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Mrs. M now visits Jean weekly and and the child's own parents when both She was not yet ready to give u shows some warmth for her. Whenever families share the same home. Before as much of the care of the baby ait is necessary for Jean to be taken to the interview was ended the case worker would be necessary in order to atten! the hospital, Mrs. M accompanies the agreed to make arrangements for Jim- the lectures. However, when she wafoster mother and takes responsibility my's placement if Mrs. D was sure that offered the opportunity to audit som for the child during the hospital visit, this was the plan she really wished. of the lectures, she accepted. Sh although at the time Jean was placed The mother decided to think it over, would not be separated from Richar?. in the foster home Mrs. M wished to and when she returned for the next in- but she was able to send her older prehave nothing whatever to do with her. terview she withdrew her request for school child to a nursery school; this

In this instance it seemed desirable placement and discussed the advisabi- gave her some relief from home refor the sake of the child, as well as the lity of living away from the paternal sponsibilities. mother, to relieve the mother of all re- grandparents. The case worker lent She has since indicated a willingness sponsibility. It was evident that Mrs. support to this idea and the young to have the home nursery-school teache: M could not develop any feeling of couple now have a home of their own visit Richard, who is now 22 month warmth for Jean until she could feel

for the first time since their marriage. old. Again the social worker did no that her burden was shared.

Jimmy is making excellent progress. insist upon the mother's use of a serr... Sometimes the thinking through of

ice before she was ready to accept it actual arrangements for placing the Overprotective mother difficult to help

herself, but did make constant effort. child makes the mother aware of what

Mothers who can only express feel

to prepare Mrs. C to use the services a giving up the child means to her, and

soon as possible. she may withdraw her request before ings of overprotection for the blind

The case worker is inclined to be fair the plan becomes a reality.

child require a longer and somewhat Mrs. D, 18 years old, was one mother

more intensive treatment plan. They ly active in planning and offering sug are likely to have strong feelings of

gestions to an overprotective mother who did this. Mrs. D and her 3-month

when these activities seem to have some old baby Jimmy came to the clinic ac

guilt over having borne a blind child
and are frequently inhibited in express-

therapeutic value. companied by her husband's parents, in

For example, if the case worker en whose home the young couple were

ing any irritability toward the child.
Such a mother cannot readily take ad-

courages the mother to release some of living. As the doctor discussed the

her child's care to experts, either by havbaby's blindness the mother-in-law took vantage of many of the services which

ing a nursery-school teacher come to the complete control of the situation.

might be helpful to the child since In spite of being only 18, Mrs. D she compels herself to assume complete

home or by placing the child in a day responsibility for him.

nursery or nursery school, her approval showed considerable maturity in her in

Mrs. C is such a mother. Mrs. C

and encouragement permit the mother terviews with the case worker and seemed to be capable of giving the baby Richard, our patient, was 4 months of was referred to the case worker when

to feel justified in freeing herself from

some of her responsibilities. adequate care. The case worker re

The worker often suggests that some assured her about her abilities, and Mrs. age. Mrs. C could think only in terms

member of the family take more D indicated that she could care for the

of the baby's care. She said that she
was unable to enjoy any of her pre-

sponsibility for the child, or that somebaby without any particular anxiety. vious social activities because she did

one be employed to look after the child When Jimmy was 2, she came to the case worker, asking if there was some not feel she could leave Richard long occasionally, or that the mother send

the child to a nursery school even if place where he could be placed for enough to even hang her clothes in the back yard.

she can only do this for one or two sestraining. She said she did not wish to

sions a week. give him up, but her in-laws brought

This mother had previously lived the

life of a happy young married woman, constant pressure on her in regard to

Mother may be violently hostile his training, so that she had come to feel enjoying Saturday night parties with

If the mother's urge to be overprothat his feeding and sleeping difficulties other married couples. Therefore, the

tective is extreme, she cannot, of course, resulted from her poor care. worker urged her to resume her pre

respond to such suggestions and will The case worker discussed Mrs. D's vious recreation activities in spite of

continue to take complete responsibility the fact that she claimed she did not ways of handling her problems and told

for the child. In such instances the her that she thought her methods were now enjoy them.

