University, where theyare considered for acceptanceorrejection.If accepted, theyarereturned with directionsforany orall of the following: Psychometric examination,complete physicalexamination, completesocial casehistory. The informationrequestedmay be secured by the visiting teacher, the schoolnurse, a part-time social worker,or the worker of the welfareagency.The doctorssee the child with the parent, makerecom- mendations, and theperson who prepared thecase record does thenecessaryfollow-up work. Although the psychiatristsare sent from

J. the medical school, andare supported by State funds, theclinic is entirely controlled by thelocal school &strict. Ann Arbor,Mich.Similarplans of organizationarein operation in other universitycenters in which the university isequippedto provide theneemsaryspecialized-service.In Ann Arbor,forexample, withapopulation of28,000, the board ofeducation has closely coordinated the workof its full-time schoolphysician,a caseworker knownasthe children'sconsultant,twonurses, adental hygienist,a psychologist, andanattendance officer.The Universityof Michigan furnishes psychiatricservice and psychologicalassistance.The Chil- dren's Center,aprivately endowedclinicalagencyin Detroit,sup- plies additionalpsychiatric consultantservice-The*namegivento CLINICAL ORGANIZATIONFOR CHILDGUIDANCE 29 the entire organization is PerryCenter, andit isanintegralpart of the public-school organizationwith officeslocated inoneof the public-school buildings. In commentingupontheprogram,the children'sconsultantwrites: Perry Center isa program for a plan(4cooperation of allthe special service agents in theschool;aplan foragrowingconcurrence of t he school with the communityagencies;abelief that theemphasis be placedon the mental hygiene of the grdup,that material beusableto the teacher and that heorshe be educatedthrough handlingthe adjustmentof theindividual to thegroup; and, lastly,a plan for the treatment, throughinterview and conference, of the individualproblem whichwouldinterfere witha con- structive parent-childor teacher-hild relationship.

CITY AND COUNTYOR STATECOOPERATION Muskegon. Mich.Muskegonisacity ofapproximately48,000 inhabitants.t. In it theTraverse City StateHospital has forsometime heldanout-patient clinic2 days each month, usingthe facilities ofa Meal hospitalasits headquarters.In 1937, throughprovision made by thecounty board of supervisors,another day of clinicworkwas added in Muskegon,this thirdsession beingheld inalocal junior high school andbeing priniarilyreserved forschoolcases.The service rendered is for allschools in thecounty. The clinical stafffrom the Statehospital includesapsychiatrist,a psychologist, andasocial worker. Theassistant principalof the junior high school inwhich the clinicis held,asupervisor ofschool nurses,andtwo counselors of the schoolgive serviceto the clinicas part of their regular work,particularly inconnection withthe referral and follow-up ofcases.Teachersreport maladjustedeases,andmay be calleduponto assist in makingcaserecords and incarryingout recommendations.Difficulthome situationsdiscover,a-inconnection with clinic cafesarereferredto the local family servicebureau, which wasestablished in1938 and is financedfronicommunity-chestfunds. It is reportedfrom Muskegonthat "there hasbeena very encourag- ing improvement inthe attitude ofteachers towardmaladjustedcases. A mental-hygienepoint of view isdeveloping towardall pupils.We have receivedconsiderable helpin dealingwith individualcum.". Again, however,comesthe complaintthat thetime allottedfor clinical service is inadequateto the need. altham, Maas. ---Asanexample ofalocal organizationfunctioning in cooperation withthe Stateprogramin Massachusetts,the planof operation in Waltham,acity of40,000 inhabitants,ispresented. In this city islocated theMetropolitan StateHospital, whichin1936, at the request Qf theWaltham public-schoolauthorities,instituteda child-guidanceclinictoserve notonly Walthambut alsothesur- 30 CLINICAL ORGANIZATIONFOR CHILD GUIDANCE rounding districts. Alocal city hospital, whichis the healthcenter of the community,waschosenasthemost desirable headquarters, offerifig both consultation andtreatment facilities.The Metropolitan State Hospital providespsychological, "psychiatric,and social service forascheduled nuipber of hourseach week. Theschools constitute onlyoneof the referring agenciesand cooperate in carryingoutihe recommendations of the clinicwhen they involveschool procedures. The problems consideredareprimarily thoserelatedto behavior, the 4umber of mentally dvficientchildrenseenbeing reducedtoamini- mum,since theseareoidinarilyhandled by thetraveling schoolclinics pf the State. L, The location of the sòirceof clinic assistance(namely,the Metro- politan State Hospital)ithin the communitywhich itservesmakes it possibleto maintainaceidainflexibility ofarrangement andto keep an opendoor for'contacts between the clinicalstaff and theschool people.Misunderstandingscanthus be eliminatedandamaximum amount of service given in the light of the timeavailable.In his first annual report of the work ofthe clinic, thedirector of theWaltham Child Guidance Clinicsays:" i It is the policy of the clinicto act bothas a consultant and treatment agency, strengthening the capacity of otheragencies, suchas parints, parent-substitutes, schools, physicians,Juvenilecourt, and social-ware organizations, in carrying out guidanceof children.The clinichas three main objectives.The first and primaryobjective isthe study andtreatment of problem children; thesecond objective isthe trainingof personnel; and the third is the securing ofdata, whichwill give thoseinterested in this problem better understandingof human problems,includingthe normal, the delinquent, and theabnormal.

A PLAN OF JOINTCITY SERVICE WITHCOUNTY ORSTATE COOPERATION Rock 181414, Ill., andMoline,Ill.Theseareneighboringcities situated in thesame county,with populatioiísof approximately88,000 and 82,000, respectively.An organizationcalledachild-guidance conference,"supported by the communitychest,servesthetwo cities andoperates underaboard of directors,membershipon,which is divided betweenthem. Membersfrom RockIslandareappointed by the centralcouncil of socialagencies; thosefrom Molineare appointed by the RedCross. The professionalstaff furnishedthrough local funds issuppleinentedby theEast MolineStatehospital.A full-time psychiatricsocial workertakesalarge responsibilityfor

The Commonwealthof Massachusetts,Department of MentalDiseases.Annual report of the trustees of theMetropolitan StateHospital for theyear ending November 30, 1936,P. 9. *The difference shouldbenotedbetween this organisationand the childguidance conference plan adopted inCalifornia. CLINICALORGANIZAtIONFOR CHILD GUIDANCE 31 organizing theprogramof the conference, securingcasehistories, and followingupthetreatmentgiven.Part-time_ psychological, psychiatric, and othermedical servicesarefurnishedasneeded. The school principals and the schoolnurses arethe chief coordinating officials of the school system, while teachers assist in compilingcasehistories and in making recommended treatment effectivesofarastheirown relationship to thecaséis concerned.Parents,too,areadvised in thecourseof the clinical procedure. Since the conference isacommunity rather thanaschoolagency, its service is notlimitedto the school systems of the two cities, but it applies also to juvenile court and to welfare agencies.However, morethan 40 percent of thecasesconsidered fere referred bythe schools. School problems studiedInclude those of antisocial behavior, subnormality, and educationalm.adjustment.The superintendent of schools inoneof the cities writes: Our clinic started without funds for maintenance but it is well estab- lishednowwith competent workers.It is too early to evaluate itssuccess, butwefeel thatourpresent procedure will get valuable results. * One city alone could not support this work, andeventhe two cities could not carry itonwithout the people at the State hospital. He points out further that thereare more cases tobe considered than theconfeiencecanhandle, but that,sofarasfacilitiesareavail- able, the cooperative arrangement isverysatisfactory. Champaign, Ill., and Urbana, Ill.In thesameStateonefindsa sOmewhatdifferent plan of cooperative service builtupintwo neigh- boring cities of 21,000 and 13,000 inhabitants, respectively. Ajoint programhas been in operation,in Champaign and Urbana since19231 when the child guidance service of the family welfaresocietywas organized, designed toservethe children of both communitiesaswell asof the surrounding territory. The clinical service is made possible largely through theState institute for juvenile research, which furnishes the psychiatricassist,- ance.Throughanarrangementmade between the institute andthe University of Illinois, situatedat Urbana, the psychology departmentof that institution makes available the services ofseveral of its graduate students.Case workers of the family welfaresociety carry onthenecessarypreliminary study and the follow-upof the casespresented. Clinicsareheldon2 days of each month' from Octoberto June. Agencies referiingcasesincludenotSnlythe schools, but alsothe family welfare society, other social agencies,thecourt, physicians, andparents.Many of the children referred áreseenrepeatedly, otherscom'e onlyonce ortwice.It is reported that about40 differ- entchildrenare seenin thecourseof theyear. 32 CLINICALORGANIZATIONFOR CHILDGUIDANCE

This projectis typical ofthe kind ofprogramencouragedby the State institute forjuvenile research,whichoperatesafully staffed parent clinic in Chicagoand has beenresponsible fortheestablish- ment of 12 local communityclinics invarious sectionsof theState. The institute givesprofessional serviceto the local clinicsaslong asitseems necessary to doso,but its aimisto withdrawas soonas andto the extentto which the localcommunitycanprovide.specialized services.

GENERAL COMMENTSON SMALL CITYPROGRAMS The foregoingdescriptions willperhaps sufficeto giveanidea of the variedpossibilitiesof clinicalorganizationfor smallcities.They should, ofcourse,beconsideredin connectionwith th.6Stateand county plans alreadydescribed inchapter II, from whiMit is difficultto divorce them ifthey involveextensive Stateor countyZoop- eration. Onedistinguishfngfeature,however, shouldbe noted.In ahighly organizedand unifiedState plan,asin Massachusetts,the wholeprogram emanates fromanofficialStateagencyand itsactiv- ities in localcommunitiesare toalarge degreedirected by,),..agt agency.Inmost of theprogramsdescribed inthis chapter,onthe other hand,the localdistrictplaysamuchmore prominentpart in theorganizationand directionof theclinicalservice, lookingohly to the couptyor totheState for thesupplementaryaid whichit cannot furnish fromitsown resources. Any numberof variationsmaybe cited,but thegeneralpatteims followedareabout thesame asthose heredescribed.Thedearth ofadequate specializedassistance iscommon to most of them.The clinic thatmakes onlyinfrequentvisitstoagivencommunitycan give-diagnosticservice butitcannot becomeintimatelyacquainted withtheresourcesand limitationsof thelocalschoolsystem, and because of this it is feltthattherecommendationsmadeoften lackAP practicalsuggestiveness.One schoolofficialrepoits that "itis better than havingnoserviceat all but farless satisfactorythanhavinga consulting psychiatristonthe schoolstaffor alocal clinichandling cases cooperatively."Another&pallsattentionto the fact thatthe psychiatrist"seeinedto feel that theapplicationof scientificterms tocases wasthesame assolving theproblems."Anothersaysthat "dueto crowded conditionsof appointment cafendar,service is slow."Stillanothermakes thecomment: "In vipwof thefact that we cannothaveour ownstaff, thisclinicis of incalculablevalue in givingus expertadviceon our most problematicalcases.We could hardly dowithout it." . Admittingall theweaknessesandinadequaciesofpresentarrange- ments,oneis encouragedby theeffortsbeingmadeto bring clinical

4. . CLINICAL ORGANIZATIONFOR CHILDGUIDANCE 33 services to bearuponthe guidance of childre.nin theschools ofsmall 4 urban centers. The variability olorganizationplans and ofagencies sponsoring them providesin itselfawholesomeexperience.The attackuponthe problem ofmaladjustmentamongchildren isbeing made from allsides.Health specialistslookuponitas aproblem in the furtherance of mentalhealth, welfareagencieslookuponitas an opportunity for socialservie, educationalspecialistsconsider ita challenge to theirprogramsof guidance.'All ofthesegroups are involved inaneffectivecoordination ofavailableresources. Whatever the immediateaffiliationorsponsorshipof the clinical organization, its majorpurposeis recognizedasservice forcdram and theonepublicagencywhich is concernedwith allthecltildié'nis the American schoolsystem.If child-guidanceproceduresaretoi influence school policiesin4tiwaythat willredoundto themenial health of all children andnot merelyserve asadevice aimedto w "cure" troublesomecases,itseemsobvious that the'remust be between the clinic and theschoolsanunbroken line ofthe closestpossibl interrelationship.Atoneenda clinical staffunderstandingchild ; guidance andthe schools,at the other endaneducationalstaff interested in mental hygieneand in applyingits implicationsto school procedures, andthe pathwaybetween themkept alwaysopenfor helpful intercoursethiswouldseemto promise much forclinical work of enduringvalue. The organizationof specializedclinical serviceas anintrinsicpart of the schooladministrative plan would,ofcourse,facilitate sucha % relationship, butit need not be consideredthe onlyprerequisiteofsuc- . cess.The small citycan use totheutmost all itsown résources of health, education,and welfare,perhaps joinwithneighboring citiesin orderto multiply themeffectively,and thensupplementthem further with thosewhich thecountyorthe Statecancontribute.Itcanthus confidently lookforwardothe possibilityof developingawelt- coordinated servicewhichcanstill becentered inthe educational programof thecommunity,but whichinany casewill requirea mutual understandingandcooperationonthepart of all theagencies concerned withthe developmentand securityof children. CHAPTER IV

PROGRAMSINCriamoOFMODERATESIZE 36 In this chapter considerationis giventoclinicalprograms organized in cities ranging inpopulationfrom 50,000to 200,000." Asone mightexpect, school systems in cities of this size havemore resources within themselves andareless dependentuponState,county,or community agencies than thosein the smaller urbancenters discussed in chapter III. Particularly isthistrue of the psychological, physical, and socialaspects of theprogram.For psychiatrie servicesmost of them still lookoutside of theirownimmediate ranks,althoughone finds in thisrespect, too, provision made increasingly bythe school system itself. The illustrativeprogramsdescribed herearearranged inthree groups, onthe basis of thesourceof psychiatricassistance, namely: (1) Those in which,asinmanyof the smaller citiesalready discussed, psychiatric servicecomesfrom the State;(2) those in which it is supplied byacommunityagency orprivate foundation;(3) those in which it isaninherentpart of the schools' facilities.The commonfactor of all theprogramsdescribed isanemphasisupon the guidarice and adjustmentfunction of the'sChoolthrough the clinical approachto the study and treatment ofpupilproblems.

