434

WESSEL-PAROXYSMAL FUSSING

9. Rotch, T. M.: quoted in Shannon, W. R.: Demonstration of food proteins in human breast milk by anaphylactic experiments on guinea pigs. Am. J. Dis. Child., 22:225-7, 1921.

10. Shannon, W. R.: Colic in breast-fed infants as a result of sensitization to foods in the mother's dietary. Arch. Pediat., 38:756-61, 1921.

11. Jeans, P. and Marriot, W. McK.: Infant Nutrition. Philadelphia, C. V. Mosby Co., 1947.

12. Todd, T. W.: The significance of developmental growth studies in evaluation of clinical allergy. J. Allergy, 9:234-40, 1938.

13. White, P. J.: The relation between colic and eczema in early infancy. Am. J. Dis. Child., 38:935-42, 1929.

14. White, P. J.: Infantile colic or gastroenterospasm. M. Clin. North America, 20:511-25, 1936.

15. Rubin, M.: Allergic intestinal bleeding. Am. J. M. Sc. 200:384-90, 1940.

16. Rosenau, M. J., and Anderson, J. F.: A study of the cause of sudden death following the injection of horse serum: Hereditary transmission of the susceptibility in guinea pigs. Bull. Hyg. Laboratory, U. S. Public Health Service, 29:73, 1906.

17. Ratner, B., Jackson, H., Gruehl, Helen: Active and passive protein sensitization in utero. Proc. Soc. Exper. Biol. & Med., 23:327-330, 1926.

18. Ratner, B.: A possible causal factor of food allergy in certain infants. Am. J. Dis. Child., 36:267-88, 1928.

19. Bain, Kathryn, and Smith, F. S.: Enteral absorption of the antigen and the apparent failure of antigen secretion in human milk. J. Allergy, 2:282-4, 1931.

20. Donnelly, H. H.: The question of the elimination of foreign protein in woman's milk. J. Immunol., 19:15-40, 1930.

21. Brackett, A. S.: Enteric colic. Yale J. Biol. & Med., 20:555-65, 1948.

22. Spock, B.: Etiological factors in hypertrophic pyloric stenosis and infantile colic. Psychosom. Med., 6:162-65, 1944.

23. Anderson, J. A.: Minor nutritional and digestive disorders of the artificially fed infant. In Brennemann's Practice of Pediatrics, Vol. I. Hagerstown, Md., W. F. Prior Co., 1947, Ch. 27.

24. Jackson, Edith B. and Klatskin, Ethelyn H.: Rooming-In Research Project. Development of methodology of parent-child relationship study in a clinical

setting. In The Psychoanalytic Study of the Child, Vol. V. New York, International Universities Press, Inc., 1950, [236-274.]

25. Kleitman, Nathaniel: Personal communication.

26. Glaser, J.: Office management of the allergic child. Allergy in Relation to Pediatrics, Official publication of American College of Allergists, St. Paul and Minneapolis, Bruce Pub. Co., 1951, Ch. 16.

SPANISH ABSTRACT

Irritabilidad Paroxística de la Infancia, en Ocasiones llamada Cólico

Con frecuencia se observa en lactantes pequeños un padecimiento llamado en formas diversas, caracterizado por paroxismos inexplicables de irritabilidad, excitabilidad, llanto, quejido o grito intenso; así, por ejemplo, se han empleado los términos de excitabilidad paroxística, llanto irritable o convulsivo, cólico infantil, dispepsia transitoria del lactante, etc.; hay distensión abdominal, el niño parecetener hambre y sin embargo no se calma con el biberón, los paroxismos son irregulares en aparición y duración, generalmente por la tarde y al anochecer y persisten durante las primeras semanas de la vida. El problema se ha enfocado en la literatura universal desde los siguientes cuatro puntos etiológicos: hipertonía congénita, alergia, inmadurez de las vías digestivas y por último transmisión al niño de la tensión familiar. El concepto de hipertonía congénita presupone un lactante con desequilibrio congénito del sistema nervioso autónomo, debido al cual los más pequeños estímulos, generalmente sin posibilidad de excitación en la mayoría de los niños, provocan en él gran excitabilidad y molestia; se recomienda una terapéutica a base de atropina y fenobarbital. Su relación a un fondo alérgico también ha sido citado por varios autores durante muchos años; se manifiesta principalmente por cólicos y diarrea, seguido en épocas posteriores de eczema y urticaria; se culpa preferentemente a los proteínas, tanto de la leche materna como de alimentos artificiales. El tercer enfoque ha sido a través de una inmadurez fisiológica del tracto intestinal asociada a actividad peristáltica anormal, del que resulta meteorismo exagerado, incurvamiento y hasta obstrucción temporal de las asas intestinales; de aquí el alivio ocasional que se observa en estos niños con los enemas. El