case worker must be prepared to deal sound and also that the problems she

When the baby was 14 months old

with rather violent expressions of hosdescribed were not restricted to a child

he had to be hospitalized; and because
of the mother's extreme anxiety ar-

tility, which may occur when feelings of who was blind but might be found in

irritability toward the child are beyond any child. She said to Mrs. D that it rangements were made for her to take

the mother's tolerance point. When must be difficult for her to live in the a good deal of responsibility for his

such feelings are expressed the mother home of her in-laws, and Mrs. D talked care in the hospital.

may be shocked and frightened by her freely about the problems her living ar

When Richard was 16 months old,

own behavior, but she can be greatly rangements presented. The case

Mrs. C was invited to join the summer- reassured if the case worker truly underworker spoke about the conflicts that school project for mothers of blind stands her reactions. frequently arise between grandparents children, but she was reluctant to do In dealing with a seriously malad

re

justed or neurotic mother it is impor- trist's care, and she continues to see the If the mother is able to move posi

tant for the case worker not only to rec- case worker in regard to finding educa- tively toward a goal for the child and 1 ognize the condition of such a mother, tional opportunities for her child. still retain her respect for her own deLe but also to be aware of her own limita- The case-work approach is a slow- cisions, the treatment has helped both t. tions in dealing with this group. moving one, and appreciable accom- the mother and child, irrespective of the

plishments cannot be quickly observed. total services offered by the agency Psychiatric treatment may help

It is necessary for the case worker to which the worker represents. It has been our observation that it

be constantly flexible and ready to is rare for a mother to break emotion- change her goal for the child and his Schooling for blind child the next step ally or physically in reacting to having family as she increases her understanda blind baby. Sometimes, however, a

As the child approaches school age ing of the mother's psychology and mother shows signs of disturbance that

the case worker should stand ready to needs. seem to indicate that she would make a

Parental attitudes are not clear-cut,

cooperate with educational authorities more satisfactory and quicker adjust- and individual parents cannot arbitrar

in making an academic plan which meets ment if the services of a psychiatrist, ily be placed in different categories.

the needs of the particular child.

A as well as of the case worker, could be

The fact that the case worker is intercase worker's evaluation of the mother's had. However, some of the milder attitudes is a continuous process. The

ested in the problems of these mothers forms of disturbance can be handled by worker must be on the alert to try to

and knows about the complications that 1 the case worker, under the supervision understand the mother's true feelings. children, and that she is available when

may arise in connection with blind of an experienced senior worker, with

Otherwise, encouragement of the mothan occasional consultation with a psy- er's accomplishments may force her to

needed, gives them a sense of confidence chiatrist.

and security—a feeling that they are aim at an ideal goal which she believes In one instance the case worker had is expected of her, but which in reality

not alone. They see the case worker as many interviews with a mother with she could not possibly reach. If the

a symbol of continuity of interest and neurotic symptoms, whom she was un

of service to them. The case worker's case worker sees that her own goal for a able to help. When the mother develmother has been unrealistic, she must

activities in general, with mothers who oped physical symptoms for which no be ready to change the goal for one

can accept the blindness of the child organic explanation could be found, the

reasonably well, may be described as a 고. doctor recommended psychiatry. Alwhich is possible for the mother.

liaison service between the needs of the

Case work cannot effect a complete though the mother was reluctant to ac

child and community resources. knowledge that she was ill enough for personality change in a mother, but in

In summary, the case workers in our such help, she was finally able to accept many instances it can bring about slight

Social Service Department who deal psychiatric treatment, largely as a result

modifications of her attitude, which will of the interpretation and the support enable her to make decisions and see her

with blind preschool children and their which she received from the case way out of situations which have pre

parents try toworker. She is now under a psychia- viously seemed impenetrable.

1. Give the mother complete acceptance and understanding of the

way

she

feels about her problem as she sees it. Frances cannot see the tissue paper, but she likes to feel it and hear it crackle.

2. Assist in developing a warm and

satisfying mother-child relationship. i

3. Support the mother in her own decisions regarding what is best for her child unless there is evidence that she is entirely incompetent and her decisions would be actually harmful to the child.

4. Modify unfavorable attitudes of the mothers to the extent that they may become constructive in regard to the child.

5. Use any or all of the appropriate available resources in the community to encourage the child's training and development.

6. Recognize the limitations of case work and seek psychiatric assistance for mothers and fathers with serious emotional problems.