s PSYCHIATRIC SERVICEFROM THESTATE Erie, Pa.-4n this city, withapopulation of118,000, there is inthe schoolsystemachild study department,which is directedbya psychologist and in which isincludedachild guidanceclinic for the study and adjustment of alltypes of pupil problem&It is reported that about 50percent of thesemaybe characterizedas"behaviorprob- lezna"The childsiudydepartment isresponsible alsofor the supervision of special schools andclasses for handicappedchildrer and for the administration ofpsychological examinationsin the school systemas awhole.Its staff consists ofthe psychologist-director;the supervisor of special educationtwo visiting teachers,oneof whom

es Except whereOtbitiliiesk_hulicated,all data reported in thissection, ,includinirquoted "filaments,aretakenfrom reports contributed in 1938by local school officialsto the Office of Education. sr All population figures usedare asof estimates made bythe Bureauof theCensus in 1933. . 34 CLINICAL ORGANIZATIONFOR CHILDGUIDANCE 35

is assigned especiallyto the work of the ChildGuidance Clinic;a secretary-assistant; andastenographer. From Wirren StateHospitalcomes apsychiatrist for2 days each month during the schoólyearfòr the considerationofcasesrequiring his attention.This service iswithoutcost to the school district. Cases of pupil maladjustmentarereferred byschool principalsor teachers, medical inspectors,schoolnurses,attendanceworkers,par- eAts, family physicians, membersof parent-teacher organizatións, court probation officers, visitingnurses, countynurses,relatives, and by various socialagencies. The general procedurefollowed in bringingaschoolcase tothe attention of the psychiatristis describedinareport of the child study department in1933: 38 In, the majority ofcases the psychologist initiates thestudy of the problem.If the factsfurnished by teachers,school records,and psychological examination warrant neuropsychiatricexaminatioh,the child is referredto the visiting teacher forthe clinic, whosets about procuringa case history, compiled accordingto psychiatric standards.Thismeans finding outevery- thing about the childfrom all availablesources.Shesecures from the parentsahistory of heredity,development fromprenatal timeto the present, physical illnesses,social adaptability,practical abilitiesoutside of school, habits, and delinquencies.School agenciesfurnish records ofscholarship, deportment, physicalexaminations, and generalobservations ofteacher& The family physicianscooperate by furnishing recordsof their findingsdur- ing various illnesses.The child isthen givenaplaceonthe clinic schedule, usually to be broughtin byone or both parents.Before seeingthe child the clinic doctor readsthe history preparedby the visitingteacher andthe report of the psychologist.Theli theneuropsychiatricexamination ismade, followed byan interview with the parent.After-thisan estimateof ,the child's difficulties isattempted fromamedical andpsychiatricviewpoint. The psychiatrist,visiting teacher,psychologist,parent, and sometimesothers immediately interested discussthe problem, andan agreement is reached asto the best practical methodof procedure.The clinicoffersnomedical treatment.Many of the childrenhave seriousphysical troubles,and in all suchcasesthe relatives,areurged to seekthe aid ofthe familyphysician. Acopyof the psychiatrist'sreport is sentto the schoolprincipal,and if medical treatment is adviseda copy is sent to the familyphysician.After the clinic examination thevisiting teacherkeeps In touchwith thechild, making note and keepinga record of hisprogress at school andat home and endeavoring tosecurethe fulfillmentof the clinicrecommendation& 4eporting for theyear1938-39, thevisitingteacher forthe child guidance cliniccalls attentiontooneofdieinterestingelements of progressin its work,asfollows: 7 The most outstandingfeature inthep}D,vi.essof the childguidanceclinic of tbe Erie publicschools during,the currentear was the introductionofa 11/4 - Schooldistrict ofthe city ofErie, Pa.Report ofthe child studydepartment; 1933. P. 17. 36 CLINICAL ORGANIZATIONYOR CHILDGUIDANCE

special children'sclinicroom.Thisroom was decorated bytwo students of the art classesat Tech High School.The wallsare a soft light Nile, witha frieze of brightlycolorednursery rhyme picturesat the levelofa small child'seye.The lowerwalls andwoodworkare painteda pale yellow-cream color,givingan impression of brightnessandexpansiveness. The ceilingisapaleorange, reflectinga spirit of sunshinein theroom. The entirecoloring of theroom givesone a feeling of restfulnessand intimacy.Dr. Rosenzweig,clinicdirector,reports thatboth childrenand parents havebeenmore responsive andmore cooperative duringthe interviews sincethe clinicroom has been inuse.The childrenare eager to talk to the doctor andat times reluctantto leave theroom, and theparents too have seemedmore relaxed and freein theirconversationswith the psychiatrist.Itis interestingto note thatone of the boyartistswho workedonthe clinicroomprojectwas at one timea behavior problemin the schools.However,through theefforts ofthe childstudydepartment his talentswere discovered andare being developed. Wilmington,Del.Thedirector ofspecialeducationandmental hygiene inthis city of107,000 inhabitantsservesalso inthesame capacity theState ofDelawareas awhole.The divisionof which he is incharge isresponsible forthesupervisionandadministration of all thespecialclasses in thecity andin theState, andalso for assistance in theadjustment ofpupilproblemsof variousother kinds. Within thedivision isthepsycho-educationalclinic. The staff of the clinicincludes,. inadditionto the director,onepsychologist for the cityof Wilmington,and it utilizesthe medicalinspectors, home visitors,and schoolnursesa the city. The primaryfunctions of thepsycho-educationalclinicare, as its nameindicates, thestudy andadjustment ofinstructionalproblems .and-thepromotion of themental hygienepoint ofview inrelationto classroom situations.Behaviorcasessometimesfindtheirway to the clinic, butserious difficultiesof thiskindareusuallyre-referred to the mental hygieneclinic oftheDelaware StateHospital,which providespsychiatric,psychological,and socialservicesin connection with thecaseswhich it studies.Thus thetwo types ofclinicalpro- gramssuppleinent eachother. In pointingout the significantelements ofthe servicegiven,the director of thedepartment of specialeducationandmentalhygiene calls attentionto the following items: 4 1. Anattempt is madeto adjust the workof theschools tothe children's needs.Thisremoves one cause of malbehavior. 2. Anattempt is madeinmany cases to adjustthe familyandenviron- mental situation. 8. Necessaryphysicaltreatment is providedinmany caws, theresults of which ari reflectedin thelater psycho-physicaladjustment 4. Greater understandingof the child'sconditionon the part of theteacher bringsan improved attitudetoward thechild. v

t4) Nr CLINICALORGANIZATIONFOR CHILD GUIDANCE 37 j

PSYCHIATRICSERVICEFROM ACOMMUNITYAGENCY Des Moines,lowa.Thedepartment ofpupiladjustmentin the schoolsystem of this cityof145,000 inhabitantscombinestheserv- ices usually ascribedtoapsychologicalclinic,anattendancedepart- ment, andadepartment ofspecialeducation.Therearealso five visiting teachersin theschoolsystem, three ofwl;omare.assigned tofull-time workwith behaviorand attendanceproblems, whilethe othertwo give about halfof t*irtimeto psychometricexamina- tions.School medicalservice islikewiseavailable. The clinicalexaminationsof thedepartmentof pupiladjustment arepsychologicalrather thanpsychiatricinnature, thepersonin charge of the clinical'work beingapsychologistby training.Prob- lems studiedinclude, inadditionto those ofapurelyeducational type, school disciplinarycases,attendanceirregularities,andamuch smaller numberof seriouscasesof delinquency:Clinicalconderences areheldasthe needdictates andareattendedby allconcernedwith thecase,includingprincipal,schoolcounselor,teacher, andr sentatives ofsocial agenciesor court.Assignmentfor folje!Tp work is madeby thepsychologist incharge. Ifcases areof sucha typethat theydemandpsychiatrictreat- ment, theyarereferred forconsultationorforpermanent assign- mentto the mental healthclinic, whichisan agency supportedby the communitychest of DesMoines andwhichhas theservicesofa part-Atpsychiatrist andafull-time psychologist.In suchin- stances,a copyof all theinformationcollectedby thedepartment of pupiladjustment issent to the mentalhealth clinicandaconsul- tation of themembers of thetwo agencies helpsto determinefurther responsibilities inhandlingcases. Pasadena,Calif.Pasadena hasapopulationof about81,000.Its school clinicalservice idefinitelycentered inthe guidancedepartment, with cooperativerelationshipsextendingtonumerous other agencies bothwithin and withoutthe schoolsystem. Thedirectorof guidance, assistedbyonefull-timepsychologist,leads inthe clinical study, whilehealth specialists,attendanceworkers,schoolcounselors, principals,and teachers allcontributeto the considerationof the problemat hand.Parents,too,mayparticipatein theclinical conferences. The chartreproducedon page 39 shows rathercomprehensively what specialservices Pasadena ôffersto unadjustedschoolchildren and whatrelationships obtainwith agenciesoutside theschoolsystem. It issignificantthat schoolmethods ofadjustment,aslistedonthe chart, beginwithapositive healthand mentalhygieneprogram 38 CLINICALORGANIZATIONFOR CHILDGUIDANCE

through classroomorganizationandpupil-teacherrelationships,and that only whenthe schoolresources are exhausted is thecase tobe referredto the special serviceagencies ofthe guidancedepartment and the childwelfaredepartment. .Important,too, is the positionwhich thecoordinatingcouncil-ad- justmentcommittee hasin thescheme ofwork.This isa com- munitygrouprepresentingvariousAsocialagencies whichattempt to mobilize theirresourcesfor theinterests ofthe individualchild. Eachcasebroughtto the attention of thecommittee iscleared byway of thesocial serviceexchange,sothat themaximumcoordination of effortmayI)e obtained. Among theagencies listedonthe chartis the childguidance clinic.This isanorganizationsponsored bythe SouthernCalifor- niaSociety forMental Hygieneand supportedby theLos Angeles and PasadenaCommunity Chest.Itservesboth ofthese citiesas a unit anddoesnot limit itscases toschoolproblems, butitaccepts from theschoolscaseswhichappear todemand thepsychiatric assistancewhich it ispreparedto give.Thus againwefinda com- munitypsychiatriccliticsupplementingthe psychoeducitionalclini- cal servicewhich isanintrinsicpart of the schoolprogramand which isintimatelyrelatedtoeveryother phaseof theschool activities affectingthe livesof children. Niagara Fa118,N. Y.Somecities havelocated intheir midsta clinical servicewhich issupported byaprivatefoundation.Niagara Falls, withapopulation of79,000, isoneof these,lookingto the childguidance clinicofthe'MarthaH. BermanFoundationfor the specializedservices whichare notavailablethrough theschool system. The board ofeducationemploysonefull-timepsychologist, afull-time schoolphysician, ttndafull-timevisitingteacher.These in themselvesconstitutetoacertainextentaneffectiveclinicalunit whichmeetsonceeach week,*ogetherwithrepresentativesofany social agenciesinvolved,to disctss problemcases.Teachersarelike- wisefrequentlyinvitedto participate instaff conferences.The 1 result hasbeenasignificant&ogress in theunderstandingand adjustment ofpupildifficulties.\ TheBermanFoundation,through thechild-guidanceclinic, furnishes psychiatrichelp,aswellasa4ditionalpsychologicaland social services.The schoolsareonlyoneo'the referringagencies.Others contributingto thecaseload ofthelinicarethe welfare orgapiza- tions ofthe city,- thecourts, parents,\relatives,friends,and 'private physicians.In theyear1936-87,15&new caseswerestudied,of which55,or86percent,werereferredythe schools.Thecoopera- tivearrangemeSa betweenschools and c1nicarereportedto bevery attisfactory. IL'

/ 11111114, N rIVDINIrlD NOLISZINVOIM 110,4 arima a;)Nvenno , 1 1 I , i . 0 AL FOR FOR FOR FOR FOR I AND ED -OF- AND CuLR dAPPE ILD PRE- MENTALLY AND TEACHERS PHYSICALLY SHuT-INs H CLASSES SPEC SCHOOLS THE SCHOOL ANO HANOI TUBERCULAR SIGHT CLASSES HEARiNG SPEECH CLASSES BLIND PARTIALLY ANO DEAF HARD CLASSES DEFECTIVES CLASSES TUBER 1 FoR HOW , , d , G mADE N HEALTH 0 TRAINING St CI CLASSES IN SPECIAL CIES COURT AFTER TO SCHOOLS STUDY PLACEMENT OFFICE MAY ANO N ATTORNEY COUNTY WELFARE VISIT COTTAGE DEPARTMENTS DEPARTMENT ENFOR CHILDREN NS T AGENCIES AND AGE SCHOOL DEPARTMENTS THE DATA, CLiNIC, ENT SHERIFF'S POLICE LAW CITY JUVENILE DISTRICT O MINORS m popDoCAPPED ASSOCIATIONS SOCIETY, T WELFARE ROSEMARY or CLINIC WORK FOR AID Schools. TESTS PAR DEPARMEN ENT DENTAL AND DE ASSOCIATION DEPARTMENT GIRLS SCOUTS SOCIETY COUNTY AND INTERPRETING OS CIES CLASSES BUILDING GUIDANCE S. N SOCIAL MENTAL Public GIRLS IN N AND EmPLOYM U SETTLEMENT AND GIRL OF STUDY ORGANIZATIONS SOCIETY E NURSE ASSOCIATIONS RECOMMENDATIONS CLUBS BOY YWCA WELFARE SERVICE - LIBRARIES GRO cATHOUC,JEWISH,PROTESTANY OTHERS CHILD AND PROBATION PARENT-TEACHERS DISPENSARY, AG BOYS HUMANE CITY V SCHOOLS Calif., GUIDANCE CAMPFIRE YMCA PLA OTHER mExIcN GIRLS' OTHERS BOY CHURCH CITY MAKING CHARACTER CHILD UNADJUSTED INDIVIDUAL ASSISTANCE CLINICAL sunitytwoN HEALTH ATTENDANCE, CITY SER- EXCIONIE If COUNCIL or Panadena. THROUGH SOCIAL ADJUSTMENT COmmiTTEE CLEARANCE COORDINATING vICE NEEDS DEGREE THE EXTRA- TEACHERS, CHILD tbe ON TO Y CLASSES AND WELT PASADENA WITH of DIAGNOSIS LO ADJUSTMENT TO WITH oF CHIC* ORGANI- RECORDS PRINCIPAL, RECOMMENDATIONS WHEN ARE SCHOOL RESOURCES EXHAUSTED REFER MENTAL SERVICE AGENCIES OTHERS CHI OF AND TO OF II THE Of DIFFICULTIES ENT SITUATION THAT AND REMEDIAL %FORKING AND AND CURRICULAR OF PROGRAMS STUDENT T-M TO courtesy SEE AVAILABLE CLASSROOm PROGRAM Of S METHODS HONE PUPIL, TO INTERVIEWS OTHERS U ExmINATION OF INDICTE AND by ADJUSTMENT METHODS NURSES TEACHERS HEALTH EXAMINATION OF AFFORDED INTERESTS DJ FOLLOwtD ALL CONFERENCES ADJUSTMENT AND A AND CHIEVEMENT AND AND CURRICULAR NEEDS ARE PRINCIPAL OF ZATION HYGIENE CONTROL PARENT, SCHOOL CASE ADJUSTMENT MENTAL ASSIGNMENT SCHOOL FOLLOW-UP DEMOCRATIC PHYSICAL STUDY Posalve PERSONAL ANALYSIS TEACHERS ICE V DOCTOR PRINCIPAL REMEDIAL COUNSELOR CLASSROOM ) Reproduced T EMS. z z v) CL Ca . LACK ETC [ICJ o -J x Ow war 4...11Mr* ADAPTED HOUSING, DISCIPLINE TEACH ETC) CAPPED NOT DI FAMILY, .. SERVICES CLOTHES, WITH POOR OVERPROTECTIvE SITUATION INTERESTS, IN Y EmOTiONAL HAN HANDICAPPED MONEY, DELINQUENCY ONSIBITAT MALADJUSTMENT LIT ANO SITUATION OF MALAIDJuSTmEN HOMES, NC RAPPORT SI PROGRAMS OF SUITABLE PRE'DELINQUINCY OF MALADJUSTMENTS Of OF Of CAUSES STA ECONOMIC !FINDING NEEDS HOWE f. IN AND PUPIL SCHOOL To (WOKEN CRIMINALITY (MALNUTRITION, LACK PARENTS, OF (LACK PHYSICALLY CASES MENTALLY CASES POOR SCHOOL OTHER Room TYPES [UNADJUSTED CAUSES SPECIAL 40 CLINICALORGANIZATIONFORCHILDGUIDANCE

