UNGRADED DECEMBER, 1916 Entered as second-class matter March 28, 1916, at the Post Office at Concord, N. H., Signed articles are not to be understood as expressing the views of the editors or publishers VOL. II No. 3 A DISCUSSION OF THE HOSPITAL CLINIC FOR MENTAL CASES AND ITS RELATION TO THE PUBLIC SCHOOL ELVIRA K. FRADKIN, M.A. When delegates from the north, south, east and west met at the sessions of the Department for the Study of the Backward and Feeble-minded Child, of the National Education Association, and openly admitted, “We don't know what we are about in our methods of attacking this problem, we who are actively interested in this field of work may feel relieved and actually encouraged. For, in this negative result, we have at least cleared away the underbrush of petty competition and misunderstanding, and we are now ready for a clear field of definite, coöperative work. The first duty ahead of us is to survey carefully and intensively our present methods of grappling with the problem to see whether they stand the searching criticism of awakened consciences. The clinic for mental cases situated in a big hospital is a recent development, which needs close scrutiny, and a criticism, both destructive and constructive. Let us impartially regard its good points and its bad points. Let us then see whether, in our opinion, it should continue to exist. If so, what is its function? What can the adequate clinic with the adequate clinicist be? What are their relations to the public school? To one who has worked and studied in a hospital clinic the good points stand out as follows: (1) There is a variety of cases which can be gained in no other way, for not only do the various departments of the hospital send in cases, but charitable agencies likewise refer their charges there. (2) Hence, a fine survey of the whole field of feeble-mindedness in children and adults and a rare opportunity for the accumulation of accurate statistics is afforded. (3) Because of the existence and coöperation of other departments in the hospital-such as the eye, ear, throat, dental, surgical, medical, etc.physical defects, almost always found in these cases, may be corrected with the least amount of useless delay. (4) The histories of these departmental cases, as revealed by the peculiar angle of observation of that department are valuable assets to the psychological clinicist, who must have accurate data on all vital questions from all points of view. (5) The opportunity for research work is readily available. The deterrent factors are briefly as follows: (1) In the clinics now existing there is a great rush of new cases constantly clamoring for recognition. (2) Hence, a superficiality of work, of diagnosis and prognosis results which, superficially considered, argues strongly against the perpetuation of the clinic. (3) A lack of definite control over the reappearance of cases for more detailed observation, due to the absence of a strongly coöperating social service bureau. (4) The present lack of adequate space and apparatus and (5) The difficulty of securing successful coöperation with institutions for the care of the feeble-minded because of the over-crowding and restrictions now in force in those institutions. The reader has probably noticed that in this list of deterrent factors to the success of a hospital clinic, I have not included a lack of adequate mental tests. To understand this omission, the following statement should be carefully considered. Until a more effective and more readily applicable standardized series of tests for motor, sensory and associative processes is evolved, the hospital clinicist must depend on a sane and trained reading of the results of the applied Binet tests, coupled with a careful observation, lasting preferably over weeks, of the reaction of the case in hand to motor, sensory and associative stimuli, naturally and artificially produced. The Binet scale is, then, used as an indicator. The observation period should either be a corroborator of first impressions gained through the scale, or should reveal any error in the first application or reading of results. Having thus outlined the good and bad points that are at present inherent in the hospital clinic, what is our conclusion regarding its permanent value? If it is borne in mind that a new departure in any field of science to meet some urgent need is always attended, at first, by chaotic methods of procedure and a general lack of adequate coöperation, I feel justified in concluding that the hospital clinic is an asset in attacking the problem of the feeble-minded from its vantage ground of distinctive good points. This conclusion may be questioned. If so, let me reiterate the two points which distinguish and elevate the hospital clinic above other means at present developed, of handling this aspect of feeble-mindedness. First, through the confidence inspired in the poor by the big hospitals, cases are attracted which would never avowedly declare themselves in any other way. We thus get the infant of a year who cannot hold up his head or the infant-minded adult who thinks the "Doctor" can do anything from curing a pain in his head to getting him a job. The public schools cannot and do not include these cases, nor can the reformed Randall's Island, through the very limitation of its physical position, act as the only central diagnosing agent. Secondly, the compactness of the hospital is a great factor in facilitating the disposal of cases. This standard even the great institutions find it hard to reach. So, again, we can conclude that at the present stage in the development of various methods of procedure against the evil presence of the feeble-minded, the hospital clinic can and ought to perform a distinct service. Before we discuss the relation of the clinic to the public school, we must clearly define the function of the clinic. The clinicist in charge should diagnose as carefully as is now possible, and suggest constructive methods of correction where that possibility is open, for those cases recommended by other departments of the hospital, for those recommended by charitable agencies and for the public school children who have, in some way, reached the clinic. Its function is then, briefly, to act as efficiently as possible with all the knowledge science has and can put at its disposal. To achieve its purpose, the clinic should have effective equipment. Separate, fair-sized, cheery, sound-proof rooms should be used for testing purposes, where interference or interruption should be prohibited. A larger room, containing all the technical apparatus necessary, should be used as an observation room, for the social reactions of the children are a very important factor. The testing rooms can, in the unused periods, be employed for individual training or individual observation. A large, clean and thoroughly ventilated reception room and a room for clerical filingcases and desks would be sufficient for the beginning of a hospital clinic. When the actual, astounding number of cases is recognized, the size of the hospital clinic ought necessarily be increased. The adequate clinicist should be a psychologically trained person of either sex, with at least one postgraduate degree in psychology; one with a thorough medical training in anatomy, neurology, psychopathology and embryology, not necessarily, but preferably an M. D.; one