in a group, as he does at Cylburn?

These and many other questions, some more general and some intensely specific about an actual incident, are the concern of staff and social worker, each from the viewpoint of his particular responsibility.

The goal of all our activities is to give every possible opportunity to each child for natural growth and development.

In the first 2 years the struggle for sheer existence was all absorbing. The house furnace didn't work; the staff was inexperienced; the children were of wide age range and had a great variety of troubles. But gradually, as the environmental difficulties diminished and we began to plan satisfying experiences for the children, we realized that we were making a grave mistake. We were asking 12 children of nursery-school age to live 24 hours a day in an overstimulating atmosphere. Each child not only shared one house mother with 11 other children, but also had a succession of other adults caring for him while his house mother was off duty. The children lived in an atmosphere of boisterousness that any group of 38 children of different ages can create. And so in the belief that no very young children could benefit from this kind of living, the lower age limit was changed to 6 years, leaving the span from 6 to 16

years.

Giving a sound group experience

When we stopped taking children from 2 through 5 years, we began to ex

amine what we needed to do to give the older children a satisfactory living experience. Certain things needed to be done, whether the institution was for short-time shelter or for planned living over a somewhat longer time. We began to move definitely toward giving each child help from group living. We could not let the time he spent at Cylburn be merely a waiting time till a family home was found or till his own parent or parents reestablished a home. We needed to consider what we could give a child each day while he was in the institution.

Not even at the very beginning were the children regimented. At no time has the staff planned to organize the children so as to make their own work lighter. The children have always had freedom to express themselves and freedom to play anywhere in the house or near it. But in our effort to give full freedom we have had the inevitable result of giving more freedom than a child can bear.

At one time a child's day was not wellenough organized to give him a feeling of security. Indeed, as we try to make Cylburn an institution for beneficial group living, one of our major problems seems to be: How to achieve a framework of organization within which a child may have only the kind of freedom that he can use with profit.

Of one thing we are sure that each child must be able to depend on, and should be required to accept, regular hours of eating, sleeping, working, and

playing. And carrying out these necessary everyday activities at regular hours must be made satisfying to him. His group experience in going to bed, for example, is as important as being with other children in a craft class, if

not more so.

We are sure also that he must have a house mother who is as dependable as the clock itself. He must know that she will always be waiting for him when he returns from school and that she will be interested in him and in what he is doing, thinking, and saying.

And his house mother must require of him certain accomplishment. She will provide clothing for him that is in good repair, but she will also require him to care for it. She will require him to come. to meals on time, but first she will be responsible for making mealtime a pleasant social experience. (It is taken for granted that the food will be good and will be attractively served.)

Any effort to plan for children living in a group should attempt to achieve a balance between time for work, time for play that is planned and supervised, and time when they may do nothing if they choose.

Certainly an appropriate balance has been hard to achieve at Cylburn. How much work should be required of a child so that he gains a sense of responsibility for himself as a member of a groupindeed, as a member of society? When does the amount of work go beyond what a child needs and become based on the need of the institution for his service? How much should a child be required to

tion to clothing, food, and living quarters? These necessities of everyday living become the foundation of either helpful or harmful group experiences.

But over and above what children should do for themselves and for the group, they should take part in other satisfying activities. Real planning on the part of the staff is necessary to meet this need. Here again a balance should be achieved-this time between physically active outdoor and indoor play and quiet, thoughtful recreation. Children should have enough stimulation to be satisfying, yet not enough to create tense excitement. A balance in play must be worked out, as well as a balance in all the other factors that go to make up a child's happy day.

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Living at Cylburn is an experience in which we of the Children's Division hope that each child will gain something of what he has lost in his unfortunate experiences before he came to the institution. Toward this primary purpose, a child may have to learn to trust adults; to live and play with other children; and to respect and believe in himself. Therefore in his life at Cylburn contact with the larger community is very important. And so he goes to public school, to Sunday school, to the movies, and to other places where children gather. He takes part in community activities with the children in his school and Sunday school. It is very important that while a child is living at Cylburn he should gain a sense of being like other children and of "belonging," just as they do.