PSYCHIA,RICSERVICEWITHIN THESCHOOLSYSTEM Gary, Ind.This city,withapopulationof108,000, haswithinits school systemanorganizedchild-guidanceclinic,thesupervisionof which is in thehands ofthe directorof childwelfareof theschools. A school psychologistgivesabouthalf ofher timeto clinicalre- sponsibilities;aschoolphysicianand schoolnursesservethe clinical caseswhen needed; and11 schoolvisitorscooperate in thesocialcase work.A psychiatristisemployedby theboard ofeducationfor half 24 daysduring theyear, or the equivalentof 2half-dayclinical sessions eachmonth. Casesto be consideredby theclinicarereferredto the school psychologistby theschools,parents,court, familyphysician,orother interestedpersons.The.psychologist,inturn,arrangesfor their presentationat clinicalconferences,whichareattendednot only by the clinicalspecialists butalso byprincipal,teacher,schoolvisitor, schoolnurse,and socialworkerfromaninterestedsocialagency. Follow-up workis assignedat theconference,and inthisresponsi- bilityprincipalsandteachersalwaysplayanimportantrolethrough the adjustme f theschoolprogram tq meet the child'sneeds.En- vironmental ustments in thehomeorcommunityarefollowedup by ,the schoo -visitorsandrepresentativesofcommunitysocial agencies. , Long Beaoh, Calif.Withapopulationofapproximately157,000, the city of LongBeach hasorganizedwithin itsschoolsystemachild- guidanceclinic.This isunderthe directionof the"coordinatorof curriculumand childwelfare,"whoseresponsibilitieslie inthe field ofadjustmentboth withreference to pupil problemsand Ecurricular adaptations inrelationto the needs of pupils.In : itionto the coordinator, theclinicalstaffincludesoneschoolpsychologistwho gives part timeto clinicalcases,thesupervisorof healthservices, who isalsoapsychiatrist,andonefull-timevisitingteacher. Clinicalconferencesareheldonceeach week.Besidestheregular clinical staff, theschoolsupervisorofattendance,principal,teacher, and schoolcounselorare present.Casesto be consideredarereferred through thevisitingteacherby theschoolsorbycommunitysocial workerswith whomacooperativerelationshipismaintained.The visiting teacher andthe schoolcounselorareresponsibleforfollowing upthe caseafter diagnosisandrecommendationshavebeenmade. The teacher of thechild inquestionassists incompilingschoolhistory and inmakingfollow-upreports. The serviceof thechild-guidanceclinic isreservedprimarilyfor the study ofcasespresentingproblemsof behaviorasdistinctfrom those ofan instructionalnature, althoughit isrealizedthat thetwo CLINICALORGANIZATIONFOR CHILDGUIDANCE 41 typesareclosely interrelated.Approximately100cases are studied eachyear,butmanyof themdonot receive full clinicalattention.It is found thatalarge numberof problemscanbe adjustedby the visiting teacher, eitheraloneorwith theassistanceofone or more staff members. In commentinguponthe values andthe difficultiesof the clinical program,the coordinatorpointsout the importanceto the clinic of the informationconcerning thepatientpossessedbypersonscoming in contact with him(suchasprincipalsand teachers)whoare not members of theclinical staff;also theimportanceto thesepersons, asthey sit in withthe clinic, oflearningthe techniquesused in approaching problemsof thischaracter.It is likewisepointedout that there is dangerof isolatingthe clinicin theschoolsystem,so that its effectuponschool practiceisnotas great asit mightbe. The question is raisedasto whether the majorfunction ofthe clinic should be definedinterms of the numberofcases towhich it gives full clinic studyorinterms of its educationalinfluenceuponpractices in individual guidance.In Long Beachtheattempt is madeto realize both these functionsin the clinicalprogram. B erkeley,C alif .Since1928, the city ofBerkeley, withits population of 86,000, hassupported withinits schoolsystemabehavior research clinic,operatingas partof its bureauof guidance,placement, and personnel.It is sponsoredby theBerkeleyCoordinating C/ouncil, whichwasthe forerunnerofalarge numberof similar councils organizedthroughout theState of Californiaand inother parts of the country." Psychometric servicefor the clinic isprovided by selectedteachers who have beencarefully trainedin thetechnique of givingmental and educationaltests.One full-timevisitingteacher andthe school counselors in allschools do the neededfollow-up andcasework. School health service isutilized for cliniccaseswhen desirable.A yediatrician is employed . by the board ofeducation for2 half days each week andapsychiatrist for3 half days each week. Clinic conferencesareheldonthree morningseach week,eitherat aschoolorat the central administrativeoffices. Thecases tobecon- sideredatagiven conferencearedesignated bythe supervisorof guidance, placement,and personnel,to whom they havebeenpre- viously referredby the schoolprincipals. Aprincipal,aschool counselor,orthe visiting teacheractsaschairman of theconference; theptchiatristand the pediatrician(when available)takealeading part;and theparentorguardian and the child'steacherarelikewise

OFor history and descriptionof the work ofcoordinating councils,see Beam, Kenneth S.Coordinating CouncilsinCalifornia.Sacramento,Calif.State PrintingOffice, 1938.54p.(State of California,Department of EducationBulletin. 1988. No.11.) 113734 42 CLINICALORGANIZATIONFOR CHILDGUIDANCE

present whenever feasible.Inany casethe teacheris notifiedof the results 2f theconference andof therecommendationsof thepsychiatrist regardingthe problemofachild inwhom gheis interested. The behaviorresearch clinicin Berkeleyis primarily(butnot exclusively) designedfor the studyand adjustmentof seriousbe,- havior problems.A "serious behaviorproblem" isdefinedas"one which variessufficiently fromnormal behaviortocausethe teacher to feel that the child doesnotgadjustsatisfactorilytothegroup." Emphasis is placeduponthe fact thatsuchcasesshould includenot only aggressivetypes of misdemeanor whichdisturb thedisciplineof the classroombut also emotionalinstability ofanykind,exaggerated reticenceortimidity, shut-inordepressedpersonality.If medical attentiori is needed,parentsareadvisedto consult theirown , physicians fortreatment. If family financesdonot permit this, thepupil is referredto city agencies for free medicalcare.Thecaseworker is also in touch.with variousother communityagencies whichgive assistance in providingspecial diets, medicine,lunches, andother needed items. The importance ofclinical service inrelationto the entire school program,with specialreferenceto provisions for handicappedchildren, is indicatedby thestatement of the superintendentof schools in Berkeley: There isno doubt that the public school shoulddevelopextensiveuse of the child-guidance clinic,where the psychiatrist,the pediatrician,and the psychologistmayassist the teachersand theparents in understanding someof themorehidden andmore subtle causes of maladjustment.The mentallyrerded childorthe child whohassome physicalor mental b handicap isways more likely to be misunderstood;is alwaysmore likely to developsome complex or fear because of his inabilityto havean even break withother children of hisown class andage.It is the'businessof jthe schoolto study the abilities and the limitationsof each child.When these abilities and limitationsare properly understood andproperlymet there will be less of thestruggle that results in failure.Thesense of failure and of inferiorityin the child isoneof the basicelements incausing social maladjustment whicheventually, unless corrected,leads to delinquencyand , crime.Ifwe are to reduce delinquency and crime,the publicschoolmust give important Considerationto child-guidance clinics, usingthe best scientific training andscientific skill in helpingparents and teachersto make

; early adjustmentsin the lives of children.

GENERAL COMMENTS The generalpattern of the local child-guidanpeclinic is evident from the foregoingdescriptions ofprogramsinacity-schoolsystems. In each of theschoolsystems consideredonefinds healthservices, visiting-teacherorsimilar functionsofacase-work'type, andpsy- chological,orat least psychometric, assignment&Psychiatricserv- ice is availableatbest onlyonpart time within the schoolsystem, CLINICAL ORGANIZATIONFOR CHILDGUIDANCE 43 and inmostcases comesfromacommunityagencyoutside the

schools., Relation of the clinicalstaff to therest of the school 8y8tern.--The clinical staff.exclusive of thepsychiatrist, israrely in citiesof this size reserved for clinicalcasesonly. but itsmemberscarry ontheir clinical dutiesas a partof theirtotal responsibilitiesin the school system.Suchanarrangement, necessitatedinmostcasesby bud- getary limitations, hasboth itsadvantages andits disadvantages. Because of themanyother demandsmadeuponthem, the members of the clinicalstaffcannot isolate themselves fromgeneral school activities butmust perforce become intimatelyacquainted withthe educationalprogramof the schoolsystem and itsnumerouspossi.- bilities for andhindrancesto adjustment of pupilproblems.This is'conducivetomoreeffective adjustmentprocedures. Onthe other hand, manifolddemands for generaliervitemaybecomesopressing asto weaken the effectiveness ofthe clinicalprográm.Unless sufficient time is definitelyand regularlyset aside for attentionto clinicalcases,both in conference andin follow-upservice, the resultsare likely to be quite unsatgfactibry.A weekly clinicalconference would seemto be the minimum in cities of thissize, withwell-organized procedures of referral,clinical consideration,and follow-up. The intervals betweenconferencesareobviously ofgreat significance for the actualtreatment of thecasesin question, and,if the clinicalrec- ommendationsareto bemorethanmere statementsfiledaway on a case-history,someonemust be activelyat worktoseethat theyare followedout.The assignmentof such responsibilitymust be definite andmust allow for the time-consumingnature of the duties involved. No standardshave been workedout to date designating the.amount of time required by thevarioustypes of specialistspar- ticipating in the clinicalprogram,but thedescriptions givenin this chapter will givesomeindication ofhow much timeis allowed.Al- most unanimouslycomesthe expresseddesire formoretimeorfora larger staff. Fractions of theclinie.Reference hasbeen madeto the question of the priority offunctions of the clinicasthey relate.ontheone hand,to the adjustment of individual pupilproblems and,onthe other hand,to bringing about desirablechanges in theeducational program.Itseemsimpossibleto separate these in theconcept ofa completely functioningchild-guidance clinicin the schoolsystem. The first isone . of immediateresponsibility; the secondisoneof ulti- mate value, the realization ofwhich will inturn minimizeorat least greatly lessen---the needof the first. The situation findsaclose parallel in theprovision of medicaland health services forthe body. Thecureof physical illhealth is impor. 44 CLINICALORGANIZATIONFOR CHILDGUIDANCE tant, and its needwill alwaysbepresent; but thepreventionof ill- nessthroughhealtheducation isjustas.important.Themodern physicianaimsto keep his patientswell, andpublic-healthagencies have thesameobjectivefor thecommunityat large.So,too, the child-guidanceclinicmust affect educationalpractice inthe interests ofmentalhealth foreverychildif it istio make itsgreatest contribu- tion inadjustmentmeasurefor thosewhose mentalhealth isendan- gered.Theveryfact that inmpst of the citiesconsideredin this chapter theclinical uctivitiesare notlimitedto "behaviorproblems" assuch, butincludeother difficultiesrelatedto the educationalpro- gramindicates thecloseness oftherelationship.Moreover,the clinicalstaff, inbeingconcernedwith allphases of theeducationalpro- gram,hasanadvantage incarryingout the larger functionof the clinic.Through theapplicationof clinicalidealsto all theircontacts andactivities,theycanconstitutealeaven throughwhichthe character of the entireschoolprogramisimproved.Mostessential,of course, arethe soundnessof theirownpoint of viewoneducational matters, theirownabilityto understandpeople, 'andtheirownwill- ingnessto make reasonableadjustmentsin thelight ofthe situation at hand. Coordinationof 8ervke8.Ofgrowingsignificancein cityprograms suchasthose whichhave beendescribed isthe consciouseffortmade to coordinate all theservices whichthecommunityhasto offer either withinorwithout theschoolsystem. TheBerkeleyCoordinating Council andthe PasadenaCoordinatingCouncilAdjustmentCom- mitteearetypical of theform oforganizationwhichhas beeninstru- mental inmanycommunitiesthroughoutthecountry inpromoting the miximumuseand 'theminimumduplicationofexistingfacilities for the welfareofchildren.Even withoutthe formalorganization .of suchabody, thereisapparentamarked effortto 'Alikeall the forces of the communitycount forawell-integratedprogram ofserv- ice, eachagencycontributingof itsownresources to the totalstruc- ture.Of the vitalcontributionswhichthe schoòlscanmaketo the entireprogram, aotthe leastimportantisawell-organizedclinical service for theadjustmtat ofpupilproblems. CIIAPTER-V

THE OPPORTUNITYOF THELARGE CITY4° Thereare41 cities in theUnited States withapopulation ofmore than 200,000.4'All but4 of thesereport the availability ofsome clinical service, withpsychiatric attendance,either within theschool systemorthroughacommunityagency notimmediately connected with the schools.Twelve of these citiesreport psychiatric serviceas adefinitepartof the clinicalprogramsponsored by theboard of education.Theseare:Los Angeles, Calif.;Chicago, Ill.; Baltimore, Md.; Detroit, Mich.; Minneapolis,Minn.; Jersey Cityand Newark, N. J.; New York City,Rochester, and Syracuse,N. Y.; Portland, Oreg.; and Providence, R. I.Certain othercities have extensive psychologicalorchild-guidance clinicsdfanonpsychiatrictype in the school system (as, for example, Cincinnatiand Cleveland,Ohio; Philadelphia and Pittsburgh,Pa.; and Seattle, Wash.),but utilize for the mostpart extra-school psychiatric facilities;while practically all the cities in this populationgroupprovide through theirschool systemssomepsychologicalorsocial service inthe interests of pupil adjustment. Siam the majority of theprogramsdescribed in the previouschap- ters havebeen characterizedby the utilization of communitypsychi- atric services for the children inthe schools, thosediscussed in this chapter, withoneexception, will be limitedto situations in whigha child-guidance clinic with psychiatricservice(or division with similar function)issetupand financedas adefinitepart of the school provisions.Anaccount of theprogramin Portland, Oreg.,is included because the publicschools in this cityconstituteoneof the official sponsoring agenciesof the clinic, althoughnot directlyem- ploying the psychiatricservices.

).4 PROVIDENCE, R. I.

(Population:255,600) In the department of researchand guidance ofthe city schoolsystem of Providence there isaschool clinic forchildren'sproblems,

*Except where otherwiseindicated, all datareported in this section, includingquoted statements,are taken from reports contributed in 1988 by localschool officialsto the Office of Education. a All population figuresusedare as of estimates made by the Bureau of theCensus in 1983. 45 46 CLINICALORGANIZATIONFOR CHILDGUIDANCE under the immediatedirectionofanassistant inthedepartmentwho is in chargeofpsychologicalexaminationsfor theschoolsystemas a whole. Servingthe clinicarethreeadditionalschoolpsychologists, eachdevotingaboutone-thirdtimeto cliniccases; two full-time socialcase workers;andapsychiatristfor8 hourseachweek.The school medicalinspectionandreferralsto hospitalclinicsin thecity areutilizedasneeded. Clinic conferencesareheld twiceeach week,withthedirector,the psychiatrist, psychologist,andcaseworkerattending.Sometimesthe representative ofaninterestedsocialagencyalsoparticipates.The director of theclinic isresponsibleforreceivingapplicationsfor clinicalserviceand forbringingthecases to the attentionof the clinic.A social workerorschoolcounselorisusuallychargedwith following upthecase.Apsychologistdiscussesthefindingswith teacher the of thechild,and, ifthecase warrants, thecase conference held is at the schoolwhere bothteacherandprincipalcan participate. Generalcomment onthe workof theclinic ismadeby thedirector, asfollows: Types ofcases considered may be dividedintopersonalitydifficulties conductdisorders.The and formerare of theneurotictype, whilethelatter involveovert behavior.In treatingthelatter,we work closelywiththe disciplinarydepartment,as it is difficultat timesto detehline partmentcan deal with whkhde- the childto bestadvantageat thetime Instudyinga case psychometric referred. testingtakesplace first,schoolhistoryis compiled,andpersonaltraitsanalyzed.Theinterview comes next, with withtheparent appointmentfor thepsychiatrist.The visitto atrist isfollowedbya conference thigsychi--' of allconcerned.Eachyear close about one-thirdofour casesas makingsatisfactory on a semiactive progress, keepone-third listas in need of possibiehelp, andcarry active forthe over one-ptbirdas nextyear. Ofthosewhosenameswere on the list lastyear, only about semiactive 10percentreturnedfor furtherhelp.A few (fiveorsix specialones each cases year)are referredto theProvidenceChild GuidanceClinic,sponsoredby the RhodeIslandSocietyofMentalHygiene and theCommunityChest,or to the clinic of theRhodeIslandStateHospital. PORTLAND,OREG. (Population: 309,100) It hasbeenpointed out howtheOregonplanfunctionsin relationtoasmallcity such asEugene.Itmightbeexpectedthata morehighlyorganized program would existinacityof\thesize of Pörtland,and thisis evidentfrom thechartofpage47.\.An inter- estingfeatureof theplan is theofficialjointsvonsorshipof theclinic by thePortlandpublic schoolstthejuvenilecourt, andtheUniversity of Oregonmedicalschool. Thechartshows,inadditionto these,the cooperatingagencies and thereferringagencies.The clinicis thusa fp- a' CLINICALORGANIZATIONFOR CHILDGUIDANCE - 47

its

CHILDGUIDANCECLINICORGANIZATIONIt. PORTLAND,OREGON

AO.

