Mrs. M now visits Jean weekly and shows some warmth for her. Whenever it is necessary for Jean to be taken to the hospital, Mrs. M accompanies the foster mother and takes responsibility for the child during the hospital visit, although at the time Jean was placed in the foster home Mrs. M wished to have nothing whatever to do with her.

In this instance it seemed desirable for the sake of the child, as well as the mother, to relieve the mother of all responsibility. It was evident that Mrs. M could not develop any feeling of warmth for Jean until she could feel that her burden was shared.

Sometimes the thinking through of actual arrangements for placing the child makes the mother aware of what giving up the child means to her, and she may withdraw her request before the plan becomes a reality.

Mrs. D, 18 years old, was one mother who did this. Mrs. D and her 3-monthold baby Jimmy came to the clinic accompanied by her husband's parents, in whose home the young couple were living. As the doctor discussed the baby's blindness the mother-in-law took complete control of the situation.

In spite of being only 18, Mrs. D showed considerable maturity in her interviews with the case worker and

and the child's own parents when both families share the same home. Before the interview was ended the case worker agreed to make arrangements for Jimmy's placement if Mrs. D was sure that this was the plan she really wished.

The mother decided to think it over, and when she returned for the next interview she withdrew her request for placement and discussed the advisability of living away from the paternal grandparents. The case worker lent support to this idea and the young couple now have a home of their own for the first time since their marriage. Jimmy is making excellent progress.

Overprotective mother difficult to help

Mothers who can only express feelings of overprotection for the blind child require a longer and somewhat more intensive treatment plan. They are likely to have strong feelings of guilt over having borne a blind child and are frequently inhibited in expressing any irritability toward the child. Such a mother cannot readily take advantage of many of the services which might be helpful to the child since she compels herself to assume complete responsibility for him.

Mrs. C is such a mother. Mrs. C was referred to the case worker when

When Jimmy was 2, she came to the case worker, asking if there was some place where he could be placed for training. She said she did not wish to give him up, but her in-laws brought constant pressure on her in regard to his training, so that she had come to feel that his feeding and sleeping difficulties resulted from her poor care.

The case worker discussed Mrs. D's ways of handling her problems and told her that she thought her methods were sound and also that the problems she described were not restricted to a child who was blind but might be found in any child. She said to Mrs. D that it must be difficult for her to live in the home of her in-laws, and Mrs. D talked freely about the problems her living arrangements presented. The worker spoke about the conflicts that frequently arise between grandparents

case

age. Mrs. C could think only in terms of the baby's care. She said that she was unable to enjoy any of her pre

vious social activities because she did

not feel she could leave Richard long enough to even hang her clothes in the back yard.

This mother had previously lived the life of a happy young married woman, enjoying Saturday night parties with other married couples. Therefore, the worker urged her to resume her previous recreation activities in spite of the fact that she claimed she did not now enjoy them.

When the baby was 14 months old he had to be hospitalized; and because of the mother's extreme anxiety arrangements were made for her to take a good deal of responsibility for his care in the hospital.

When Richard was 16 months old, Mrs. C was invited to join the summerschool project for mothers of blind children, but she was reluctant to do

So. She was not yet ready to give up as much of the care of the baby as would be necessary in order to attend the lectures. However, when she was offered the opportunity to audit some of the lectures, she accepted. She would not be separated from Richard but she was able to send her older preschool child to a nursery school; this gave her some relief from home responsibilities.

She has since indicated a willingness to have the home nursery-school teacher visit Richard, who is now 22 months old. Again the social worker did not insist upon the mother's use of a serv ice before she was ready to accept it herself, but did make constant efforts to prepare Mrs. C to use the services as soon as possible.

The case worker is inclined to be fair ly active in planning and offering sug gestions to an overprotective mother

when these activities seem to have some therapeutic value.

For example, if the case worker encourages the mother to release some of her child's care to experts, either by hav ing a nursery-school teacher come to the home or by placing the child in a day nursery or nursery school, her approval. and encouragement permit the mother to feel justified in freeing herself from some of her responsibilities.

The worker often suggests that some member of the family take more responsibility for the child, or that someone be employed to look after the child occasionally, or that the mother send the child to a nursery school even if she can only do this for one or two sessions a week.

Mother may be violently hostile

If the mother's urge to be overprotective is extreme, she cannot, of course, respond to such suggestions and will continue to take complete responsibility for the child. In such instances the case worker must be prepared to deal with rather violent expressions of hostility, which may occur when feelings of irritability toward the child are beyond the mother's tolerance point. When such feelings are expressed the mother may be shocked and frightened by her own behavior, but she can be greatly reassured if the case worker truly understands her reactions.