Application and selection

The change in assigning children to Cylburn shows most clearly the metamorphosis of Cylburn from a shelter home to a group home.

When Cylburn opened, the Children's Division of the Department of Public Welfare had no application department. Children were committed. to the agency by the court and often had to be placed that very day. Any child committed was likely to be sent directly to Cylburn if there was a vacancy.

Now all applications for placement in Cylburn are received in the application department of the Children's Division. The workers in that department deal with parents only, not with children. They study with parents not the specific question of whether a child should enter Cylburn but the whole problem of separation from him

whether it is best to have the child committed to the Department of Public Welfare by the circuit court for placement. When a parent and the agency have reached a joint decision that placement seems to be the best solution for parent and child, the case is referred to the department of temporary care. The district supervisor and the casework supervisor of this department determine with the parent whether the child is to be placed in a temporary foster-family home or at Cylburn. Every effort is made to place only those

children at Cylburn who can profit by living for a while in a group.

How the children change

It is surprising to us that in spite of home, of our blunders, of our shortage our inexperience in running a children's of workers and the frequent staff changes, and of our lack of program, most of the children have gained someliving there. Through the help of a thing substantial for themselves from living there. Through the help of a children have changed from belligerent case worker and the institution's staff, children have changed from belligerent street-urchins into children acceptable. for placement in a foster-family home. Children have learned to be children, to get satisfaction from playing children's games with other children of their own age instead of sex activities and begging in taverns.

Our task ahead

A few children have found no satisfaction in the group life of Cylburn. This is partly because we did not provide what they needed and partly because they had deep-seated emotional difficulties requiring treatment, possibly in a psychiatric hospital.

We know that we have given no child enough, but now our staff is better qual

ified for the work, and more stable, we hope that we can begin to refine our day-to-day process.

We are beginning to be more thoughtful and responsible about the way a child is prepared for coming to Cylburn. the way he is received, and the way he leaves.

We are being more responsible about each child's part in the day-to-day living at Cylburn. He is having more choice in his clothing and more responsibility for caring for it. We are hoping to plan for his taking part in selfgovernment, being mindful of his limitations. We are starting to keep for each child a record of his living at Cylburn; heretofore there has been only the case worker's record of the child, kept for the Division's use.

This group living is offered as part of the foster-care program of the Children's Division of the Baltimore Department of Public Welfare, in addition to care in foster-family homes. We of the staff of the Children's Division feel that we are now on the brink of being able to give a stable, beneficial background for living to those children committed to the Division's care who need and can use with profit a short-time group experience.

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he city of Memphis, attempting to t one aspect of its obligation to its 11 handicapped citizens whose par

are unable to arrange for proper ntion from private physicians, has en steps to solve the problem of rheuic fever in children, as part of a ader community plan for child lth, in which many public and rate agencies are sharing.

'he rheumatic-fever problem that the is attacking is the disease as it ocs in children under 13 years of age o are residents of Memphis and ShelCounty, who are not under care of a vate physician, and who attend the -patient department of the John ston Hospital (the city hospital) or admitted to the hospital itself. Rheumatic fever is by no means a rare dition in the South (Memphis is no eption to the rule), though the dise does not strike so frequently as it es in colder climates. Among the ildren we are considering, about 2 perit either have the disease or are suscted of having it. For example, in e past 5 years 200 children were seen the clinic or the hospital who were agnosed either definitely or tentavely as having the disease.

Despite the frequency with which eumatic fever occurs in the children of

the city, and the severity with which it strikes, no organized attack on the problem was made until 1947, when a special rheumatic-fever committee was established as a subsidiary of the health steering committee of the community

council.

The rheumatic-fever committee consists of physicians from the University of Tennessee, others in private practice, social workers, medical-social personnel, public-health representatives, and per

sons representing other civic groups. Through the efforts of this committee a children's heart clinic was organized.