AGENCIESSPONSORINGCHILDGUIDANCECLINIC

UNIV E HSITYOF OREGON (PORTLAND PUBLICSCHOOLS JUVEN ILECOURT i MEDICALSCHOOL

CUNIC COMMITTEE

'ab

CHILD GUIDANCECLINIC

PSYCHIATRIC MEDICAL PSYCHOLOGICAL VISITING TEACHER- SERVICE SERVICE SERV ICE SOCIAL SERVICE

ICOOPERATING AGENCIES REFERRING A GEN CIES

sf 1 . .. ---... e DEPARTMENT OF VISITING SCHOOL HEALTH RESEARCH AND I ,.-tr, HANDICAPPED TEACHERS 3 , CHILDREN ml am Mob eme=Noimme @ SeHOOLDOCTOR EDUCATIONAL ATTENDANCE %

o 1 \PLACE M ENT DEPARTMENT 3 'SERVICE

MEND=1, AMIN. 411 =1. 1.6 It- 1 s 0 NURSES PSYCHOLOGICAL VOCATIONAL GUIDANCE II 0z o SERVICE PLACEMENT = 0 BUREAU 4AaIla 3 44 111 imp one sim Ip sm. am us ictI. e me i3oi)z SPEC! CHILDREN'S s 4c.Ift 40as= uo ala ..., e EDUCATION . DEPARTIgNT kla i: - InJ Wo co-41 DENTAL BUREAU iz ici= CLASSES 0 s-- ,, A NOW. P.P Zgot 0g vs-s-- CHILD WELFARE woos....gotidins 0..EA /.1 0 Z 02 l'a-'biZIIIa Z '41 J" 0 X4fig .p. ePR4al j Is . COMMUNITY a or 1 t;4biX 74InJA CHEST do -a. E,:.1s:VI CLEARING HOUSE 4 42 she e=o2 all0...4 ìr 11100130 5: z OP6.

CHILDREN A

Reproducedbycourtesy cif thePortland, Oreg.,public schools. J.

. .

_ 48 Wiwi,ORGANIZATIONFOR CHILDGUIDANCE

real communityproject, inwhich theschools participateas oneofthe communityagenciesinvolved. Duringa4-year periodof the clinic'swork forwhichdataare available, tileschools referredabout50percent of thecasesstudied, and two-thirdsof these involveAproblemsother thanthoseproduced byeducationalretardation.Significantis the factthat ofthetotal number ofcasesreferredduring thisperiod,165,or25percent,were diagnosedas"recessive."Thisrepresents the highestfrequencyof any one diagnosis made,and itisindicative ofthe increasingrecog- nitionbeing givento the dangersto mental health ofexcessivetimid- ityaswellasof excessiveaggressiveness. Despite thesuccessfuloperation ofthe cliiiicas acommunityproj- ect, its limitationsarepointed.outby thedirector ofchildstudyand specialeducationfor the Po-elandschools.Ile ascribestheselimita- tionsto the lack ofadequatecrinioal timefor theschoolsandto the lack ofopportunityonthepart of school peopleto work withqie clinic ontheirown cases. To remedy thissituation, hesuggests the desirability i3destablishingirithin theschoolsystemaclinicalservice throughwhich teachers andadministratorsmayhelp insolvinga problemthroughconsultationwith clinicalspecialists.Hewrites:" Bringing the clinic intothe schoolwill bri it closerto thecommunity tlibough the teacher,principals,schoolnurz:,:, parent-teacherorganizations, as well as through theparents of thechildrenserved.Thiswould a better understanding develop of the woikbeing doneand thusmake possiblethe more adequate financialsupport neededfor sufficientexpansionof clinical facilitiesto provi»or the needs of thecommunity.

'JERSEYCITY, N.J.

(Population:319,900) a. The general organizationof thebureau ofspecialservice.inthe school system of JerseyCity isdepictedon page 49. Thepurpose.of , this bureauis "to handleallcasesof juvenilemaladjustmentordeliii- quenbYwithin the schoolsystem."Itsprogram is of particularintAir- est because it not only coordinatesthe usualchild-guidanceservides ofa schoolsystem but bringsintoimmediate Telationship'tothem the services ofone . policeinspectorand fiveplain-clothesofficers. Thefollowingstatementappters inamimeographedrefort describ- ing theworkdf theorganization: The¡bestsof this entireprogram is thatevery case of has definite maladjustment causal fitCtorsofaphysical,mental,pr environmentnature .rNbielt shouldberecognized aildeitrefully l' considered beforethe clgldis insti- . 4.;. , t , . .. e- . 1 a Martin,Lewis C.. I Organizationof*IIchildguidanceclinic.Journalof eiceptional children, 6:212-216,May 1989. . , ' . . . , e ,. . . . _ N o - a

- 4 O a CLINICALORGA.NIZATIONFORCHILDGUIDANCE 49

ORGANIZATIONOF BUREAUOF SPEOIALSERVICE BOARDOFEDUCATION,JERSEYCITY,N.J. UNDERTHESUPERVISIONOF ASST.SUPT.

1 SUPERVISOR (4,27 ATTENDANCtI OFFICERS

o IPOLICE I SUPERVISOR INSPECTOR TEACHERS 5 POLICE 8VISITING OFFICERS 5 HOME (PLAIN I NSTRUCTION CLOTHES) 2 HOSPITALCL IEXPERIMENTAL READINGCLi

CLINIC DOCTOR

DENTIST . I1RECREATIONAL OTOLOGIST 10 6 CENTERS , OPHTHALMOLOGIST SPECIAL, 78 INSTR as% 3 NURSES C LASSES 3PSYCHOLOGISTS 41. PSYÇHIATRIST. ReproducedbycOurtenyof theJersey City, N!J.public'ichools. 50 CLINICAL ORGANIZATIONFOR CHILDGUIDANCE

tutio-nalizedorheld responsibleinanyothermanner.Themany sociological studies of recentyears have served to pointout the importanceof environmental influences, ofmaladjustedhome conditions,maladjustmentwithin the school,as well as physical andmental maladjustment.Until theschool has thoroughlyinvestigated allof thesepotential influencesand has attempted tounderstand theindividual in the lightof them,it hasfailed in its duty to the childand to society andmust accept fullresponsibility for the failurerather thanattempt to place ituponthe child. The procedureused in handlingschool problemcasesis charac- terizedasfollows:

1. Childrenshowing definitesigns of abnormalphysicalor mentalcon- ditionsare reported to the bureauof special serviceon special forms prepared forsuch reports.Accompanying thisreport isa complete statement of theschool historyonthe permanentrecord cardof theschool systemaswellas the analytical statement ofpersonality traits,recreational habits andinterests, andanyspecial indicationsof maladjUstment. 2. Thesecases are then referred to thevisitingteachers forcomplete investigation ofboth homeand school conditions.This recordbecomes a cumulative one bymeansof weeklyfollow-upvisits bythe visiting teacher& a All childrenare scheduled for completeclinicalexamination inthe light of theinformation gainedfrom schooland- home.Specialattention is given tosensory defects due to thealarming numberwhich havebeen found toescape detection by the classroomteachers. 4. Weekly conferencesareheld forthe discussionof thesecases in an attempt to formulatea well-rounded Judgmentoftheproper way of handling eachindividual. 5. Recommendationsare made to thesuperintendentof schoolsregard- ing thenecessity fortransferring childrento the variousspecial classes and schools.Further thanthis,recommendationsare also made forthe establishment ofadditional classesofagiven typeor additional typesof classes. For handlingseriouscasesthat demandpoliceattention,the procedure isoutlinedasfollows: To replacethe oldsystem of allowing-,individualpolice officersto take boys to policestationsor place them in correctionalinstitutionspending action of thecourt, the followingprocedurein thehandling of policeleases has beenestablished: 1. Wheneverachild isdetectedcommittingsome juvenile offense of sufficientimportanceto demand policeattention, heis escortedto his home bythe officerwhosecures thename, age, address,and school attended.The followingdaya complete reportis madeto the inspector of thepolice detailassignedto this bureaugivingthe above informationtogether with the.offensecommittedby the child. 2. Parentsare notified to presentthemselvesat the officeof the bureau ofspecial serviceaccompaniedby the childfora conference regardingthe reportedoffense. . a Completestatementsare taken fromparents andchildrenregard- ing thefamilyconditions,home life,and recreationalhabits ofthe child.Theyare given to understandthat continuanceof suchoffenses CLINICALORGANIZATIONFOR CHILDGUIDANCE 51 will leadto serious difficultyandare advised in regardto the regula- tion of thechildren'shabits alongconstructive lines. 4. All ofthesecases are given clinicalexaminationsas those described forchildren reportedby the schoolauthorities,when they seem advisable, and theparentsareadvised inregardtonecessary treatment. 5. Follow-upvisitsare made to the homeand theschool byplain- clothes officerswhosecure information.regarding thechild'sactivities until such timeas there is sufficientevidencethat thereisno further need for thisfollow-up work. 6. Inthosecases where parentsshow theproper cooperation, and still thechildren continueto be delinquent,the childis takenbefore the Juvenilecourt witha complete statementof thecase and the desirability ofa correctional institutionis decidedby theJudge.This has beennecessary in less than 10percent of thecases whichwere formerlyautomaticallyreferredto sucha court. It is pointedout in thereport of the bureauof specialservice that oneof themost importantfeatures ofthe entireprogramin Jersey City is thecoordination ofall publicagencies inthe interestsofchild- hood.The schoolwaschosenasthe centralagency"since italready hadalargegroupof trainedworkers whowereboundto be in close contact with the childfor aboutone-third ofhis wakinghours during the formativeyearsof his life.In additionto this, the schoolsystem inchided inits personnelmanyof theexperts neededtocarry outthe objectives oftheprogramand couldoffernot only theguidanceneeded but thephysical facilitiesfor botheducationaland recreationalac- tivities.The addedexpense tothetaxpayer has beennegligibledue to the existence ofsuch facilities."

ROCHESTER, N.Y. (Population: 833,500) The functionsof childstudy and specialeducation inthe school system of Rochesterarecombined inonedepartment, withadirector in charge.Besides thedirector, thecentral staffof thedepartment e. consists of1 assistantdirecitrfor specialeducation,2 supervisors, 15 psychologisti;1 part-time psychiatrist,and 1 part-timeotologist. An ophthalmologist'sservicesareavailableupon request. Lighty-six teachers of specialclasses forhandicappedchildrenscattered through- , out the citycomeunder the supervisionof this childstudy andspecial educationdepartment.The board ofeducation alsohasaworking relationship withthe psychiatricdivision ofthe StrongMemorial Hospital, locatedin Rochester,to whichcasesneeding suchattention arereferred fortreatment after examinationby thechild-study department. The functions ofthe departmentof child studyand specialeducation,aslisted by theRochester publicschools, indicate hoWclosely 4 I

411). 52 CLINICALORGANIZATIONFOR CHILDGUIDANCE the adjustment ofbehavior andpersonality problemsis relatedto the diagnosis findadjustment of othertypesof pupildifficulties.These functionsare asfollows:

. 1. Todiagnoselearning difficulties ofindividual childrenand tosuggest remedialtreatment and gradeplacement. 2. Toinvestigatecauses of personality and socialmaladjustments;to plan fortreatment in cooperationwith other personnelworkers; andto arrange for psychiatricinterviewsat child-study office,at health bureau,or in hospitalclinics. 3. Tohelp discover,through specialtests, pupils with unusualability in art, music, mechanics,and other specialfields. 4. Toexamine allpupils bygroup intelligence testsat kindergarten, fourth-grade,seventh-or eighth-grade, and ninth-gradelevels. 5. Toadvise inthe organization ofspecialgroups for remedialor enrich- ment work and inthe organization ofungraded andnonregents classes. 6. To organizeand supervisespecial classes andschools formentally handicapped children;to provide adaptedinstruction forchildren having defects of hearing,speech, and vision;to conductaudiometersurveys for hearing acuityat three grade levels;to conduct hospitaland convalescent classes. 7. Toarrange home tutoringas provided by the Statefor pupilsexempt from schoolattendance. 8. Tomake contactswith agenciesand Statedepartmentscaring for physically andmentallyhandicapped children. 9. To maintainafile ofcase records. There isa separatevisiting teacherdepartment inRochester, witha directorand 16 visitingteachers.Thesecooperate with thechildstudydepartment infurnishingcase reports, but they alsocarry on theirownsocial-case workwithcertain problemsreferred directlyto them.Visiting teachersareassignedtoservespecificschools,and accordinglymanydifficultiescanbe handledin theschool without referralto the central office.The healthand physicaleducation department likewisecooperates throughmedicalexaminationsand special healthservices forchildrenreferred forclinicaltreatinent. At thecentral office,acouncil ofpersonnelservicesacts to coordinate activities inrelationtoanyproblemsinvolvingtwoor morede- partments, looking towardthe realizationofwell-balancedandcon- sistenttreatment.This councilalsoserves asa meansof keeping each departmentinformedof whatotherdepartmentsaredoing. A complete diagram sho.wingall agencieswithinthe schoolsystemcon- cerned withadjustmentservices isinserted.

NEWARK,N. J. (Population:447,000) The directorof thedepartmentof childguidancein thé Newark public schoolsisapsychiatrist,and withhimarlassociatedthree full-timepsychologists,threefull-timevisitingteachers,andtwo CHILD STUDY AND SPECIAL EDUCATIONDEPARTMENT STAFF Director Aseietest director (Spciel Education) VISITINGTEACHER DEPARTMENT 3Supervisors IS Psychologists STAFF 114Special edscatioa teachers Director I Psychiatrist (pert time) 16 Visitingteachers IDialogist (part time) 1Psychiatrist(parttime) FUNCTIONS