NURSES ARE TALKING ABOUT
THE SIXTH AMERICAN CONGRESS

by Ann Kirchner, R.N.*

Chicago Lying-In Hospital, Chicago, Illinois

NO ONE would have attributed the success of the Sixth American Congress on Obstetrics and Gynecology to the propitious choice of the date, December thirteenth, just two weeks before Christmas, time for shopping and gift wrapping, time to conserve funds for Christmas purchases and holiday travel. Although this was the first time the Congress had ever been held in Chicago, one would not have said that the city would be the best place to be in winter; the windy city, with its reputation for sharp winds fresh off Lake Michigan. Nevertheless, about thirty-five hundred professional people, doctors, nurses, public health and hospital administrators, nutritionists, who form the organizational and individual membership of the American Committee on Maternal Welfare convened to participate in the deliberations sponsored by the American Committee on Maternal Welfare and its distinguished offspring, the American Academy of Obstetrics and Gynecology, which had chosen to make this their annual meeting.

As though to confer a blessing on this first Chicago meeting, Dame Nature remained, calm and the weather was mild until the very last day when snow flurries reminded the Congress goers that this was Yuletide and snow was a traditional part of the Christmas decorations. The gaily decked State Street with its alluring shop windows added to the gay and enthusiastic spirit which seemed to pervade throughout the sessions. The giant Christmas tree in the Palmer House Lobby made a convenient meeting point and the fact that this was the holiday season seemed to add to the bustling conviviality of this multiprofessional group. If there was any doubt about the value and the satisfaction to be derived from a meet-

ing which affords channels of communication between professional groups who share a common interest in the childbearing woman and her newborn infant, with all the medical, physiological, emotional, sociological and nursing problems, this meeting should serve to forever dispel it. There is a stimulating quality about an interdisciplinary meeting which is lacking in other types of deliberations. It is more sociable and much more stimulating.

Not the least important of the values to be derived from attending a national meeting lies in the opportunity it affords to greet your friends and colleagues and to rub elbows with the famous. In this kind of meeting this opportunity is manifold. The Who's Who of the effective Congress program might have served as a Who's Who in the specialized fields of obstetrics and gynecology, in medicine, nursing, public health and hospital administration. Many nurses had an opportunity to reminiscent with doctors who have worked and studied with them at one or another of the famous halls of learning, some of these halls being the hospital corridors. One of the nurses who served at the professional host and hostess table remarked at the happy sociability of the groups as the halls buzzed with conversation between meetings, on elevators and wherever the Congress members met. The conversations between meetings generally centered around the content of the last meeting or round table. There was little griping even when the elevators were unable to handle the sudden rush as each meeting closed. There was a sort of jovial kind of growling about it. Everyone seemed to be in agreement about the expert management of the whole program from the advance publicity as early as April when the tentative program was published in the *Bulletin of Maternal Welfare* to the mailing of the reservation

*Director of Nurses: Secretary of The American Committee on Maternal Welfare.

THE BULLETIN OF MATERNAL WELFARE

and physicians that the infants needed to be protected against the possibility of contagion from mothers on the ward, particularly in those days against scarlet fever and diphtheria; "the physical welfare of the infants demanded nurseries wherein they could be kept separate from the mothers". Nutritional studies had demonstrated that babies could thrive on cow's milk mixtures and could, accordingly, be fed by nurses in place of the mothers.

## Control of Morbidity and Mortality Emphasized

Too much emphasis cannot be placed, in my opinion, on the mobilizing effect of the rapidly advancing knowledge in bacteriological control of disease and nutritional caloric measurements on the transfer of maternity care from home to hospital and the consequent development of separate nursery care of infants during the first part of this century. World War I necessitated the immediate utilization of all available knowledge about control and prevention of disease in large scale application among the armed forces, and this facilitated thereafter the diffusion of its public health application in civilian communities throughout the country. (Similarly, World War II has served to focus on advances in psychiatry and the possibility of prevention in this field.) Physicians began to feel greater security for the welfare of their maternity patients in the regulated hospital environment. As a result, the monthly nurse faded out of the picture, midwifery became mostly limited to rural sections and put under public health control, and pediatricians in teaching hospitals began to assume responsibility for the child's care from the moment of its birth.