The first group to come under the surveillance of the new children's heart clinic was the backlog of 200 children who had been suspected of having rheumatic fever.

Intensive efforts were made by the social-service department of the John Gaston Hospital and the junior department of the Nineteenth Century Club (a woman's club specially interested in children's health) to locate and bring these children back for study. Many had moved and could not be located, but the majority were found and their cases reviewed.

In many instances, it was clear on further study that a diagnosis of rheumatic fever was not tenable, so that the total number of children in whom the diagnosis was substantiated fell considerably short of 200. Nevertheless, there are more children with the disease than one likes to think of and they constitute a sizable problem.

Owing to the efforts of the public health department, a drive has been going on through the visiting nurses' group to bring to the new clinic all children suspected of heart disease. This has brought to light many children with congenital heart disease, some of whom can be helped by surgery.

As was to be expected, many children with functional heart murmurs have been weeded out from the group with organic disease of the heart.

Many diseases may simulate rheumatic fever. One such disease is sicklecell anemia, which is prevalent in Memphis.

Serious difficulties found

The problem of rheumatic fever in Memphis children has been approached from four angles:

1. Diagnosis, which implies proper facilities and personnel for this purpose. 2. Hospitalization facilities for the acute or active stage of the disease.

3. Convalescent facilities for the subacute stage.

4. Follow-up supervision of patients. In all four of these major aspects of management of rheumatic fever serious deficiencies were encountered. Facilities for diagnosis needed improvement-not only better equipment but also more careful medical supervision. Hospitalization facilities for children in the acute or active stage of the disease process were none too good. Convalescent services were lacking, as they are now. Follow-up supervision of the patients was not being carried out.

Typically a child with rheumatic fever had been seen in the out-patient department or admitting room of the hospital, was hospitalized during the acute stage in crowded surroundings, sent home as soon as the immediate condition permitted, and not followed in the home. Subsequent medical examinations, with few exceptions, had been given him only if new symptoms arose, or if former ones returned.

The following steps have been taken to improve conditions with regard to rheumatic fever:

In the new children's heart clinic, not only children with rheumatic fever but. also those with congenital and other types of heart disease now receive special supervision. Furthermore, any child suspected of having heart disease

is sent to this clinic to determine the presence or absence of significant heart involvement.

At the present time, the clinic meets every other week, but the number of children who are being seen is increasing so rapidly that it will soon be necessary for it to meet every week.

Space for the clinic activities has been acquired in the out-patient department, adjoining the hospital. There are waiting rooms for these children separate from the general clinic waiting room. This decreases the opportunity for crossinfection.

The medical personnel of the children's heart clinic consists of three to four pediatricians who are members of the staff of the university, and six pediatric residents. Two nurses assist with the records and in the management of the patients.

Volunteer workers assist as clerks. In addition, they help the hospital socialservice department to contact the patients for clinic appointments, and, when the weather is inclement, transport the children to and from the clinic. This latter service is invaluable, considering the dangers rheumatic patients face from recurring attacks of sore throat.

The junior department of the Nineteenth Century Club has adopted, as its permanent project, the field of heart disease in children. These women learned of the need for better X-ray learned of the need for better X-ray diagnostic facilities, which would enable children to obtain an improved and a more easily available service. As a consequence, the organization gave approximately $8,000 to the city of Memphis to equip a special cardiac diagnostic laboratory, which is chiefly an X-ray room. Through the kindness of an X-ray equipment company a very fine machine was obtained at a marked reduction. The new room, worth about $12,000, is a part of the suite of rooms of the X-ray department of the John Gaston Hospital.

A step forward

With the new X-ray facilities children can be handled as a special group, appointments for examinations are readily filled, delays are at a minimum, and children can be seen without having to wait in the general waiting room,

where they would be exposed to the hazard of cross-infection. In this new room children who have been singled out for fluoroscopy and X-ray films in the clinic are examined at the end of the clinic session. A bronze plaque in the shape of a heart is on the door of the room, bearing the words: "That the Hearts of Children May Be Made Glad Again." The problem of obtaining adequate X-ray facilities has been solved.