FUNCTIONS I. Todiagnoselemming difficulties ofindividual I. To pima sad effectshortormotionedpsychiet- childree sad tosuggest remedial treatment sod ric socialcase wort trageseet in the interest of grade *cement. individual children who show deviations fromthe 1.To inyeedgetecauses of persoodiry end wash averagein nutters of personality and behavior. msllsdimtmsnts; toplanlortreatment inco-opers- thou with other personnel workers;sad to 2. To maintain home contacts for the school in arrange for psychiatric interviewsst Child Study office,st cases where home coachtions or peseta attitudes Health Bureau,or ia hospital clinics. do not favor astiedsctory childdevelopment. 3. To discover throegb specialtests pupils with 1. To co-opseet with all accredited family, child unusual shaky isart tonic,sadmechanics. welfare, and recreatioaal species in the unit 4. To examineallpupils bygroupintelligeoce 4. To co-operste specifically with social agencies tests atkindergarten,4thgrade, lthor f/th grade, cook-weed with the prevastion of delinqueocy sad sad goth gradelevels to plea with the Court sad model agencies for the LTo shim la the orgamisetionof ungraded,op- welfare of children who have become delinquent. portunity, andnen-rageete chimes. S. Tosecure is co-operation with the odor,'ewes 6. To otgurise end supervise special clewsand and the Health EducationDeterment dinical moist- schools lot mentally handicapped children; to pro- sacsfoe isdividuel children needing physicaltreat- videadaptedinstruction lot childrenbevies defects ment, sad to omega Mr.-psychiatric treatment. of bearing,speed',endvidez; toconduct audiom- eter surveys.forhearing acuityet three grade levels 6- TosuPervisecity, stetet, or federalreliefGO : mach retie applies to children d school age. to conduct hospital sad coevalseceat clams& ' 7. Touremia home tutoring se provided by the 7. To give the consmilegservice ofone shift stag for pepik exempt from school attendance. menabar to children teceivitsochoisrahipe from the II. To makecontacts withwadessad state tie- Childrenee Memariel ScholsrehipPend. partamb ariasfor phyekelly andmentally kilo& L To mmintaissIlk alcase motif GI builviduells cappedchildren. midis&e S. Titsmieedis Up ofcue gem& rrri - r -

t . CHILDSERVICESROCHESTERPUBLICSCHOOLS

1111=1111 t SUPERINTENDENTOFSCHOOLS

4 ASSISTANTSUPERINTENDENTOFSCHOOLS ------1 1 1

1 1 : CO-ORDINATOROF CHILDSERVICES 1 1

1 i + 1 1

1 DEPARTMENT OFCO-Of _DINA TION.. I AND RESEARCH I STAFF Diractoe DEP A RTMF.NT OFEDUCATIONAL AND FUNCTIONS HEALTHANDPHYSICAL EDUCATION VOCATIONAL GUIDANCE CO-OR DIN A TION DEPARTMENT STAFF L Toact asa conference caster kw thecorridors. Director tiesol policiessodcasesinwhich all the child Ctsideoce counselors services shouldworkas s snit. 2. To A. hFunction*is Relationto Co-optioning with the cossmeling secure istegrated action isprojects involv- servicesofthe ing twoor more of the child services. talivWaal Pupils PARENT EDUCATION ANDCHILD secondary schools: DEVELOPMENTDEPARTMENT Girls'sadboreadvisers This columndossoatincludetheprogramof the Registrationofficers 14 [St ARCH Health sod PhysicalEducationDeportmentasa while. the Dsportasont hoods report of which is node through the 1. Toprepare sod diatribe*. remelts of eleemetery assietant superinteedeet of schools. STAFF school FUNCTIONS tests related to eachcraterof interest is the Specialist , curriculum. ATTENDANCE L To °remise sod directa 'widow. commis STAFF Teacher ofparent educed°.classesandsupervises DEPARTMENT serviceiemock school to mast pupils io forusdedas 1 Topreparewith committees sodto distribute Director ofnursery schools metefor Narsery school loss-term educstioaelsadoccupational plans. the eighth,ninth,sodteethgrades of 1 Associate director teacher sod assistant secoodary schoolsissediects where =dormcity 1 Assists= director 2. STAFF To deterushte withheadsof departments the tests are &West 103 Health moocher. possibalties of hategretiag guidnoc.materielwith Director 3. To compile semiotics ofall city-widetestssod FUNCTIONS' thecourses of studyistheirrespectivenew d ao 14 Atteodsoceofficers develop this sestsrisl. to send to eachprincipalmatieticalsteadiesofhis ownschool. FUNCTIONS I. To stimulateindividualparents to studytbe 1 To developeclose co-oediostion with ell other intermits andneedsod children of all 4. To sendto each elemeetery school priacipal I.To pion sod directcorrectiveprograms in agese.-.d to FUNCTIONS %action! services Glebe schoolsystem which deal worttoward meeting these throughthefamily. wilt pupil peruses& for poremmest record wadiesof the work of Mili- physical educed= forchildrenbevies remedial Tidedchiffon. ph yokel defect. school, and community. 4. To meistain caresistive I. To investigate records embody*/ I. To participate cases of irregular attendance psychological, pkysisloolcel, sad sociekelicelWee- iscurriculum beading. 2. To conductparent*dormicegroups under pro- reportsdbytheschools swim sad geseosellt, fiction emestldto fa. To conduct research avails 2. Todiscoverclaim whoare below par is rigor fesaoael leadership for thestudyof childhood sod piths related to thecur- sod ladivideele I. asceticism' sod occopetiondpins. victimssemi to the chid service& to keep the schoolmesh'swanof doe health seeds familylife of eachchildren. 1 To aid lasecuring home conditioosleading to . regularity of L To co-opwste with existing wadesinmot- I. To train diacuseionSeeders kw localparent edu- atteodance. ingemploymesit sod io soshasininga follow-op 3.To sid the cationgroups, church groups,or neighborhood service foeeadrop-pets sodallgraduates ofw- MuslimsDeportee= in escorts* orgenizatioos. school heel&sopervisiassled activitiesfor 3. Toholdbearings inpersistentcafes of irregu- s, miryschools. =AIM pupilsritturuiegto schoolaltarOres exsenetirma, larity ofattendance. 4. To conductnurseryschoolsas laboratoriesfor 116 6. To catalog material cootaistiog authentk infor- I. errordascewith the advice of physicians. for use la widows. wrest education. mess 4. loprepare *nd proem.isCity Courtcues 7. To dwelt* basiccoursesofstu.dyforgroup 4. Toco-operate with the ChM daft sod Visit*" S. To ol!fercomma sadedocational informarloo where there issopareetalco-operationinsecuring gshissce11111111r1Kt1011sadto publish professional and Teacher Downbeatshasecuringhome sod school to parentsofpro-echool children. mistral stteedossc. occepotionid gsideace WM. adjaammas 0111w necessary to improve the vigor of pupils having health 6. To familiarise 6. To assiateistfilesof occepedimel sod 'date- difficulties. permits with tbe progress of pres- & ToWeework certificates. MOM ent-day education lined lafermMiost tech 1937 MM. sodtheways in which they may Is schoolEpidemic.depart- cp-operste with the school. N W& & To work withcommunityovariesie the 6. To Ilene newsboys' hedges. healthisessitsts of Imillyiduelawes. 9. T.sperm sad directaprogrestfor theis- ! SOARD 7.l'o makeavailable!to west., =schwa, sod porresset of cesseellai methods. group Wilder. literatureinthe fields of child dowel- 7. Totaketheschool.rows by street canvass h.To co-opmets is relief activitiesretain to--- (vowel and parent education. 10,T.study local asaliOtwall sad occupstiosal OF party sadto maintain thecorrects...ofmaul umilmnourielsedchainsorchilireeseediss ststistics by monthlyreports from the schools. appottioidee is co-omnibus whb *sleds' public r glomsor school egtiessese related to the bad& sodphis*swedes. EDUCATION t To counsel student,interested ia working ia al doe la/hid. nursery school.. ROCHESTER NEW YORK s. To reloadse file of ettomisocecaws. at. Reproducedbycourtesy of tbe Rochester,N. T., publieschools. : , Z. 118724. (Facep. 52) . S; ,-L eta.141. CLINICAL ORGANIZATION FORCHILD GUIDANCE 53 clerical helpers.The departmentwasorganized in1926as aseparate division responsible directlyto the superintendent of schools.For severalyearsprevioustothe organization ofthe department,the public schools of Newark had receivedchild guidanceservice from the Essex County Juvenile Clinic, but,when the demandfrom the Newark schools becamesoheavyasto require almost one-half of the time of the Essex County Clinic,stepsweretaken by thelocal board of education to organize itsownservice and thustofree thecounty clinic formoreassistanceto other parts of thecounty. The department carriesthe three major responsibilitiesof psychiatric service, clinicalpsychology, and visiting-teacherwork. Cases referred include boththose needing intensiveanalysis andtreatment and those. needingonly consultative serviceorbrief study fora particularpurpose.The psychologists, forexample, administerpsy- chologicaltests to children recommended forplacement inoone ofthe special classes ofthe public schools,to children for whom evaluation of ability is requestedas abasis for determiningschool adjustment, andto children who wish post-elementaryschoolorpost-high- school adviceasit appliesto further educationorvocational choice. The visiting teachersarehelpful in adjustingmanyproblemsnot requiring full clinical study,only About25 percent of thecases sebn by them being referredfor intensive analysisandtreatment.These cometo the attention of the psychiatrist throughthe visiting teacher assignedto the school in which the problem hasoriginatedor,if there isnovisiting teacherat hand, through the principal. The psychiatrist-directorreports that, in all the activities ofhis department, special emphasis isplaceduponteacher participationin casestudy andupontreatment through theuseof the schoolas an important part of the child's environmentwhichmust be modified t.A3meet hisneeds.With this objectivein view,aconsultativeserv- iceto classroom teachers has been established, wherebythe teacher gathers all data needed and discusses withthe visitingteacher the facts of theeaseand possible lines oftreatment.Suchcasesdonot reach the clinic unless developments indicatethe need ofpsychiatric help. MINNEAPOLIS, MINN.

(Population:477,700) To Minneapolis belongs the distinction ofhaving organizedthe first psychiatric child-guidance clinic in thecountry, which functionsas an'integralpart of the city school system.In 1924 suchaclinicwas establishedas anoutgrowth ofanexperimental projectfinanced during the precedingyearby the CommonwealthFund. Withafull-time psychiatrist in charge, the staff includedalso psychological,pediatric, and social-service specialists.For 9yearsthe clinic functionedas a 54 CLINICAL ORGANIZATIONFOR CHILDGUIDANCE separate school department,directly responsibleto the superintendent of schools. In1933areorganization tookplace throughwhich thechild-guidanceclinic tookon newduties andassumed thenameof childstudy department,with the clinicas oneelement of theprogram.Thepsy- chiatrist-directorremained in chargeof the expandeddepartment and wasgiven theopportunity of utilizingthe servicesof psychologists, visitingteachers, and attendance socialworkers whowerealreadyem- ployed inthe schoolsystem. In 1938 the clinicalstaff included,besides thepsychiatrist,3 psychologists and25 visiting teacherswhogave about one-fifthof their timeto the work of the clinic. Inaccordance with theenlarged functionsimplied in thenameof the childstudy department, thisunitnowincludesamongits activities thefollowing:Diagnosis, advice,andtreatment of emotionally andmentally disturbed children;neurological andphysical examinations andadvice; examination anddecisionasto placement in special classes for theretarded;examinations andadvice in specialproblems of gradeplacement, promotion,demotion,curricular changes,application andeffort of pupils, andother largelyeducationalmatters.It is reportedthat about50 percent of thecasesstudiedby the clinicpre- sent well-defined behavior difficulties. Thus inMinneapolisonehasanexample of howacliniçal organization,originallyestablished for the considerationof behaviorandper- sonalityproblems only, hasevolvedover aperiod ofyearsintoade- partment withamuch largerrangeof responsibilities,in orderthat its contributionto the life of the schoolsystem might bemoreeffective and widespread.Inarecent annualreport of thedepartment,its directorsays :

b Thegreatest service the childstudy departmentcan render to theschools and the children ofMinneapoliswill be throughtheprevention ofmalad- justment andnot through aidingasmallpercentage ofthose whoare becoming warpedtoasatisfactorystate of mentalhealth.This preventiveservice is calledmental hygiene, andin its aimsit is closelyalliedto if not identical with education itself. Followingout this philosophy,members ofthe departmentgive series of lecturestogroupsofparents and teachers,lead ingroupdiscussions onmental health problems,and participatein varioustypes of school projects directedtowardmoreeffectiveguidanceandcurriculum adjustment for all pupils.

DETROIT,MICH.

(Population:1,666,100)

For administrativepurposes,the Detroit public-schoolsystemcom- bines itsresearch andadjustmentservicesinonelarge divisionand CLINICAL ORGANIZATIONFOR CHILDGUIDANCE 55 places them in chargeofasupervising director,who inturn is responsibleto the deputy superintendent ofschools.The responsibilities thus combined includeresearch, attendance,special education, guidance andplacement, parentaladvisory service,and thepsychological clinic.Each of theseconstitutesaseparate section of the division of researchand adjustment,and eachhas itsowndirector. The psychological clinicis the unit in whicharecentered the clinical activities of theschoolsystem and to which othersections, departments, and divisions look forcasework. The responsibilitiesof thepsychological clinicarebroad inscope and relateto the entire schoolsystem.They includegrouptesting; individual testing,diagnosis, andadjustment;vocational testing; physicalexaminations;and social work.The staff in1938was com- posed of1 psychologist-director;13 other psychologistsand mental examiners;1 psychiatrist anda other physicians,each for half-time; 6 visiting teachers;1 reading diagnostician;6groupand vocational examiners. The directorreports that from30 to 40percent of thecases referred forclinical adjustmentmight be termed"behavior problems," but he callsattentiimto the fact that "itis difficultto make clear-cut distinctionsasto those thatarebehavior problemsonly.* * * Many childrenwithsomementalorphysical handicaphave certain behavior difficulties.Thismayalso betrue of children havinga readingorother educationaldisability."The clinic's workthus concernsitself withpupil problemsof all kinds, indit regards undesirable behaviororpersonalityasonlyoneof themanymani- festationsto which it should giveattention.The effort is madeto reacheveryschool of thecity in promotingmental healthpractices and in furtheringinsightonthepartof supervisors,teachers, and principals into thecausesandtreatment of undesirablebehavior. In additionto the psychiatric servicemade availablethrough the psychological clinic, therearevariouscommunity clinicsin the city of Detroitto which urgentcases maybe referred.Thesesupplement theprogramwhich the schoolsystem is ableto provide, but members of their staffscannot, ofcourse,inacityaslargeasDetroit, have the intimate acquaintancewith the schoolfacilities andpossibilities for adjustment whichthe members of thestaff of thepsychological clinicpossess.As the populationofacity,nears orexceeds the million mark, it becomesincreasingly difficuftforany one / adjust- mentagencyto keep intelligentlyinformed/ ofwhat otheragencies aredoing.In citiesôfthis size especially,one must expect, for successful coordination of theprogram, a veryclearstatement of interrelationships,adefinite allocationof responsibilities,awell- planned provision for interchangeof zecordsand forreports of 56 CLINICAL ORGANIZATION FORCHILDGUIDANCi. iifindings, andawholehearted willingnessonthepart of eachagency I'to giveaswellasto ask cooperation. Detroit is unique in havingestablished, also,anendocrine gland clinic andanepileptic clinic, for the studyandtreatment of endocrine disturbances and epilepsy.Theseareboth functioningunder the general guidance of the director of specialeducation, and eachis staffed withonehalf-time andtwo full-time physicians.Educational adjustments inspècial schoolsorclassesaccompanythe physician's treatment. NEW YORK, N. Y.

(Population: 7,154,300) While the populationof New York Cityissofar beyond that of most cities in thecountrythat its educational organizationas awhole cannot be considered typical,yet its plans for certain phasesof the program arehighly suggestive ofatype of organization thatcanbe applied in accordancewith population needs.One of these isthe bureau of childguidance, which constitutesoneof eight distinct divisions operatingunder in associate superintendentof schools, all of whichareconcerned with adjustmentsfor handicapped children and others in specialeducational need.The othersevendivisions included in thiscategoryare(1) bureau forchildren with retarded mental development;(2) division of the blindand sight conservation (3) division of physicallyhandicapped children(4) industrial and placement work forphysically handicappedchildren;(5) school for the deaf;(6) speech improvement;(7) visiting-teacherservice. ft Thereare many sourcesof psychiatric child guidance serviCein New York City functioning underalarge variety of auspices.In 1931 the board of education tooksteps to organize itsownbureau of

child guidance for the schoolsystem, and in April 1932 clinical_ activitieswerebegun.In successiveyearsadditional personnelwas appointed, until in 1938 the organizationwas asrepresentedin the charton page57.The bureauas awhole is tinder thedirection ofapsychiatrist, but its activitieshave been decentralizedin such a waythatoneclinical unit ts assignedtoserveeach resAtivesection of the city. A unit consists ofapsychiatrist-director,apsychologist, two to four psychiatric social workers,aschool social worker,and the necessarystenographic assistance.Each of the boroughsof New York -City is thus provided withclinical facilitiesas a partof the public-school system. Theprogramof the bureau is described by thedirectorasincluding (1) clinicalorchild-study activities, (2)educationil responsibilities, (3) community activities. The first of thesepertainsto the direct study and treatment of pupil problems;the secondto-theorientation CLINICAL ORGANIZATIONFOR CHILDGUIDANCE 57 4

(

(BUREAU OFCHILDGUIDANCE) L I (A1AIMS7RA71er SEFLP AWPERSVAINEZ] ISERVSERVICE 1_ DIRECTOR OF AREAL'OF clapGUIDANCE I 1. . r STUDIES AND TREAT- INTERPRETATION OF tiI ASSISTANTDIRECTOR) *SENT OF FERSOWUTY CHILDREN WI*9 MSC e-DI 1AND BEHAVIOR BEEN STUDIED'BY I I 8 DISORDERS or CONFERENCE AND CHIEF CHIEF CHIEF PSYCNICRISTSCHILDREN WRITTEN AND ORAL e 461111111~ r PSYCHIATRICSOCIAL REPORTS TO SCHOOL SOCIAL WORKER WORKER PREVENTION OF F PERSONALITY MO , e.....---, (-3-- COURSES AND DISCUSSION PsrametworsPSYCHIATRIC SOCIAL BEHAVIOR DISOR- DERS BY STUDIES GROUPS IN PRINCIPLESOF SOCIAL TrOliKiNir MENTAL HYGIENEAND AND TREATMENT WORKERS CHILD GUIDANCEFOR OF CHILDREN AT TEACHERS AND PARENTS 10 I 8 6 '''AN EARLYAGE

INIIIIIMMINO e CLERK 1 8smosRAPHER3 .