In dealing with a seriously malad

justed or neurotic mother it is important for the case worker not only to recognize the condition of such a mother, but also to be aware of her own limitations in dealing with this group. Psychiatric treatment may help

It has been our observation that it is rare for a mother to break emotionally or physically in reacting to having a blind baby. Sometimes, however, a mother shows signs of disturbance that seem to indicate that she would make a more satisfactory and quicker adjustment if the services of a psychiatrist, as well as of the case worker, could be had. However, some of the milder forms of disturbance can be handled by the case worker, under the supervision of an experienced senior worker, with an occasional consultation with a psy

trist's care, and she continues to see the case worker in regard to finding educational opportunities for her child.

The case-work approach is a slowmoving one, and appreciable accomplishments cannot be quickly observed. It is necessary for the case worker to be constantly flexible and ready to change her goal for the child and his family as she increases her understanding of the mother's psychology and needs.

Parental attitudes are not clear-cut, and individual parents cannot arbitrarily be placed in different categories. A case worker's evaluation of the mother's attitudes is a continuous process. The worker must be on the alert to try to understand the mother's true feelings. Otherwise, encouragement of the mothor's accomplishments may force her to aim at an ideal goal which she believes is expected of her, but which in reality she could not possibly reach. If the case worker sees that her own goal for a mother has been unrealistic, she must be ready to change the goal for one which is possible for the mother.

Case work cannot effect a complete personality change in a mother, but in many instances it can bring about slight modifications of her attitude, which will enable her to make decisions and see her way out of situations which have previously seemed impenetrable.

If the mother is able to move positively toward a goal for the child and still retain her respect for her own decisions, the treatment has helped both the mother and child, irrespective of the total services offered by the agency which the worker represents.

Schooling for blind child the next step

As the child approaches school age the case worker should stand ready to in making an academic plan which meets cooperate with educational authorities. the needs of the particular child.

The fact that the case worker is interested in the problems of these mothers and knows about the complications that children, and that she is available when may arise in connection with blind needed, gives them a sense of confidence and security-a feeling that they are not alone. They see the case worker as a symbol of continuity of interest and of service to them. The case worker's activities in general, with mothers who can accept the blindness of the child reasonably well, may be described as a liaison service between the needs of the child and community resources.

In summary, the case workers in our Social Service Department who deal with blind preschool children and their parents try to

1. Give the mother complete acceptance and understanding of the way she feels about her problem as she sees it.

2. Assist in developing a warm and satisfying mother-child relationship.

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.

Reprints available in about 5 weeks

ST

TATE PLANS for providing maternal and child-health services under the Social Security Act during the fiscal year ended June 30, 1947, showed as many variations as there are States. And by definition in the act, the term "State" here includes not only the 48 actual States of the Union, but also Alaska, Hawaii, Puerto Rico, and the District of Columbia. (The Virgin Islands also are now included, but were not at the time the plans for the fiscal year 1947 were prepared.)

The variations in the plans, of course, indicate the variations in the needs of the States for different types of maternal and child-health services. The Social Security Act recognizes the fact that conditions vary from State to State when it describes the purpose of the funds authorized for maternal and child-health services. The purpose, according to the act, is to enable each State to extend and improve its services, "as far as practicable under the conditions in such State."

Basically, of course, through the nature of the subject matter, the State plans resemble one another. Also a certain amount of uniformity is brought about by the fact that the Social Security Act makes certain requirements that each plan must fulfill in order to be approved.

One of these requirements, for example, is that the responsibility for administering the plan must be in the hands of the State health agency. Another is that personnel standards be maintained on a merit basis. Again, every plan must provide for extension and improvement of local maternal and child-health services administered by local health units. The act also requires that each plan provide for cooperation with medical, nursing, and welfare groups. And, in harmony with one of its expressed purposes, the act requires each plan to provide for de

This analysis excludes all data on Emergency Maternity and Infant Care

velopment of demonstration services in needy areas and among groups in special need.

In every State the annual plan for maternal and child-health services is prepared by the State health agency. The services that the health agency intends to provide for the purpose of promoting the health of mothers and children in the coming fiscal year are outlined in the plan, and the estimated cost of the various items of service is given. After the State plan has been approved by the Children's Bureau the Federal funds apportioned to the State under the Social Security Act for help in carrying out the plan are paid.

We are presenting here a partial summary of the 52 State plans for maternal and child-health services for the fiscal year ended June 30, 1947.

The plans from which these summaries were made provide for the expenditure of approximately $14,000,000 of Federal, State, and local MCH funds.

These plans were made some time before Congress increased the amount. authorized by the Social Security Act for annual appropriations for grants to the States for maternal and childhealth services. After the additional funds were authorized, the States revised their plans accordingly, and the final plans for the fiscal year 1947 included at least $2,000,000 more than the original ones, summarized here.

Fifty percent of the total was specifically budgeted for expenditure by local health agencies. A much larger percentage than this is actually expended for local services, since many States budget as "State" expenditures all, or a major share, of the cost of MCH services actually provided in local communities.