A chronicle of the maternity care shift from home to hospital was informally outlined for me by old inhabitants of my home town as follows: Up to 1915 doctors did not suggest the hospitals for mothers who had previously had "uncomplicated and painless childbearing". But about that time twilight sleep began to be talked about; this may have directed the interest of some mothers to hospital maternity care and also may account for the willingness of doctors to recommend it. Anyway, by 1920 if a mother wanted to have her baby at home, she had to insist on her right for this. Ten years later, mothers all over the country, especially urban ones, found that insistence was no longer of any avail, that they had no privilege of choice, that it was the doctor's right to insist on hospital deliveries.

The doctor's right to insist was based

on the evidence that morbidity and mortality rates were decreasing as the number of hospital confinements, with separate care of the infants, increased. It naturally followed that home deliveries by the family doctor faded out of the picture, and the home delivery service of most teaching hospitals was gradually starved out of existence. Hospital methodology with its aura of sickness and surgery thus came to dominate and transform maternity care during the 1920's and 1930's and established itself quickly as the American tradition. By 1950 nine out of ten babies were delivered in a hospital.

In England, the transition from home to hospital deliveries proceeded at a slower pace, and is now meeting reversal. About half of the English babies are born at home and the present trend is toward increasing the number of home deliveries. According to a recent professional visitor from London, the government has enacted a measure for increasing the subsidy for English babies born at home to families of a certain socioeconomic group. Whereas the respectable Boston families of 1873 found it financially advantageous for the mother to have her confinement in the hospital, the increased English subsidy turns the financial advantage toward home deliveries.

To repeat, the new hospital maternity care of the 1910's and 1920's es-

tablished itself during the 1930's as traditional in this country by virtue of its apparent association with prevention of sickness and saving of lives. From this vital standpoint it resists modifications which are suggested to support the less commanding claims of the patient's happiness, peace of mind, reduction of anxiety, and promotion of confidence through appropriate education. These claims are made with regard to the neglected fact that pregnancy, labor, and delivery for the majority of mothers are all part of a normal, nonpathological process of growth and change.

## Recognition of Family-Centered Care Sought

An impetus for modification of hospital maternity care first made itself felt during the late 1930's and early 1940's with particular reference to the postnatal period. It appeared as a protest against the impersonal, inappropriate, and inconsiderate management of mothers, newborn infants, and fathers under the "hospital-centered" system. The initial protests came alike from professionally trained mothers, their sympathetic pediatricians, educational psychologists, child psychiatrists, and a few inter-disciplinary groups which included also obstetricians, nurses, anthropologists, and social workers (5,6,7,8).

The mothers were revolting, first

## Wet and Wonderful

Students at the Frances Payne Bolton School of Nursing have found that bathing babies on the floor is fun—and the babies love it too. During the past three years this method of bathing babies, who are able to sit up in a tub on the floor, has been used successfully. The babies seem to know about a tub and they enjoy splashing and playing in the water. There have been no bath-time accidents since this practice was started. Phyllis Mertz, assist-

ant instructor of pediatric nursing, enjoys watching Maureen Dean and the baby decide who will wield the wash cloth. (Photo from Frances Payne Bolton School of Nursing, Western Reserve University, Cleveland, Ohio)

Johnny's "Problem Nose"

The child with a "problem nose" may be defined as one with chronic nasal symptoms persisting longer than three months according to a study discussed by Sam H. Sanders, M.D., in the April 2, 1955 issue of the J.A.M.A. (pp. 1205-1208). Five thousand youngsters who were hospitalized for removal of tonsils and adenoids were grouped under four types: (1) nasal, with constant nasal catarrh, general good health, and occasional sore throat, or snoring; (2) general, with occasional vague headaches, fever often of unknown origin, mental dullness between attacks, and a muddy pasty complexion; (3)

pulmonary, with recurrent bronchitis, tuberculous aspects, intractable cough, and lowering of general health; and (4) referred, with disease in organs distant from the infection, such as rheumatism or nephritis. Types 2 and 4 are of infectious origin and types 1 and 3 allergic, infectious, or both. There may be many more symptoms.