(ITITE. coPmfr ITEL OPERAro

ORGANIZATIONOF TXUE BUREAUOF CHILD GUIDANCEOF THE NEw YORK Crry PUBLIC SCHOOLS. Reproduced bycourtesy of theBoard of Education, cityof New York.

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CLINICA v P4 I 58 . , CLINICALORGANIZATION.tiORCHILDGUIDANCE I 4,,

p of the sctipof.personnel in'the' fie10-- ofmental hygiene;and the third tothexinbainten.anceofa*mtitually.cooerotiverelationshipwith all comrnuniti.ag-enciescontributingto the mental healthof thepeople. . . The-ease services of thebureau.aredesignedprimarily forthe . sdy andtreatment of perspna-lityand behaviordisorders ofschool children(if!aPproximatelynormaIorabove-norinalintelligence. Children-whoarereferredtothe bumat4 butwhouponbeing give') _E¡psyc,hólogituartestshow evidenceof tinintelligencequotient of 15 orbelòw.liteauttimaticall3:referredtothe bureaufor childrenwith - retarded mentaldevelopment,to is-hich all *clinicalrecords concerning theiiiarethen transferred.This bureau'has its owhpsychological and visiting.teicher staff,-inadditionto facilitiès for medicalinspec- tion.Itsservicesaredipected towardthe educationaladjustmentof lI the child Ompughassignment.toaspecip..1 schoo.1orclass mo-fenearly suitedto his &eds. : Casesare-alisully referredto the buieau. of.childguidance bya school principal bymeansofanapplicatioilform made.out for that. .purpose.Itrisreported Iliathree-fourthsCif thegases'referred require attention .ofilyfrom theRsychologistorti psychiatricsocial worker,or-pprhaps, both,-wbfking..it-conjunctionwith- theshool. The .other fourtikyepresent difficultproblems,dernandingafull ical study, whichinvolves socialcasehistory; physirAil,psychological. `,and psychiatviç examinations;clinicalconferencewith,diapiosis;and aplan i5ftreatment. The psychiatricsocial workeimakes neeaed , contiéts with *achers. and -parents andwheneverfeasibledtawsAem -ink')the treatinentprogram.It ensuing conferences-the-progress on thecaseis ngtori and furthersteps outlined, teach niemberof: the clinical teatn keeping in tpuch vrithdevelopments. 4. Inaspecial report oftheactivitiesof/thebureau ofchild- kruidance, theditectot ca1J Attention-toits .L. éduc.litionalvalues forOachers:4 3 Z. % . The ..exaikilnjitipn ofa,child discloses,noti-.only the 'causes . of 'his.problem . .biit revetil0`4114WOpera'.printip14of tiumabehaviojthat:.applyto other- .. cbildi.eil.Prea,ch66,- ininèipils, _. and abed; attenalfig.theinitial eoyiterenCe O , at .1N-bleb . ctii exalninatloimesula,ofachildarepreLntectand. discussed _ .. gcquirenöt n17_an _ upderstiuiingof ,that.c.,13ilii'sproblems but"opiiiiit.also , anInsight`bltóbasicp;intipIes.bf cettduct,¡list . átiply 'to . . , other children-as e *ell..Itithseieewitérvices, conceptiòf _childdevelopmefit . t . and childtrain-,-. . : e.. in¡, t40ir "Withtbard.'practicali9jAleatlowe9rne t.ip'for tlitiçnssignwith -,.-.- the genera- result ihaeuitose , .. attendhigcarry miraywiih,them' aibetter , ..4 i understanding- ofchild life Iligeneral; whrch irrcludes'the srple played -: bf . . the adult -in tte.fórtattle-9 'ofthe cbild's personality.' ,. e 4, .. . . sim..--.". . , I P , ts fr r ... tp ..additióil . , to atifilcase'work, the 'ehild7stu4Y..funCtion Ofthe. . .1AtinSaùincludes psyghologioliueveys ... . . of entiregracjes,..locking , . ,. , . , . , . . . , _, , ._ . I. Minim'.ofritilii"gildance5-teaf ,.. report, 1932-37: tspecial reportstibmittied *iththe .; . thirty-ninthannáa.1- report bfthe i skperintesidenpofschools, Otrof NeivYork, New"-Yorkv is , . .. ' board of . SO . A \ education.l'.55. -,. . . . > . . . . 0 , .. . i t e .. e a - /4\ . IOW . . a 4 I.4. , .. e C o 4 o I . \\ . ' L. 6 i C I , . a 41, .- . .. e ...... r it ,db - ...e . .. 411, " r l . ; . !; # V e . . t ... I qs ----7.-e - _ ,vo2 .- CLINICAL.ORGANIZATIONFORCHILDGUIDANCE 59 toward thepreventionofeducationaimaladjustmeutswhich are,so often theforerunnersof behaviorproblems.In thisLOitl itap- proachesthescopecif servicerepresentedby thedepartm:its-of child study in citiesin whichthe Adjustmentprogramof theschools isnot sohighlydifferentiatedasin NewYork.It isto be eipectedthat, as a city increasesin size,its servicesmaybeincreasinglybroken" çlown intoseparate divisionsordepartments,eachdepartmentcarry- inga moreiestrictedtype of responsibilityforalarger schoolpopu- lation.Thisis..what has happened inthesciioo.1system of NewYork City, and thebureau ofchildguidancebecauseof itsrestrictedsphere of activitiesprobablymorenearlyrepresents the originalconception ofamedicallyrecogniiedchild.-guidanceclinic thananyothersimilar organizationwithinaspoolsystem., with thepossibleexception 4of that of Newark, N.J. Yet in NewY9rk alsothe role ofthe. clinical 'unitis- itssuminga widérsignificance;and it isidentifying-itselfmoreandmorewith the problems- oftile entireschoolsystem.The directorvisualizes educationas atotaJ clinicalprocessin whichthe functionsofshild euidauceandinstruction-naustultimalelybe combined."To this end," hesays,"Ian)encourágingourpsychiatrists,psychobigists,and social workersto observè inclassrooms, have,discussionsor con- . ferefice:s inkthe schoWs wiihprincipalsfoci teachergroupsfor mutual learning, inorder that w&maybring aboutacloser identitythan nowexists." GENERALCOM1fENTS e

From theaccounts presented in thischitpter1 itappearsthatevenin Many of thelatgésrcities of'thecour4ry which haveawell-defined organiiationfor childguidance. withirohèschoolsystem, the film- . tioriordinarily attributedtoachild-guidanceclinicmaybe found within thedivision ofgeneral-educatio.nalguidanceor, moreoften,as Tait ofa more,highly sp.ecialized bu-reauof -individualchildstudy andAdjustment.In'anycaseit is cpnceived'asonephase ofthe totalprogramofcikildstudy, guidance,and-adjustmentfor allpupils and'is accordinglyassignedtosomedivisionof thesuperintendent's .stag chargedwith thistype of service. 4 . k The gxpèrience ototherlarge cities,thepiogramsof whichhave not.' been.describedin detail;seem tobearoutthisconclusion.In -Chicigo, for example, the'bureauof chi Q study isresponsiblefor diagnosis adjustment.service for allp sand thebehavior clinic a part of this bureau.In LcsAngeles, i.; win&program iftdfvidualadjustmenOtsit coordinatedone towhichse , De cart- ,.menti.contribute.'ClevelandandPhiladelphiahaveeaten& .psichOlogicalclinics&ringattenticontolargevariety ofproblems. oft

o 60 CLINICALORGANIZATIONFORCHILDGUIDANCE These cities,inadditionto DetroitandNew YorkCity,eready discussed,areall closetoorexceedthemillionmarkinpopulation. Similarly,in Cincinnati,thevocationbureau(whichisessentially abureauforindividual guidanceandadjustment)includesapsycho- logicalclinicand visitingteacherservice.Seattlehasitschild- guidancedepartment, which ischargedwith"settingup apreven- tiveandremedialprogram ofgroup and individual including guidance," theclinicalstudy andtreatment ofchildrenwith Oakland, problems. Calif.;hasitsdepartmentofindividualguidance. timore, In Bal- a child-guidanceclinicwasinitiatedduringthe the chief year 1938-39, responsibilityof whichat preséntisnotso much cases as to coordinate totreat. all schoolandcommunityagencies available alrefidy for thestudyandtreatment ofbehaviorproblems. cities These rangeinpopulationfromabout300,000to 800,000. Theexacttype of affiliationwithinalargeschoo)systemmust necessarilyvary to sonfe *extent, butit issignificantthatso programs many of clinicalserviceforbehaviorproblemsare identifying themselveswith the totalprogramofindividualguidance.Toschool peoplewhoseethepersonalityorbehaviorproblem types of as one ofmany individualdifficultiesencounteredin theschool andso frequently program associatedwithotherfactorsinvolvingschool adjustments,thisappears to bealogicaladministrative The releonship. danger insuchan arrangement isthatproper precautioris not be takento may preservetheintegrityof theclinicalunitwithinthe largerorganization,withall thatthisimplies as to qualified. adequate and staff forintensivecasework.Ifsafeguardsare thrown aboutthe programso as to avoid thesubmergenceof'individual clinicalstudyandtreatment in themazeofdepartmental bilities, responsi- thistype oforganizationmighteventuallyprove to be the onebestadaptedto schoolsystems. Themost important objectiveto be achievedis theprovisionof clinicalservice somewhereeitherwithinorwithouttheschoolsys- ,temforallchildrenwho needthem.In theirchild-guidanceclinics, Stevenson andSmithsay:" There are no yardstickswithwhichtomeasure theamount servicea given ofclinical 'community _ needs.Theexperienceoftwo-scorelarge communitieswhichhavechild-gtlidanceclinics ratio of yieldsonlya rule-of-thumb one full-timepsychiatrist.,one full-timepsychologist, threefull-time andtwoor psychiatricsocialworkerstoa populationof 200,000.Such approximately. a staff is keptbusy ina well-organizedcommunity size, andsuch clinics ofthat' have beenstablefinancially.Obviouslythis is means an idealor a maximum byno quota ofworkers,but itis thenorm about whichclinicsnow seem togather. Citiesmuchlargerusuallydevelopa u Stevenson, George,and Smith,Geddes.Child-guidance development. clinics,a quartercentury of NewYork,Thecommonwealthfund.Pp. 134-135. CLINICAL ORGANIZATIONFORCHILDGUIDANCE 61 number ofclinical units,sometimesas a result ofa deliberate ', timesat random. plan,some- Citiesmuchsmallerrarelyhavethesocial whichjustifies equipment full-timeservice,even thoughtheymay havetroops of childrenwho wouldbenefitby skilledattention. Stevenson and Smithare considering theneedsandthefacilities tht- entire of communitynotonlythoseof theschool s3rstem. the Hence figures theysuggestmust beappliedaccordingly.* of the ffthesum child-guidancefacilitiesmadeavailablethroughthe andthrough schools othercommunityagenciesreachesthenormhe cites, it mightbethoughtthat a well-coordinatedprogram could bedevel- oped forthe cityas awhole.If,ontheotherhand, of the only.source psychiatricclinicalserviceisa communityagency outside schools,the the definiteallocationofareasonableproportionof time servicefor the and schoolsappears essential.Fromschoolsystems in whichsuchprovision hasnot beenmade,statementshavecomeindi- catingaserious lack intheschoolprogram from thepointof view of theschoolpeople. Forexample,froma schoolofficialinonecitywithapopulationof approximatelya halfmillionacity inwhichthereisan extensive psychological, visiting-teacher,andguidanceservicein theschools whichis but restrictedin schoolpsychiatricserviceto thatwhichis available fromcommunityagenciescomesthefollowing: Field workersand directorsin theschoolbureauagree thatthe only advantageis thatit (i.e., the utilizationof is better communitypsychiatricservice) thannot havingany psychiatricserviceat all.The vantages chiefdisad- are that it isnot possibleto haveearlyenough nosis,or to have psychiatricdiag- adequatefollow-upinterviewsbetweenpsychiatristand child, andpsychiatristandworker.Besidesthese with which difficulties,the clinic we have had themost frequentcontacts islocated in generalhospital,and it the city is exceedinglydifficultto getchildrenandparents togo there, and, ifthey do go, theyare frightenedbytilenecessary redtape of beingregisteredas patients ofthehospital. Fromanothercity of approximatelythesamesize inawidelysepa- ratedpart of thecountry comesasimilarstatenient."It (i.e.,the useof thecommunity clinic) ismuchbetterthannoclinicserviceat all. Aclinic as partof theschoolset-up wouldinsureamuch mutual better understandingonthepart of theclinicstaffand theschool people." It is an open question whetherthedisadvantagesofextra-school community'clinics,as seen by schoolpeople,are necessarilyinherent in thistype of organization orwhethertheyareduetotheinade- quacies oftotal clinicalserviceavailableand ofmechanical ments for arrange- most effectivecooperation.Ifa communityclinicwere sufficiently'staffedto give definitelyto the schoolsa reasonable ment of time allot- and service,and ifdesirableadjustmentswere worked

4 62 CLINICAL ORGANIZATIONFOR CHILDGUIDANCE

outwith regardtomethod of referral,place of clinicalconferences, and exchange of findingsand of counselbetween clinicalspecialists and school people, thedisadvantages mightlargely disappearsofar asthetreatment of individualcasesof maladjustmentareconcerned. The integration of the clinicwith the entirestructure of the school programand its effective influenceuponschool policies forthe mental health of all pupils would bemoredifficultto achieve inalarge school system without making the clinicanactualpart of the school organization.It is this entire problem ofcoordination of school dcom- munityresourceswhich the newly initiatedproject in the Efaltimore public schools is attemptingtosolve through theestablishment ofthe child-guidance clinicas acoordinating ratherthanas a treatment agency.It will be interestingto watch developments in this direction inacity in which thereare so manycommunity facilitiesfor clinical service outside the schoolsystem. In the publishedreport ofa surveymade in 1935 of theCincinnati public schools, attentionwascalledto the fact that "no psychiatric help is availableexcept through the cooperation of clinics,hospitals, and private practitioners.This has been most'generousin spirit but necessarily limitedin time.It is reported thatonlytwo weekly appointmentsaregiven by thecentral clinic for schoolcases,with additional time foremergency cases.But the timetogive attention tountAustedchildren is beforethey becomeemergencycases."45 Thesurvey reportcontinues with thefollowingstatement, which is of generalsignificance and withwhich this chapteris concluded: If the childguidance facilities ofthe school systediare to functionas a complete unit,a more nearly adequate amount ofpsychiatric timemust be allocated for theconsideration ofschool problems.Itmay not be necessary for the schoolsto employa full-time psychiatrist, althoughthis has been done inseveral cities ofthe size of Cincinnati,but certainly 2 or3 daysperweek wouldnot be too much.If thiswere supplemented by adequate visiting-teacherservice (or somethingof similartype) in all the \ schools, and adequatepsychological andmedical facilities,there would be \ anucleus forachild guidanceor mental-hygieneprogram that could be \extended intoevery classroom of the city.Sucha program would involve 016, only the handling of behaviorproblems in theirearly stagesbut also aneducation of teachers,looking towardthe developmentofaninsight Into mental higieneproblems whichwould supplementthe work ofthe specialists.Classroom adjustmentof behaviordifficulties isthe simplest and most desirableprocedure; butthe teachermust be trainedtograsp the' ,signiticanceof certainsymptoms and to dealwisely withthe children displáyingthem. Only throughaclose relationshiponher part withall the specialized agencies inchild guidancecanshe learnto make her daily contacts with children effectivein this direction.