The communities where most of the services are provided are in rural areas. Only a small proportion of the program is carried out in counties that have any city of more than 100,000 population.

As for the types of services provided for, the plans show that payments to

physicians, dentists, and hospitals fo services to mothers and children ac count for more than $1,000,000 of th year's MCH funds.

When examining these figures, the reader should remember that not all the maternal and child-health services in any State are included, but only those provided under the auspices of the State health agency. In every State many public health services for mothers and children are provided under other public auspices. And in every State private agencies provide some services.

HOW MCH UNITS ARE SET UP IN
HEALTH DEPARTMENTS

In every State the plans show that the health department has a maternal and child-health unit. In all but 12 States this unit is a separate division or bureau directly responsible to the State health officer. In 7 States the MCH unit is in the health department's division of preventive medicine, in 4, in the division of local health services, and in 1, in the division of medical administration.

In 16 States the maternal and childhealth director is responsible also for the crippled children's program.

MEDICAL PERSONNEL

A total of 185 physicians were provided for in the 52 plans, 160 on fulltime and 25 on part-time salaries.

In every State there is a State requirement that the director of MCH services be a physician; in all but one State the director gives full time to MCH services or to MCH and CC services. Three States reported the position of MCH director as vacant; in six there was an acting director at the time the plan was submitted.

Among 15 States there were positions for 18 assistant or associate directors; 6 of these positions were vacant.

In addition to these 70 positions for directors and assistant or associate directors, positions for 115 staff physicians were provided for among 36 States. These 115 positions included positions for 14 full-time and 4 part-time obstetric consultants in 17 States; 16 fulltime and 3 part-time pediatric consultants in 16 States; 9 full-time maternal and child-health consultants in 6 States; 5 full-time and 1 part-time mental

health consultants in 5 States; 1 parttime ophthalmological consultant; 1 part-time surgical consultant; 40 fulltime and 6 part-time physicians not otherwise designated in 15 States; 2 full-time and 4 part-time obstetricians in 5 States; and 5 full-time and 4 parttime pediatricians in 7 States.

Postgraduate training for 19 physicians on State and local staffs, ranging from 1 month to 1 year in duration, was provided for in the plans of 16 States. In 8 States courses of from 1 to 6 weeks duration were planned for approximately 160 practicing physicians, principally those who serve in maternity clinics or or child-health conferences. (After this analysis was made, practically every State provided for greatly increased training programs for physicians, nurses, and other professional personnel.)

MEDICAL SERVICES

FOR MOTHERS

Maternity clinics.-In 38 States, according to the plans, fees were paid to practicing physicians who conduct maternity clinics. On an hourly basis the fees ranged from $3 an hour to $10 for the first hour and $2.50 to $3 for each subsequent half-hour; on a clinic basis. they ranged from $5 for a 2-hour clinic to $40 for a 1-day clinic, including travel time.

Seven States allowed 50 percent higher rates for specialists who conduct clinics. One State paid part-time salaries to obstetricians for conducting clinics.

Medical delivery care. The plans of 16 States provided for payment for delivery by a physician, usually in limited areas or for special groups such as unmarried mothers.

Obstetric consultation. - Obstetric consultation was provided for in the plans of 23 States. In 12 States this service was on a case basis, the fee ranging from $5 to $15 for consultation in the home; from $5 to $10 for consultation in office or hospital, and from $25 a day plus maintenance and travel to $25 a half day plus travel. In the other 11 States, consultants were paid parttime salaries or were full-time staff members.

FOR CHILDREN

Child-health conferences.-All but 2 State plans provided for health supervision of children through child-health conferences. Some of the conferences were conducted by local health officers and others by practicing physicians. The latter were paid on an hourly or a clinic basis. The hourly rate ranged The hourly rate ranged from $2.50 an hour to $10 for the first hour, $5 being the rate most frequently paid (14 States). In general, the higher rates were paid to physicians with special training in pediatrics.

Twenty-six States made additional payment for time spent in travel, the rates varying from the usual mileage allowed State employees to 25 cents a mile.

Medical examinations of school children. Medical examination of school children was provided for in 14 State plans. The rate of payment to general practitioners for this service was usually on an hourly or a clinic basis; the rates ranged from $3.50 an hour to $10 for the first hour and $3 for subsequent half hours, and from $6 to $10 a clinic.

Diagnostic clinics.-Provision for diagnostic service for infants and preschool children was made in the plans of 8 States, in 4 of which children of school age also were included.

Medical treatment.-Medical treatment was planned by 13 States for infants and preschool children. In 4 of these States the service was limited to 1 county; in 2 States it was limited to premature infants; in 1 to refractions; in 1 to infants of unmarried mothers; in 1 to certain cases not eligible for emer

gency maternity and infant care; in 1 to pediatric clinics in 3 areas; in 1 State it was limited to 1 county and given only to children under 16 years of age at monthly clinics and to children in the home; in the other 2 it was State-wide for infants in need of care.