The same club group also gave $500 for an electrocardiograph machine for the children's heart clinic. Previously electrocardiograms were difficult to obtain because of the long list of patients waiting for this service. Now the tracings are taken after the clinic sessions, and the machine is also available at other times in the Children's Hospital.

Laboratory facilities for serology, blood counts, urinalyses, sedimentation rates, and so forth, are quite adequate and offer no problem.

Children with rheumatic fever in the active stage are hospitalized in the Children's Hospital.

New children's hospital needed

Every effort is made to isolate these patients from children with acute infections, and there have been surprisingly few cross-infections to rheumatic patients. Still, when the hospital is crowded, the rheumatic-fever patients are not shielded from the possibility of cross-infection as much as would be desirable. No solution to the problem is seen until a new children's hospital is obtained.

Increase in the number of pediatric residents after the war has resulted in

much closer supervision of all children in the hospital, and has meant that there have been very few delays in getting patients of all sorts discharged as soon as their conditions permitted. Previ ously, a small, overworked staff was unable to cover the cases so completely, and delays occurred which led to overcrowding of the wards. The wards are much less crowded now, and, therefore, the rheumatic-fever patients have more space and better protection.

The crux of the problem of rheumatic fever in Memphis and Shelby County is the lack of facilities for convalescent care. There is no need to dwell on the importance of such facilities, for it is widely recognized that no successful

maintenance of the home itself, but also the salaries of a cook, a maid, full-time nurses, a full-time medical-social worknurses, a full-time medical-social worker, and a recreation worker. A teacher er, and a recreation worker. A teacher could be supplied by the city. Medical supervision would be by the pediatric department of the University of Tendepartment of the University of Tennessee. A senior medical student or a pediatric resident would live in the convalescent home in order that the children would have medical attention available at all times. Staff members of the pediatric department would be of the pediatric department would be assigned to the convalescent-home service.

No attempts have been made to organize foster-home care for convalescent children, but such homes are probably going to be required in the future even when a convalescent home is available. when a convalescent home is available.

At a meeting of the rheumatic-fever committee it was agreed that efforts should be made to obtain the consultation services of representatives of the Children's Bureau in planning a rheuChildren's Bureau in planning a rheumatic-fever program, especially with regard to facilities for convalescent care. It was thought best, however, to wait

until local efforts could take care of the obvious fundamental steps in improving the clinic's service before asking for consultation. Meanwhile the Children's Bureau has been kept advised of the rheumatic-fever problem in Memphis and the steps that have been taken to solve it, and consultants from the Bureau are planning to come to Memphis in the near future.

It is hoped that the Memphis program will become the start of a State rheumatic-fever program, with special funds for this purpose under the Social Security Act; such programs are now being carried out in about half the States. These special funds are appropriated for grants-in-aid to States for services to crippled children. The services are administered by official State agencies, and the Children's Bureau of the Federal Security Agency administers the grants-in-aid.

The problems of the education and rehabilitation of children with rheumatic fever, of helping them to prepare to gain a livelihood, are also to be met. But these needs must await the more fundamental one of proper medical care, which should come first, and which is still not adequate.

In the city's efforts to attack its rheumatic-fever problem, as with its other child-health problems, the health steering committee of the community council, the College of Medicine of the University of Tennessee, the Memphis and Shelby County Public Health Department, and private agencies have all shared in one way or another in planning to give the chronically handicapped child his chance for recovery, or at least, improvement.

Particularly valuable have been the contributions of private organizations, especially the junior department of the Nineteenth Century Club, the Junior League, Le Bonheur, Les Passes, the Council of Jewish Women, and the Society for Crippled Children and Disabled Adults.

One of the finest things that comes. out of such joint participation in health projects by various groups is the tradition of service which is established and the increasing tendency of additional organizations to make contributions in service and funds for new projects.

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