Recalling a previous study in which the similarity of symptoms in the pre-rheumatic child and the child with chronic sinusitis were noted, Dr. Sanders calls for careful examination and observation of symptoms to facilitate differential diagnosis.

and foremost, against the failure of the hospital routine to help them be good mothers. The routine care of the baby in the nursery, except for feedings, deprived the mothers of the natural satisfaction of looking and watching, of holding and cuddling, of coming to recognize the baby's response to this and that. In some hospitals, as Drs. Clifford and Davison note, non-breast-fed babies were not brought to the mothers at all until the end of the hospital stay. What else can that be called but cruel?

The mothers rebelled against the absolute fixity of the feeding schedule which often bore no relation to the time the baby woke from hunger, or to the fullness of the mother's breast. I do not know just when the 2-hour or 2½-hour interval between daytime feedings was extended to 4 hours. Miss Marie Baurle, former obstetric supervisor at French Hospital in New York City, who helped to organize a rooming-in unit there, told me that she worked at the Boston Lying-in Hospital during 1911 and that at this time the babies were fed every 2½ hours during the day. I have presumed that the decision for a 4-hour schedule included consideration for the nursery staff, as well as for the baby's welfare.

It troubled breast-feeding mothers that nurses and doctors seemed to have no time and little understanding for helping them and their infants adjust to the process of breast feeding, that the tendency of the hospital staff was to discourage breast feeding.

They minded the absence of supervision in learning to take care of the baby while they were still in the hospital—the most appropriate time—and the lack of opportunity to discuss what to expect of themselves and the baby on going home from the hospital. They felt frightened, uncertain, bewildered, and unprepared on going home.

The father was treated like an outsider, with no possibility of feeling close to his baby, and never being told what to expect or how he could help when his wife and baby came home.

Members of the aforementioned disciplines reached similar conclusions and supported the point of view that hospital maternity care was conducive to stress and tended to thwart natural family relationships and feelings of parental responsibility. They called attention to the need for interdepartmental coordination on the advice given to the mother regarding the care of the infant, especially regarding breast-feeding. They expressed concern over the lack of vitality and realism of the wholly intramural training experience for obstetric, pediatric, and nursing staffs under the system of "fractioned" care.

From such psychological and educational considerations grew the idea of bringing normal, healthy hospitalized mothers and newborn infants together under the care of one set of nurses with joint obstetric and pediatric supervision, in a relaxed and cheerful atmosphere. The idea of humanizing hospital maternity care has now been developed as a new trend. The unified care of mother and infant was provided with the name of rooming-in by Drs. Gesell and Ilg in 1942(9); this name took root in the next few years when plans for the joint care of mother and infant were realized with the establishment of rooming-in facilities in Washington, D.C., New Haven, Detroit, and Los Alamos (10,11,12,13).

The initial rooming-in plans were quite simply conceived to bring satisfaction for the family unit into the medically safe hospital situation, and to substitute for the consistent supervision once afforded by the family physician an integrated obstetric,

pediatric, and nursing plan of education for parents in preparation for the birth and the care of the child. Such a simple conception of bringing together the better elements of the old-time home delivery and the traditional hospital delivery may be likened to the youngest daughter's modest wish in the Story of Beauty and the Beast—a wish for just a rose—without expense, which caused well-nigh insurmountable complications.

Because of a fortunate set of circumstances at the Grace-New Haven Community Hospital, cooperative interdepartmental relations, and the support of grants-in-aid, it was possible to put the idea into practice. The rooming-in project was under way only a few months when the training-for-childbirth program was initiated. The latter, like the former, was prompted by proddings from mothers, specifically by a few mothers who had elected rooming-in in advance and who had been enthused by popular accounts of Grantly Dick Read's work or by reading his book, *Childbirth Without Fear* (14,15,16,17).

These mothers felt quite rightly that natural childbirth was a fitting preliminary to rooming-in. They correctly understood the similarity of the basic principles involved—recognition by medical and nursing staffs of the mother's capacity for appropriate action on the basis of her understanding of what is happening or about to happen—in childbirth training, an understanding of successive stages of pregnancy and labor, and of delivery procedures; in child-care training, an understanding of the stages of child development; and in both cases adaptation of the physician's counsel to the particular situation at hand.

There are other subjects which should be fitted into the present historical framework such as the role of the public health nurse in maternity care programs (18), the influence of early ambulation, the effect of the diminishing duration of the lying-in period, and the over-reaction to self-demand. But instead, I want to refer to a confusion about rooming practice which has arisen because of differing motivations for the establishment of rooming-in arrangements.