with pedagogical experience with the mentally backward and feeble-minded; a student of psycho-analysis, for cases arise, especially with adults, where a knowledge of that is imperative; one whose executive ability will not only attract a staff of capable assistants, but will also organize the routine on an accurate, effective basis. With such a clinic and such a clinicist daily more available, the future of the hospital clinic is assured, and the coöperation with the public school made a reality. For there are various ways in which the duplication of effort may be avoided and a dove-tailing of activities ensue, which will be a step toward a needed general coördination throughout this field. Let us consider the detailed manner in which this goal may be accomplished. From observation, it seems at present advisable for those children who are actually attending school, in the graded or ungraded classes, to be referred back to school authorities if they come to the hospital clinic. As long as children are actually attending school, they are under the jurisdiction of school authorities. Outside interference must be deprecated, since it cannot but be distracting. This rule may seem strange to the ungraded teacher who wants a definite opinion about one or all of her pupils to aid her in planning her work, but cannot obtain it because of the discouraging delay of school routine and lack of psychological experts. She should remember that if she, and others likewise thwarted, would but sufficiently emphasize the really crying need for psychological examination of their pupils, and reiterate the demand with unceasing steadfastness— they would gain a well-organized department of psychologists, under the direction of the head of the Department for Ungraded Classes. To inaugurate this reform, it rests in the final analysis with the ungraded teachers. If, from each teacher, there came this statement, varying in wording, but ever with the same, ceaseless burden: "We are preparing ourselves, in every way open to us, to perfect our teaching methods with these backward and feeble-minded children. Give us the trained psychologist to direct that training, and our results will be more evident and satisfactory.” This emphatic, unified appeal could not be ignored. On the other hand, those children who, because of their mental or physical disability are suspended or excluded from school attendance, can be diagnosed and prognosed at the clinic, and the results and suggestions sent to the school principal and class teacher. These feeble-minded children, referred directly to the clinic by the school nurses or other school authorities, should be disposed of as the judgment of the clinicist, in consultation with the school authorities directly concerned, dictates. These arrangements may be temporary, for with the urgently needed enlargement of the Department of Ungraded Classes, this method of interchange may be rendered useless. The coöperation between school and clinic-through the children -is dependent, at present, on whether the case is temporarily, or perhaps permanently, removed from school jurisdiction. This prerequisite is necessary so that amicable relations between two great constructive forces are maintained, and so that the clinicist has unfettered freedom in time and thought for closer observation and impartial decision. But there is another more permanent and more binding connection between the hospital clinic and the public school, which with sufficient time and abrasive contact, should be mutually beneficial. The position of assistant to the Head Clinicist affords an excellent insight into the manifold factors that go to make up the final decision on a case, giving experience in the many important side-issues of psychology. Because of their peculiar training, teachers of ungraded classes would be valuable assistants. This is particularly applicable to the observation period. They would in turn gain an all-round vision, which no university course can supply. It would give them other points of view to balance the purely pedagogical one, such as the remedial effects of the removal of physical stigmata, the quick mental adjustment of the examiner to each case, the concentrated observation because of the realization of the importance of the final decision, the knowledge of the actual size of this problem, and the methods of grappling with it outside of the school. In other words, the clinic experience is a bird's-eye view of the whole problem with its successes and failures, its compromises and temporary adjustments, its human equation in the worker, parents and children. Then, the clinic gains not only the trained observation of teachers, but also the secure realization that its diagnoses and suggestions will be intelligently understood and pursued if, during the winter session, a case is referred by the clinic to the trained teacher. There are objections and difficulties to be met in the application of this scheme, as there are to all new schemes. But with time and patience they may surely be overcome. It may be said that there are too many Ungraded Class teachers and too few clinics; I answer that this summer course in hospital clinics should not be compulsory, that if too many applicants desire admission, either a competitive written examination, or special recommendation for superior ability from a competent authority, would be resorted to. It will take years of slow, quiet, effective work until all the teachers are reached, but the main point is the practical value of this clinical experience. It might be objected that the routine of the clinic would be upset. The routine of a well-organized clinic should be adjusted to this emergency. Further, it may be said that this innovation would bring a lay element into a strictly scientific field. The task of science is not only to spread its doctrines among the laity, but also to give that lay element-here the teachers-a scientific viewpoint toward the problem. There is, too, one other side to this new form of coöperation. It opens up to the ungraded teacher-as Head Clinicist, for instance a new and larger field with larger possibilities, responsibilities, and remuneration. I have heard more than once the serious complaint that interesting as the work of the ungraded teacher is, it does not open out to avenues of greater freedom or responsibility. Perhaps this one outlet for the ambitious may lead to other opportunities. Even when the adequate clinic has been established, it should be definitely understood that this is no cure-all for feeble-mindedness. We are simply clearing our field of vision by a remorseless criticism of our present institutions, and those that remain after this process is completed, can only fulfill one mission,-to accomplish as efficiently as possible their set task. Not even with all our plans and ideals in full swing, can we ever hope to strike at the root of the matter. That lies with the public. When it came to the absolute necessity for sanitary measures, the public had to be slowly but surely educated. So must we slowly but unabatingly inform the public of the true causes of feeble-mindedness and unhesitatingly push forward, not as heroes or martyrs in the common good-they have been before us in this field--but as determined workers, exposing the truth as best we may and seeking with scientific zeal, remedies for present conditions. |