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State Plans for Maternal and Child-Health physicians, dentists, and hospitals for

services to mothers and children acServices Show Expected Variations

count for more than $1,000,000 of the

year's MCH funds. Some data tabulated from plans for fiscal year 1947

When examining these figures, the

reader should remember that not all the CLARA E. HAYES, M. D., Senior Medical Officer, U. S. Children's Bureau

maternal and child-health services ir

any State are included, but only those TATE PLANS for providing ma- velopment of demonstration services in provided under the auspices of the ternal and child-health services needy areas and among groups in spe

State health agency. In every State under the Social Security Act dur- cial need.

many public health services for mothers ing the fiscal year ended June 30, 1947, In every State the annual plan for and children are provided under other showed as many variations as there are maternal and child-health services is public auspices. And in every State States. And by definition in the act, the prepared by the State health agency.

prepared by the State health agency. private agencies provide some services term "State" here includes not only the The services that the health agency in48 actual States of the Union, but also tends to provide for the purpose of pro- HOW MCH UNITS ARE SET UP IN Alaska, Hawaii, Puerto Rico, and the moting the health of mothers and chil

HEALTH DEPARTMENTS District of Columbia. (The Virgin dren in the coming fiscal year are out

In every State the plans show that Islands also are now included, but were lined in the plan, and the estimated cost

the health department has a maternal not at the time the plans for the fiscal of the various items of service is given. and child-health unit. In all but 12 year 1947 were prepared.)

After the State plan has been approved States this unit is a separate division The variations in the plans, of course, by the Children's Bureau the Federal

or bureau directly responsible to the indicate the variations in the needs of funds apportioned to the State under State health officer. In 7 States the the States for different types of ma- the Social Security Act for help in

MCH unit is in the health department's ternal and child-health services. The carrying out the plan are paid.

division of preventive medicine, in 4, in Social Security Act recognizes the fact We are presenting here a partial sum

the division of local health services, that conditions vary from State to State mary of the 52 State plans for maternal

and in 1, in the division of medical ad when it describes the purpose of the and child-health services for the fiscal

ministration. funds authorized for maternal and year ended June 30, 1947.

In 16 States the maternal and childchild-health services. The purpose, ac- The plans from which these sum

health director is responsible also for cording to the act, is to enable each State maries were made provide for the ex

the crippled children's program. to extend and improve its services, “as penditure of approximately $14,000,000 far as practicable under the conditions of Federal, State, and local MCH funds.

MEDICAL PERSONNEL in such State."

These plans were made some time beBasically, of course, through the fore Congress increased the amount A total of 185 physicians were pronature of the subject matter, the State authorized by the Social Security Act

vided for in the 52 plans, 160 on fullplans resemble one another. Also a cer- for annual appropriations for grants time and 25 on part-time salaries. tain amount of uniformity is brought to the States for maternal and child- In every State there is a State reabout by the fact that the Social Secu- health services. After the additional quirement that the director of MCH rity Act makes certain requirements that funds were authorized, the States re

services be a physician; in all but one each plan must fulfill in order to be ap- vised their plans accordingly, and the

State the director gives full time to proved. final plans for the fiscal year 1947 in

MCH services or to MCH and CC seryOne of these requirements, for ex- cluded at least $2,000,000 more than the

ices. Three States reported the posi

tion of MCH director as vacant; in six ample, is that the responsibility for ad- original ones, summarized here. ministering the plan must be in the Fifty percent of the total was specif

there was an acting director at the time hands of the State health agency. An- ically budgeted for expenditure by local the plan was submitted. other is that personnel standards be health agencies. A much larger per

Among 15 States there were positions maintained on a merit basis. Again, centage than this is actually expended for 18 assistant or associate directors; every plan must provide for extension for local services, since many States

6 of these positions were vacant. and improvement of local maternal and budget as "State” expenditures all, or a In addition to these 70 positions for child-health services administered by major share, of the cost of MCH serv- directors and assistant or associate dilocal health units. The act also re- ices actually provided in local com- rectors, positions for 115 staff physicians quires that each plan provide for co- munities.