41 Surveyreportof the Cincinnatipublic schools madeby the Officeof Education, United States Departmentof the Interior.Cincinnati, Ohio,The Cincinnati Bureauof Governmental Research,July 1985.P. 150. 6 a CHAPTERVI

ACONFERENCEAND ASUMMARY One of theearlysteps taken bythe Officeof Educationincarrying ontheinvestigationreportedin thisbulletinwas toinviteto Wash- ington fora2-dayconferencea group of 14 specialistsactive in clinical serviceforschoolchildren,to exploresomeof themajor problems involved insucha program. Theobjectivesof thecon- ferencewerestated bytheOffice ofEducationasfollows: 1. Toalyze the problemsoforganizationins9hoo1systems forthe diagnosisandtreatment ofbehaviorproblems. 2. To assistschoolauthoritiesto developeffectiveservice inthis field. 3. To determinethe spheresin whichthe Officeof Educationcan be of serviceto schoolsystems inthedevelopmentof such 4. To assist programs. in planninga study by theOffice ofEducation ofclinical organizationinschoolsystems. Itwasthought that.apreliminaryexplorationof theentire problem witha few ofthe peoplewhowere experienced incarryingon localprogramsand inmeetingtheexigenciesof localsituations might indicate thedirectionwhichfurtherstudy shouldtake,as wellasthe type ofreport whichwould behelpful.Thediscussions at the conference touchedupon general problemsof clinicalorganization, servi4esto be rendered,participationof teachersand principals in thecimicalprogram, relationshipof theclinicto the total schoolprogram andto the community,and theimportanceof insti- tuting coordinatingtechniquesamongthevariousogenciescon- cerned. Sinthese pointsarealso thogewhichhavebeenconsidered in theprecedi s chapters,a report of theproceedingsof theconference becom in largeparta summary of themajor itemsbrought outint'this study.Thetwoaretherefore combinedin this _ of the chapter. bplletin.Exceptwhereotherwiseindicated,itmaybeas- sumed that thestatements madein thefollowingpagesexpress the consensusof judgmentonthepart of thevisitingconfereesandthe findings of subsequentinvestigation.Theyare presented inthe form ofanswers to certainquestionswhichare pertinentto the developmentof childguidancefacilities. VISITING CONFEREES Conferenceon organization for clinical adjustmentof behaviorproblems of school children

Office of Education, May193g

Margaret E.Bennett, Directorof Guidance, PublicSchookt, PaAatlena,Calif. Alan Challman,M. D., Bureau of ChildGuidance. PublicSchools, New York, N. Y. Malcolm H. Finley,M. D.. Department ofEducationalCounsel. PublicSchools, Winnetka,/11. Roy D. Halloran,M. D., Superintendent,MetropolitanState Hospital,Waltham, Mass. Arthur S. Hill,Assistant Directorof Pupil Adjustment,Public Schools,Des Moines, Iowa. Zoe I.Hirt, Psychologistand Director ofChild StudyDepartment, Public r Schools, Brie, Pa. Thomas W. Hopkins,Assistant Superintendentof Schools,Jersey City, N. J. Elisabeth Lincoln,Elementary Supervisor,Public Schools,Leominster, Maim A. Leila Martin,Director of Child Studyand SpecialEducation, PublicSchools, Rochester, N. Y. Alice Metzner,Director of SpecialEducation,Public Schools,Detroit, Mich. George S. Stevenson,M. D., ator of Divisionof CommunityClinics, Na- tktnal Committeefor MentalHygiene, NewYork, N. Y. (Morerecently appointed Medical Directorof theCommittee.) M. LaVinia Warner,Superintendent,Blosson Hill School,BrwksvWe, Ohio. Helen M. White,School Clinicfor Children'sProblems,Public Schools,Provi- dence, R. I. F. E. Willard,43sis1ant Sup( rinte)'(lcutof Schools,Seattle, Wash. 64

---- CLINICALORGANIZATIONFORCHILDGUIDANCE 65 a What clinicalservicesareincludedina comprehensivechild- guidanceprogramP As theterm "child guidance"isinterpretedby theNational Committeefor MentalHygieneand associatedagencies, itsfunc- tion isspecifically thediagnosis andadjustmentof behaviorand personalityproblemsof children.The servicesofachild guid- anceclinicarerendered "throughthe directstudy andtreatment of selectedchildrenbya teamconsistingofapsychiatrist,a psychologist,and psychiatricsocialworkers, andalso through focusing theattention ofphysicians,teachers,socialworkers, andparentsonwhat iscommonlycalledthe mentalhygiene approachto problems of childbehavior."46 A What contributiondoes eachmemberof theteam maketo the child-guidanceprogram? Thepsychiatrist isaphysicianwho hasspecialized inthe study andtreatment of the patientas atotal organism,with all the complexinterrelationshipsof physical,mental, andemotional experiences. Achild psychiatristisapsychiatristwho is quali- fiedto analyze the experiencesof childrenin thesedirections andto ferretout,onthe basisof thetotal clinicalstudy, the underlyingcausesof behaviormaladjustment.Since heis medically trained,hemaymake hisownphysicalexaminationor hemay turnthis responsibilityover toaphysicianassociated with himin theclinical service.FollowingaClinicalconfer- enceat which the findingsof. allmembersof theteamaredis- cussed, he makesrecommendationsfortreatment andfollow-up, looking towardthe ultimateadjustmentof the child'sproblem. Pending suchadjustment hemayneedtoseethe childagain and akainover aperiod oftime. The psychologistusually studiesthe mentalequipmentof the child, hiseducational abilitiesand disabilities,andmayhelpto apply remedialmeaSures in cooperationwithprincipal and teacher.Psychologistsvarywidelyin theirqualifications,some restricting theiractivitiesto the administrationof standardtests, while otherareequippedtogodeeply intoaclinicalaniklysis of the mental andemotional lifeof the child. a The psychiatrksocial workerisa caseworkertrained inthe techniques of thepsychiatricinterview butwithoutthe medical training ofthepsychiatrist.She studiesthe influenceof envi- ronmentalfactors in thehome, school,andcommunityuponthi

0Stevenson, GeorgeS., and Smith,Geddes.Child-guidanceclinics: A quarter century of development.New York,The commonwealthfund, 1934.P.1. 66 CLINICALORGANIZATIONFOR CHILDGUIDANCE behavior of the childand does whatshecan toadjust undesirable conditions.Othertypes ofcaseworkersfrequentlysubstituted for psychiatricsocial workers,particularly inclinicalorganiza- , tions withinschoolsystems,arethe socialworker withoutspecial psychiatricassociation;the visitingteacher, withtraining in both teachingand socialwork andthe schoolvisitingcounselor, who doespart-time teachingand part-timecasework. To whatextent havesuchcompletelystaffed childguidance clinicsbeen establishedeither withinorwithout the school system P Accordingto data compiledby the NationalCommittee for Mental Hygiene,approximately650 communitiesin34 different Statesarereceiving theservic'es ofone ormorechild-guidance clinics.In onlyabout20cases,however, havesuch clinicsbeen establishedasintegral unitsof theschoolorganization.Other auspices underwhich theyareoperatingincludeStateorcity departments ofhealthorwelfare;State,county,orcity hospitals;universitiesoruniversityhospitals;soçieties formental hygiene;juvenilecourts; and privatefoundations.Wherever clinics havebeen established,someserviceistenderedto children referred bythe schools.

Should schoolsystemsattempt tobuilduptheirownfull- time clinicalorganizationsof thishighlyspecializedtype P Present trendsseem toindicate thatthistype of specialized clinic, restrictedin generalto the considerationof behaviorand personalityproblems,doesnot lend itself easilyto schoolorgan- izationexcept in cities in whichthe populationserved issolarge that thevariousfunctions ofguidancecanbe assignedto different bureausand coordinatedthroughthecentral office.How- ever, every schoolsystem has theresponsibilityfordevelopinga child-guidanceprogramwhich willmakeavailabletoeverychild i 'whoneeds itintensive clinicalattentioncovering hisphysical, mental, emotional,and socialneeds.In meetingthisresponsi- bility, itshould utilizeevery source of specializedassistance available inthe city,county,orState.

To whatagenciescanruralcommunitieslook forspecialized assistance P For ruralcommunities,aswellasformanysmallurban districts,oneof themost logicalsourcesof highlyspecializedassist- anceis eitherthe Stateorthecounty.Throughaproperly CLINICALORGANIZATIONFORCHILDGUIDANCE 67 ,4eroordinatedplan thesameclinicalspecialistscan serve several school districtswithin thecounty-orin someecasesthe entire county.Severalprogramshave beAldevelopedonthis basisout- side theschools, butservingschoolchildren,as,forexample, in EssexCounty, N.J148 throughacommunityproject; inMilwau- kee County,Wis.,47throughatax-supportedmentalhygiene clinic;and inRocklandCounty,N. IT,4Rthrougha'Statehospital located in thecounty.Similany,ifadequatecoordinationob- tains,aneffectitveservicecanbe builtupthroughtraveling clinics, withaStatedepartmentasthe basisofoperations,as, forexample, inMassachusetts,"through dieStatedepartment ofmental diseases;and, ofmore recent initiation,inMaryland," throughthe Statedepartment ofhealth. 6 Whataretheadvantagesanddisadvantagesof suchaplan? One of themajorproblemsencounteredinanyclinicalorgani- zation thesourceof whichisremote from theschools isthe lack ofopportunityonthepart of the clinicalspecialiststo become intimatelyacquaintedwithexistingeducationalpracticesand school facilitiesin thelocalcommunities.Coupledwith thisis the difficultyencounteredbyatravelingclinicinfollowingup 'acase orin advisingwithteacherorprinciparregardingits adjustment.In orderto be ableto makerecommendationsthat arepracticalaswellasscientificallysound, itisimportantthat the specialistknownot only his patientbut alsothepossibilities and thelimitationsof theschool, thehome,and thecommunity in which the patientlives--withaclear vision,foo,of howthe existingpossibilitiesmaybe capitalizedandimproved. On the otherhand,throughtheuseofatravelingclinic,a given schooldistrictlats thebenefitofatollyobjectiveap- proachtothe child'sproblembyone not connectedwith the school system,aswellastheadvantageof profitingfromthe clinic'sexperience withotherschooldistrictswhich ithas visited. If thedisadvantagesofinfrequentcontacts and lackofmutual understandingandcooperationcanbecorrected,thedevelopment ofchild-guidanceservicesemanatingfromaStateor county department,whether inthe schoolsystemor outof it,appears to have significantpossibilitiesfor smallcommunities,partic- ularlyin-ruralareas. I. «Seep. 21. "Seep. 24. Seep.10. "Seep. 19. 68 CLINICALORGANIZATIONFOR CHILD-GUIDANCE

Lacking theavailabilityof clinicalassistancefrom Stateor ____ county, whatcan a county schoolsuperintendentdo to initifitiac a. childguidance P The experienceof schooladministrators incertaincountiesof California Ill shouldbe helpfulin answeringthis question.Every encouragement is given inthat Stateby botheducationaland welfare authoritiesto develop localinterest inthe mentalhealth of all childrenin theschools andto utilize whateverfacilitiesare available forchild guidance,eventhough theymay not ificlude psychiatricservice.Acounty supervisor ofguidancein the schools,avisitingteacherorothercaseworker,aschoolpsychol- ogist,or aschoolcounselormightconstitutethe nucleusofa programofcaseconferencesthat willeventually drawinto activeparticipationall theprincipals andteachers of thecounty. Insome casesalimitedamount of psychiatricservicemaybe 1 availableon avolunteer basisfromaprivatepractitioner.Orig- inating withthe schoolsandpermeatingthem withthe clinical point of view,sucha programmay exertavitalinfluenceupon classroom practicefor themental healthof allpupils. kowcan acity schoolsystem proceedto inaugurateaclinical programP Granting theexistenceofeven alimitedguidanceand adjust- mentprogramfor thechildren inthe schools,the procedureused ineipandingsuchafunctionmaybe muchthesame as ina county schoolsystem, discussedin theprecedingparagraph. In the absenceof psychiatricservices,aqualifiedschoolpsychol- ogist,anattendance workerwithasocial visionof hisrespon- sibilities,avisitingteacherorothercaseworkercan,with the cooperation ofthe schoolphysician,carry on effective clinical service formany cases of behaviordifficultiesif given'enough time forthe work.The . type ofprogramcarriedoninSanta Barbara62 and in othersmall citiesin Californiaisillustrative of constructiveefforts inwhichthe schoolsthemselvestakean importantpart withoutextensivespecialized savice.Inboth counties andcities,however,every attempt shouldbe madeto locateeither withiiorwithoutthe schoolsystemapsychiatrist. versed inchild guidancewhose servicescanbe madea part of the totalprogram. Sometimesseveral adjoiningcitiescanmakearrangements for thefinancialsupport ofaclinicalproject whiclino one of aSeep.22. " Beep. 26. CLINICALORGANIZATIONFORCHILDGUIDANCE 60: 7' them couldprovidealone,as,forexample,in thecaseof Rock Island and Moline,111.,53orofChampaignandUrbana,54 inthe sameState. Social-welfareagenciesexistinginthecommunity may supplement thecaseworkfurnishedby theschools;and the school orcityhealthdepartmentmightcontributethe needed health services.Ineffectingacooperativeprogramof thistype it ismost importantto haveaclearunderstandingof the to be served areas byeachagency, as wellas a well-plannedinter- change ofrecordsamongthem. Ifa clinicalunit isorganized,inwhatdivisionofaschool system doesit logicallybelong P Ifacity is largeenoughtowarrant theemploymentofafull- time childpsychiatristwho isconversant withmodern tional educa- philosophy,afullclinicalunitmight besetup,withthe psychiatrist asdirector,responsibleto thesuperintendentor associate superintendent.Thisprocedureis favoredbypsychi- atricauthorities. However,inmost cityschoolsystemsa psychiatristis, likelyto be employed forpart ti P that only.In case present practiceis infavor ofincludinallprovisions for thestudy andtreatment ofbehaviorproblemsas a section withinthegeneralprogramof childstudyorpupil This adjustment. arrangement isjustifiedbyeduc: naladministrative authoritiesontile basisof thefacts (1) thatthere. isseldoman ) isolationofa behaviorproblemassuch,apafrom 11; or eating ! causalfactorsfoundwithintheeducat alistory child; othe and(2) thatthepreventivefunctionso aprogram of guidanceandadjustmentfor allchildren are legitimateaspects 1 ofachild-guidanceorganization. Folio !,!:rutout suchaplan, theschoolsystemmay employ or more full-time one psychologists,case workers, andschool sicians. phy- Apsychiatristisemployedforastatednumber hoursper of week.Theseconstitutetheclinicalstaff,but thefull- timeworkers have, inadditionto theirdutiesofastrictlyclini- calnature, other responsibilitiesrelatedto the entireschoolsys- , tem.Thusone finds inBerkeley,"Calif.,a behaviorresearch,

clinic Ito operatingwithinthedivisionofguidance,placement, personnel. and InPasadena" the clinicalserviceispart ofthe departmentof guidance.InErie,"Pa.,andRochester,"N.Y., aSeep.80. "Seep. 81. Seep. 41. IsBeep.87. "Seep. 84. " Seep.51. \ 70 CLINICALORGANIZATIONFOR CHILDGUIDANCE

it isaunit withinthe departmentf childstudy andspecial education.inProvidence,"R. I., itoperates withinthe department of researchandguidance.Suchanallocationseems to -facilitatethenecessary coordination of the.variouspupil-ad- justmentservicesthat theschoolsystem hasto give. How muchdoesachildguidanceclinic cost? It has beenestimated6° that, in citiesofapproximately200,000 population,the budgetofafull-timecommunityclinicmight be about$20,000peryear.This would.includethe 'servicesofa full-time psychiatrist,afull-timepsychologist,twoorthree full- time psychiatric.socialworkers,andtwoorthreeclerks.How- . ever,in schoolsystems in whichthe clihicalservice isonlyone phase ofalargerprogramof pupiladjustment,and inwhich members ofthe clinicalstaff performother relatedduties, itis difficultto arriveatanystandards ofcost for clinica1workalone. One schoolsystem inacity of appioxiitaiely450,000population reports totalannualsalaries forits departmentof childguidance, which isdirected bya full-timepsychiatrist,.asamountingto $25,820.Anotherschoolsystem inacity of250,000reportsan- nual salariesallocatedto the clinicservice,includingtheimount paidtoapart-timepsychiatrist,butexcludingthe salaries.of schoolphysicianswho givetimeto the clinic,ofsombwhatmore than.,!,000. Inacity withapopulationof80,000 thespecial sal- arybudget isreportedasabout $5,006:Thisincludestheamount paidtoapart-timepsychiatrist,apart-timepediatrician,afull- time visitingteacher,andahalf-timeclerk.Additionalserv- icesare: contributedto the clinicbye*choolcounselors,school nurses,and schoolmentalexaminers.insmallercitiesit be- comesincreasinglydifficultto isolate theclinicalcosts, these beinganintegralpart of thecosts ofpupil-adjustmentwork as awhole.