Seven State plans provided for medical treatment for children of school age. This was limited in 3 States to 1 county; in 2 States to care of visual defects; in 1 to pediatric clinics in 3 areas of the State; and in 1 to the treatment of school-age children through local and State funds.

Medical consultation.-Consultation by physicians was provided for in the plans, by 22 States for sick infants and preschool children and by 12 States for school-age children. In 9 States the service for infants and preschool children was given by personnel of State and local health departments; in 2 by both staff and consultants in practice; of the university medical college; in the in 1 State by a member of the faculty other 10 States part-time practicing consultants gave this service and were 6 of the 12 States providing consultapaid on an hourly or a case basis. In

tion for school-age children the service was given by the maternal and childhealth staff, in 5 by consultants in practice, and in 1 State by both.

basis, for unmarried mothers in 8 States, and for indigent patients in 2. In the other 7 it is limited to 1, 2, or a few contiguous counties or to a few communities.

FOR CHILDREN

The plans of 13 States included provision for hospitalization of infants and preschool children. In 3 of these States this service was limited to premature infants in certain areas. In 4 States it was limited to a single county; in 3 of these States it was a demonstration service. One State provided hospitalization for infants of unmarried mothers

during their first year of life; 1 hospitalized certain infants not eligible for emergency maternity and infant care; 2 States, on a State-wide basis, hospitalized infants who were medically indigent, 1 made provision for this group in all parts of the State except in cities of 50,000 or more population, and another in 4 specific areas of the State.

Provision was made by 3 of these 13 States for hospitalization of school-age

children in limited areas.

HOME DELIVERY NURSING SERVICE

Home delivery nursing service was available in 16 States, the plans indicated, in 2 of which it was limited to 1 county. In the others a very small number of patients in scattered areas were given this care, and in most it was on an emergency basis only. The fees paid to graduate nurses for home de

livery service on a case basis ranged from $5 for 12 hours to $15.

SERVICES FOR PREMATURE INFANTS Thirty-nine States included in their plans some service, in operation, for premature infants. Of the other 13 States, 5 described services proposed for the fiscal year 1947. Eight States included no service, either in operation or proposed, for premature infants. One described no program in its plan but has recently made a survey of hospital facilities for premature infants.

In the 39 States whose plans included services for improvement of planned ranged from such comparacare of premature infants, the services tively minor efforts as postgraduate training for "a few" hospital nurses, or studies of the causes of prematurity, or in-service staff training, to Statewide programs including establishment of centers for the care of premature infants, hospitalization, and medical consultation; or provision of incubators, tion; or hospitalization and medical home nursing service, and hospitaliza

consultation.

Eight States had centers for the care of premature infants already in operation. Five of these States had 1 center only, 1 State had 2, 1 had "a number throughout the State," and 1 had 48 centers. Two of these States and 6 additional States included the establishment of centers as a service proposed for the fiscal year 1947.

Other types of service provided in the interest of premature infants included postgraduate training for State and local staff physicians and nurses, in 7 States; for hospital nurses, in 8 States; in-service training for State and local staffs, in 15 States; and instruction in the care of premature infants for practicing physicians, in 5 States. Consultation to practicing physicians was made available by 5 States, and nursing service in the home by 9 States. This nursing service in the home was limited in 3 States to areas having public-health nurses (2 cities); and to 4 counties in another.

Two States had demonstration services for the care of premature infants, and 1 State proposed to establish such a service during the fiscal year 1947. In 2 States technical advisory committees on prematurity had been ap

pointed, and in another a medical conference for premature infants was conducted in 1 county.

The organization charts of 45 States show dental units. In 26 States the unit is shown as a separate division responsible directly to the State health cfficer. The service is in the division of maternal and child health in 10 States, in the division of preventive medicine in 6, and under local health services in 3.

A total of 100 dentists, 85 full-time and 15 part-time, and 32 dental hy gienists were included in the plans of 31 State programs. Thirty dentists and 7 hygienists' positions were vacant when the plans were submitted.

Nineteen States provided payment of fees on either a clinic or an hourly basis to local practicing dentists for educational and diagnostic services at clinics. The fees varied from $3 to $10 an hour for the first hour, and from $3.75 to $6 for each additional hour, and from $5 for a 2-hour clinic to $28 for a 4-hour clinic. One State included travel time at the same rate paid for clinic service and 6 others allowed for travel at the usual State rate. The plans of 21 States provided for corrective dental service. some at clinics in dentists' offices and other clinics, and others by the hour in dentists' offices. Payment for this service ranged from $3 to $10 an hour, and from $10 for a half-day clinic to $28 for a clinic day, with an addition of