were provided for among 36 States. operation with medical, nursing, and The communities where most of the These 115 positions included positions welfare groups. And, in harmony with services are provided are in rural areas. for 14 full-time and 4 part-time obsteone of its expressed purposes, the act Only a small proportion of the program

tric consultants in 17 States; 16 fullrequires each plan to provide for de

is carried out in counties that have any time and 3 part-time pediatric consult

city of more than 100,000 population. ants in 16 States; 9 full-time maternal This analysis excludes all data on Emergency As for the types of services provided and child-health consultants in 6 States; ! Maternity and Infant Care

for, the plans show that payments to 5 full-time and 1 part-time mental

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Medical delivery care.— The plans of gency maternity and infant care; in 1 to 16 States provided for payment for de- pediatric clinics in 3 areas; in 1 State livery by a physician, usually in lim- it was limited to 1 county and given ited areas or for special groups such as only to children under 16 years of age at unmarried mothers.

monthly clinics and to children in the Obstetric consultation. – Obstetric home; in the other 2 it was State-wide consultation was provided for in the

for infants in need of care. plans of 23 States. In 12 States this Seven State plans provided for mediservice was on a case basis, the fee rang- cal treatment for children of school age. ing from $5 to $15 for consultation in This was limited in 3 States to 1 county; the home; from $5 to $10 for consulta- in 2 States to care of visual defects; in tion in office or hospital, and from $25 1 to pediatric clinics in 3 areas of the a day plus maintenance and travel to State; and in 1 to the treatment of $25 a half day plus travel. In the other school-age children through local and 11 States, consultants were paid part- State funds. time salaries or were full-time staff Medical consultation.—Consultation members.

by physicians was provided for in the t

plans, by 22 States for sick infants and FOR CHILDREN health consultants in 5 States; 1 part

preschool children and by 12 States for

school-age children. In 9 States the time ophthalmological consultant; 1 Child-health conferences.—All but 2

service for infants and preschool chilpart-time surgical consultant; 40 full- State plans provided for health supertime and 6 part-time physicians not

dren was given by personnel of State vision of children through child-health

and local health departments; in 2 by otherwise designated in 15 States; 2 conferences. Some of the conferences

both staff and consultants in practice; full-time and 4 part-time obstetricians were conducted by local health officers in 5 States; and 5 full-time and 4 part

in 1 State by a member of the faculty and others by practicing physicians. of the university medical college; in the time pediatricians in 7 States. The latter were paid on an hourly or a

other 10 States part-time practicing Postgraduate training for 19 physi- clinic basis. The hourly rate ranged

consultants gave this service and were cians on State and local staffs, ranging from $2.50 an hour to $10 for the first

paid on an hourly or a case basis. In from 1 month to 1 year in duration, was hour, $5 being the rate most frequently

6 of the 12 States providing consultaprovided for in the plans of 16 States. paid (14 States). In general, the

tion for school-age children the service In 8 States courses of from 1 to 6 weeks higher rates were paid to physicians duration were planned for approxi

was given by the maternal and childwith special training in pediatrics.

health staff, in 5 by consultants in pracmately 160 practicing physicians, prin- Twenty-six States made additional

tice, and in 1 State by both. : cipally those who serve in maternity payment for time spent in travel, the clinics or child-health conferences. rates varying from the usual mileage

HOSPITALIZATION (After this analysis was made, practi- allowed State employees to 25 cents a cally every State provided for greatly mile.

FOR MOTHERS 1 increased training programs for physi- Medical examinations of school chil

Hospital care during delivery was cians, nurses, and other professional dren.-Medical examination of school

provided for in the plans by 17 States. 1 personnel.)

children was provided for in 14 State In 10 the service was on a State-wide

plans. The rate of payment to general MEDICAL SERVICES

practitioners for this service was usually 6

on an hourly or a clinic basis; the rates FOR MOTHERS

ranged from $3.50 an hour to $10 for the Maternity clinics.-In 38 States, ac- first hour and $3 for subsequent half cording to the plans, fees were paid to hours, and from $6 to $10 a clinic. practicing physicians who conduct ma- Diagnostic clinics.—Provision for diternity clinics. On an hourly basis the agnostic service for infants and prefees ranged from $3 an hour to $10 for school children was made in the plans of the first hour and $2.50 to $3 for each 8 States, in 4 of which children of school

subsequent half-hour; on a clinic basis age also were included. e they ranged from $5 for a 2-hour clinic Medical treatment.—Medical treat

to $10 for a 1-day clinic, including ment was planned by 13 States for inA travel time.

fants and preschool children. In 4 of ]

Seven States allowed 50 percent these States the service was limited to 1 1 higher rates for specialists who conduct county; in 2 States it was limited to preal clinics. One State paid part-time sal- mature infants; in 1 to refractions; in

aries to obstetricians for conducting 1 to infants of unmarried mothers; in ] clinics.