Whatspecificmeanswillpromote theactiveparticipationof principalsandteachers inthe cjinicalprogram? A childguidanceclinical semi&hasnot achieveditsultimate goal untileveryprincipal,teacher, indsupervisorin t,,40school system becomesconsciousof themental heilth-'needsof the pupils andis abletocooperate withthe clinicin thepreventive aspects of itswork.Throughpre-serviceandin-servicetrain- ing theycanbecomeactiveparticipautsin theclinicalprogram, st_ *Seep. 45. a a 0 Stevenson,George S.,and Smith, Geddes.Op, eit.,p. 55. CLINICALORGANIZATIONFORCHILDGUIDANCE 71 detectingincipientcasesofmaladjustmentandapplyingthe general 'principlesofmentalhygienein theclassroom.The following .havebeenfoundto4beeffectivemeansofbringing principalsandteachersintocloserelationshipto the clinical service:

1. Appointnientofanadvisorycouncilof.principalsto consultwiththedirectorof thechildguidanceuniton problemsof childguidanceasrelatedto schoolmanage- ment. 2. Professionalcourses for principalsandteachersin the principlesof childguidance. 3. Round-tableconferencesofgroupsofteachersandprin- cipalsto discuss theapplicationof childguidanceto the clasroom. 4. Referral ofcases initiatingasschoolproblemsthrough theteacherand theprincipal,or at lea t withtheir knowledge andunderstanding. 5. Cooperationofteacher inwritingcasehistory. 6. Holdingof clinicin schoolbuildingin whichthe child is enrolled. 7. Presenceof child'steacheratcase conferences,withdis- cussion ofspecificdifficultieswhichshecanhelpto adjust. 8. Reports bothto and fromthe o teacheronprogress of the case.

. What istherelationshipof theclinicalservice tóthetotal schoolprogram? Thepurposefaclinicalchildguidanceprogram is not limited to the adjustmentofacomparativelysmallnumberof serious 'behaviorproblems.Asalreadyindicated,itsinfluenceshould be preventive aswellas remedial, anditsserviceshouldbe directly orindirectlyto all thechildrenin theschöolsystem. Moreover,psychologicalfindingsconcerningtheabilitiesand disabilities ofchildrenshouldhelpsupervisorsandteachersto makeadequate curricularadjustments.Social . workwhich bringsinformationconcerninghomeandcommunityenviron- ment should iissistindevelopingfor allchildrena.closecoopera- tion betweenschool andhome.Physicalfindings ,shöuld.indicate theimportance ofnutrition andotherprovisionsto meet the needsof alltypes of physicallyhandicappedpupils.Psy- chiatricdiagnoses _. and recommend.ationsshouldpointto desir- ablechangesinthe entireschooladmiftistration'4and '4W. 726 WNICAJI GANIZATION FO3Cil-ILDGUIDANCE

adjustment:measuresconduciveto rileeting theemotionalneeds- of all children.Finally,aneffective childguidanceprogram- will bereflected ina.rhorecáreful selectionof te-achers, witfi attentionto desirable,personality andemotion idadjustmenton thepartcifcandidatesasweltasto their iutellettuilqualifica- tions: Whenthe influenceofaneikiently siaffedand efficiently ccinduct:edchild guidanceclinic hasthuspermeatedand affected school practicesthroughout. ihesystem,itscentributionto the total guidanceprogramisOfmaximalimport. The directorof the bureauof childguidanceof theNew York City pulAicschools pointsoutsome of the specificareasin which mental hygienecliniciansshould beof serviceto the schoolsystem.Aftercallingattentionto the outstandingneedof the the mentalhygienist'scontributionin theselection ofcandidates for teacherlraininginsitutions andteachingpositions,hesays:61 It isnot possiblelpdiscussevenbriefly themanyopp6rtunit1bsthat $ the field ofeducation offersfor theapplication ofmental hygieneprin- ciples. Thetype ofexaminations childrenshouldreceiveonentèring school;practicalmethods ofgiving .1; these examinationsand the.fre- quency with whichthey shouldbe repeated; homogeneousversus heterogeneousgroupings;100percent promotions;sex education;the place -of religions trainingin public-schooleducation;vocationaland educationklguidance;the:activityprogram ; thefuniorhighschool and its 'ethic:fees on the genek.al,schoolorganization;and thechangestaking place in thetype of studéntnow entering highschoolare samples of problems tobe foundin schoolsystems, the ultimatesolutionof which involves theknowledge, experlen7ct? andcooperative actfonof botheduca- torianticlinielans 8". in mentalhygk4.

What_means can be usedto coordinateeffectivelythecom- munityminute's for clinicalservice P . . , , Community.resources establishedin theinterests pf wholesOme- dhil0dévelopnlAt . frequently findthemselvesduplicatingpi in- upon pne Anothees -!terrices.In ordertòprevent such duplication,topromottia'dorrespondingéconomyottime and effort,. andto minimize theniimberof agenciesoepersonsdealing *ith- thesame cases,apIan ofcoordinationin whichallcooperat- .ing agencieshave'a part isessentialta the,successofachild- guidanceprogram.Whetherlithesotrce of servicebe thecity, the abtinty,orthe Stateorevenavonibinatioftof theseLthearea of eq.& agencyshould be cleirlydefined totthe satisfaCtionof all. concerned andwithaspeCificunderstandingof theactivities expected- ofeach.To tiemost effective,suchcoordinationmust bi) itroluntary.--notlegislatedinto being.Its chiefimpetustiomes 7. -4 fa O'Brien,Frank J.Educating formental health. The Americanjournal oferase- , peyebiatrwl 9:2716406, April1pe. g 0. a.,

41. .1 .4.. ' g' 1;

41, __ 4 CLINICAL ORGANIZATIONFORCHILDGUIDANCE 73 from the desiretocooperate in servingthechildrenof com4unity. the One ofthe most effectivemediadevisedto date.throughwhich coordinatiowcanbegiventangibleexpressioqis i6.coordinating or community council, consistingofrepresentativesof thevarious akencies in thecommunityconcerned witthumanneeds. ularly Atreg- scheduledmeetingsproblemsof mútualinterest arè cussed, dis- individualcasesmaybeconsidered,responsibility action Mr assigned,andfolloiv-upreports received.It isnot a.clini- calgroupbut it isaspiDnorof theclitnicalprogramas one of the means through whichitcanmake itsunitedservicesfor the drenof the chil- communityeffective.Childguidanceisclearly the sole not responsibi4tyofanyoneagency.Regardlessofwhere it iscentered, its workwillbe welldoneonlywhenthecoordi- natedresources of allagenciesare at the disposalofasingle child whoneedsthem. Becauseof theirstrateticpositioninrela- _ tionto all the childrenof allthepeople,theschoolshaveat their °verydoorsachallengingopportunityandresponsibilityfor leadershipin sucha program.

a Ss

. 0

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76 CLINICALORGANIZATIONFOR CHILDGUIDANCE

ROGERS, CARLR.The clinicaltreatment of theproblemchild. NewYork, Houghton Mifflincompany, 1939.393.p. RYAN, WILL CARSON.Mentalhealththrough education.New Ybrk,Thecorn- monwealth fund, 1938.315p. STEVENSON, GEORGE S.Community clinicsas training centers forlidehiatrists. Mentalhygiene, 18:353-61, July1934. 0 Lines ofdevelopment ofchild-guidanceclinics.Psychiatricquarterly supplement, 13: 31-38, January 1939. Thesocial worker'sfunction idthe communityclinics.Psychiatric quarterly, 6:147-53,January 1932. and SMITH, GEDDES. Child-guidance clinics: a quarter centaryof development.New York,Thecommonwealthfund, 1934.186p. TALLMAN, FRANKF.Child guidancein schools.Psychiatricquarterly,9: 436-57, July 1935. TheorganizationofState-hospitalchild-guidanceclinics.Mental hygiene, 20:579-87, October1936. UNITED STATESDEPARTMENT OFTHE INTERIOR, OFFICEOF EDUCATION. Adjustment of behaviorproblems of schoolchildren.By EliseH. MartensandHelen Russ.Washington, D. C.,United Statesgovernment printingoffice, 1932. 78p.(Bulletin 1932,no.18.) A WILE, IRA S.The visitingteacher:interpretrngthe schoolto thehome and the hometo the school.Mental hygiene,18: 380-92,July 1934.

110 A GUIDETO STATES,COUNTIES,CITIES,ANDCLINICAL AGENCIESREFERREDTO INTHISBULLETIN NormThisIs not an exhaustive listof localitiesor school syst6msmarked by clinicalprograms for child guidancewithintheschoolsorof clinicalagencies contributingto such programs.Itpresents onlythoseconcerningwhich materialhas been contributedfor thisbulletinand whichfurnishexamples of thetypes ofprograms carriedon. Ann Arbor,Mich., 28-29. sion ofMentalDeficiency,10, 12,13; State Baltimore, Md..19. 45, 60.62. Departmentof Mental BaltimoreCounty. Md., 19. Diseases, Division of MentalHygiene, 10, ; Berkeley, Calif., 11 Metropolitan 41-42. 44.69. StateHospital.29, 30; Waltham, 29-30. BermanFoundation,Niagara Falls.N. Y., 38.MetropolitanState Hospital. Boston, Mass., Mass., 29,30. 10. Michigan,Ann Arbor,28-29; Child Guidance California. 16.18-19. 68; Berkeley, 41-42, 44, Inaltute,23; 69; Long Beach, 40-41 Children'sCenter,Detroit, ; Los Angeles, 45. 28:Detroit,28. 45,54-56. 59; Oakland,60 60; Muskegon, ; Pasadena, 3748, 39, 44. 29; StateWelfareDepartment,23; Tra- 69;Santa Barbara,19, 26-28.68; South- verse 4it5 StateHospital,29; University ern California Societyfor MentalHygiene, of, 28. 88; StateDepartment ofInstitutions, Bu-MilwaukeeCounty, reau of Juvenile Wis., 21-22,24, 67. Research, 18.19, 22;Ven-Minneapolis.Minn.. 45,5. 4. tura County,19. 22-23. Minnesota, Minneapo 45. 53-54;Univer- Champaign,Ill., 31-32,69. sity of, 23. Chicago, Ill..V. 32, 45,59. Moline,nit 30-31,69. Children's Center,Detroit. Mich..28. Muskegon,Mich.,29. Cincinnati. Ohio,45, 60, 62. NationalCommitteefor MentalHygiene,5. Cleveland, Ohio,45. 59. , 7, 9,65,66. Connecticut% StateDepartment of Health.Bu-Newark,N.J., 45,52-53, 59. reau of Mental Hygiene, 23. New Jersey.EssexCounty, 24.53, 67;Jersey Delaware,StateHospital,36; Wilming- City,45,48-51;Newark, ton, 36. 45,52-53,59 StateDepartmentofInstitutionsand Des Moines, Iowav87. 'Agencies,23. Detroit, Mich.. 28,45..54-56. 60. NewYork City,N. Y..45, 56-59,60, 72. East Moline StateHospital. Ill.,30. New York(State).New YorkCity, Erie, Pa., 34-36, 69. 45, 56-59. 60. 72;NiagaraFalls. 38;Rochester,45, Essex County, N. J.. 24.53, 67. 51-52, ;%!; Rockland 'County.24. 67; Rbck- Eugene, Oreg., 28,46. land StateHospital,24; State DepartMent Gary, Ind" 40. of MentalHygiene.DivisionofPrevention, Illinois,Champaign.. 31-82,69; Chicago, V, 23;StrongMemorialHospital.51;Syra- 82. 45, 59; East Moline StateHospital, 30; cuse, 45. Moline, 80-31, 69; Rock Island, 30-31, 69; NiagaraFalls, N.Y.. 38. StateDeparjment of SocialWelfare,Insti-Oakland,Calif.,60. tute of JuvenileResearch, 23,41114 32; Uni-Ohio,Cincinnati,45. 60,62; ClevOank,45, versity of,81; Urbana,81-82, 69;Win- 59; StateDepartmentof PublieWelfare. netka, 25-26. Bureadof JuvenileResearch, 23. Indiana, Gary,40. Oregon,15-16,17;Eugene, 28,46; Portland, Iowa, Des Moines,87. 45, 46-48;Universityof, 15.17, 28,46; Jersey City, N.J., 45, 48-51. WascoCounty,16. Johns HopkinsUniversityHospital,Md:, 20.Pasadena,Calif.,37-38,39.44, 69. Pennsylvania, Long Beach,Calif., 40-41. Erie,34-36, 69;StateDepart- Los Angeles,Calif., 45,59. ment ofWelfare,Bureauof MentalHealth, 28;Philadelphia, Maryland,19-21, 67; Baltimore, 19.45, 60, 45, 59;Pittsburgh,45; Universityof, V; 62; BaltimoreCounty, 19;,JohnsHopkins WarrenStateHospital 35. PerryCenter,Ann Arbor, UniversityHospital, 20; StateDepartment Mich., 28-29. Philadelphia,Pa., 45,59. of Health,Bureau ofChildHygiene, 20,67. Pittsburgh,Pa.,45.(s Massachusetts,10-15, 16, 82, 67;Boston, 10;Portland,Oreg., 45,46-48. StateDepartmentof Mental Diseases,Divi-Providence,R. I.,45-46, TO. 78 CLINICALORGANIZATIONFOR CHILDGUIDANCE Rhode Island, Providence, 45-46,70; SocietyUniversity ofMinnesota.23. for Mental Hygiene, 46;State Hospital,46.University ofOregon, 15,17, 28,46. 1Rochester,N. Y., 45.51-52, 69. Universityof Pennsylvania,V. Rock Island,Ill., 30-31,69. Urbana, Ill.,31-32, 69. .. RocklandCounty, N.Y., 24, 67. VenturaCounty, Calif.,19, 22-23. RocklandState Hospital,N. Y.. 24. Virginia, StateDepartment of Santa PublicWelfare, Itarbara, Calif.,19, 26-28, 68. Bureau ofMental Hygiene.23. Seattle, Wash.,45, 60. Waltham,Mass., 29-30. SouthernCaliforniaSociety forMental Hy-Warren StateHospital,Pa., 35. giene,38. Wasco County,Oreg.,16. StrongMemorialHospital, Rocbestdt,N. Y..Washington, 51. Seattle, 45. Wilmington, Del.,86. Syracuse,N. Y., 45. Winnetka, Ill., 25-26. TraverseCity State Hospital, Mich.,29. Wisconsin,MilwaukeeCounty, 21-22, University ofIllinois,31. 24, 67; StateDepartment ofMentalHygiene, Divi. University ofMichigan,28. sion ofPrevention, 28. o