1 to certain cases not eligible for emer

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basis, for unmarried mothers in 8 States, livery service on a case basis ranged
and for indigent patients in 2. In the from $5 for 12 hours to $15.
other 7 it is limited to 1, 2, or a few

SERVICES FOR PREMATURE INFANTS
contiguous counties or to a few com-
munities.

Thirty-nine States included in their

plans some service, in operation, for FOR CHILDREN

premature infants. Of the other 13

States, 5 described services proposed The plans of 13 States included pro

for the fiscal year 1947. Eight States vision for hospitalization of infants and

included no service, either in operation preschool children. In 3 of these States

or proposed, for premature infants. this service was limited to premature

One described no program in its plan infants in certain areas. In 4 States

but has recently made a survey of hosit was limited to a single county; in 3

pital facilities for premature infants. of these States it was a demonstration

In the 39 States whose plans inservice. One State provided hospitali

cluded services for improvement of zation for infants of unmarried mothers

care of premature infants, the services during their first year of life; 1 hospi

planned ranged from such comparatalized certain infants not eligible for

tively minor efforts as postgraduate emergency maternity and infant care; 2 States, on a State-wide basis, hospital-training for a few” hospital nurses,

or studies of the causes of prematurity, ized infants who were medically indi

or in-service staff training, to State- pointed, and in another a medical congent, 1 made provision for this group

wide

programs including establishment ference for premature infants in all parts of the State except in cities

was of centers for the care of premature in

conducted in 1 county. of 50,000 or more population, and an

fants, hospitalization, and medical conother in 4 specific areas of the State.

DENTAL SERVICE
sultation; or provision of incubators,
Provision was made by 3 of these 13
States for hospitalization of school-age tion; or hospitalization and medical

home nursing service, and hospitaliza- The organization charts of 45 State children in limited areas.

show dental units. In 26 States the consultation.

unit is shown as a separate division HOME DELIVERY NURSING SERVICE Eight States had centers for the care responsible directly to the State health of premature infants already in opera

cfficer. The service is in the division Home delivery nursing service was

tion. Five of these States had 1 center of maternal and child health in 10 available in 16 States, the plans indi

only, 1 State had 2, 1 had “a number cated, in 2 of which it was limited to 1

States, in the division of preventive throughout the State," and i had 48 medicine in 6, and under local health county. In the others a very small

centers. Two of these States and 6 ad- services in 3. number of patients in scattered areas

ditional States included the establish- A total of 100 dentists, 85 full-time were given this care, and in most it was

ment of centers as a service proposed and 15 part-time, and 32 dental hy. on an emergency basis only. The fees for the fiscal year 1947.

gienists were included in the plans of paid to graduate nurses for home de

Other types of service provided in 31 State programs. Thirty dentists the interest of premature infants in- and 7 hygienists' positions were vacant cluded postgraduate training for State when the plans were submitted. and local staff physicians and nurses,

Nineteen States provided payment of in 7 States; for hospital nurses, in 8 fees on either a clinic or an hourly basis States; in-service training for State to local practicing dentists for educaand local staffs, in 15 States; and in- tional and diagnostic services at clinies. struction in the care of premature in

The fees varied from $3 to $10 an hour fants for practicing physicians, in 5 for the first hour, and from $3.75 to $6 States. Consultation to practicing for each additional hour, and from $5 physicians was made available by 5 for a 2-hour clinic to $28 for a 4-hour States, and nursing service in the home clinic. One State included travel time by 9 States. This nursing service in at the same rate paid for clinic service the home was limited in 3 States to and 6 others allowed for travel at the areas having public health nurses (2 usual State rate. The plans of 21 States cities); and to + counties in another. provided for corrective dental service,

Two States had demonstration sery- some at clinics in dentists' offices and ices for the care of premature infants. other clinics, and others by the hour in and 1 State proposed to establish such dentists' offices. Payment for this serva service during the fiscal year 1947. ice ranged from $3 to $10 an hour, and In 2 States technical advisory commit- from $10 for a half-day clinic to $28 tees on prematurity had been ap- for a clinic day, with an addition of

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