Shortly after the introduction of rooming-in plans which were based on psychological and educational considerations, the strange paradox of nursery care for newborns was openly discussed. Originated, at least in part, to protect infants against infection, the nursery itself became an increasingly active threat as a center of cross infections, because of overcrowding and shortage of nursing personnel. Chiefs of some maternity and

pediatric services saw in the relatively
small rooming-in unit of two to eight
beds the possibility of avoiding the
nursery threat to newborns, and they
transformed their services into "rou-
tine rooming-in." This was first done
at Jefferson Hospital in Philadelphia
and Duke University Hospital (19,20).
Mothers were frankly recognized as
helpers who attended to the needs of
their babies in default of adequate
nursing personnel. This new develop-
ment, while it was constructive for
the hospital emergency situation,
tended to confuse the thinking about
rooming-in, since the basic ideas of
the initial rooming-in plans were that
rooming-in should be elective, and
that there should be constant avail-
ability of a nurse to meet the mothers'
immediate needs and questions.

Early ambulation makes it easier
to leave the mother to her own re-
sources with the baby. The short
hospital stay increases the nurse's rou-
tine duties incident to admissions and
discharges and decreases rest and in-
struction for the mother. These fac-
tors, together with a high birth rate
and a low quota of nurses, are work-
ing against the humanistic trend of
providing satisfaction as well as safety

in maternity experience, and they call
for careful integration of antepartum
and postpartum maternity care pro-
grams.

REFERENCES

1. JACKSON, EDITH B. The old way is new: rooming-in. *Vassar Alumnae Mag.*, Dec. 1948.

2. LINDSAY, ELIZARETH A. The old way is new: natural childbirth plus rooming-in. *Vassar Alumnae Mag.*, Dec. 1948.

3. CLIFFORD STEWART H., and DAVISON, WILBUR C. The origin of obstetric nurseries. J. Pediat. 44:205-212, Feb. 1954.

4. HERRICK, CHRISTINE TERHUNE. Cradle and Nursery. 1889.

5. SIMSARIAN, FRANCES P., and TAYLOR, ROBERTA W. Two mothers revolt. *Child Study* 22:45-52, Winter 1944-45.

6. Report of the Conference of the Committee on Infancy and Early Childhood: feeding of the newborn. *Psychosom. Med.* 7:169-173, May 1945.

7. WITMER, HELEN L., ed. Pediatrics and the Emotional Needs of the Child; as discussed by pediatricians and psychiatrists at Hershey, Pa., March 6-8, 1947. New York, Commonwealth Fund, 1948.

8. DOWNEY, RICHARD. CONFERENCE ON PROBLEMS OF INFANCY AND CHILDHOOD. *Transactions of the First-Fourth, and Sixth Conferences, New York, 1947-1952*, edited by Milton J. E. Senn. New York, Josiah Macy, Jr. Foundation, 1947-1953, 4 vols.

9. GESELL, ARNOLD, and ILG, FRANCES L. Infant and Child in the Culture of Today. New York, Harper and Brothers, 1943.

10. McLENDON, PRESTON A., and PARKS, JOHN. Nurseries designed for modern mater-

nity. *Mod. Hosp.* 65:46.

11. JACKSON, EDITH B., and rooming-in unit for infants and their mothers. *J. Pediat.* 1:28-43, Jan. 1948.

12. MOLONEY, JOHN C., and OTHERS. born: his family and the medical care of the mother. *Mod. Hosp.* 67:43-46, Dec. 1948.

13. BARNETT, HENRY B. Note on expectant androoming-in arrangement newborn infants in a small hospital. *Pediat.* 31:49-53, July 1947.

14. JACKSON, EDITH B. Pediatric and psychiatric aspects of the Yale rooming-in project. *Connecticut Med.* J. 14:616-621, July 1950.

15. THOMS, HERBERT. Training for Childbirth; a Program of Natural Childbirth with Rooming-In. New York, McGraw-Hill Book Co., 1950.

16. GOODRICH, FREDERICK W. *Natural Childbirth*. New York, Prentice-Hall, 1950.

17. READ, GRANTLY DICK. Childbirth without Fear. New York, Harper and Brothers, 1944.

18. HARRIS, ANTOINETTE. A public health nurse in rooming-in. *Pub. Health Nursing* 44:580-584, Oct. 1952.

19. MONTGOMERY, THADDEUS L., and OTHERS. Observations on the rooming-in program of baby with mother in ward and private service. *Am. J. Obst. and Gynec.* 57:176-186, Jan. 1949.

20. MCBRYDE, ANGUS, and DAVISON, WILBUR T. C. Compulsory rooming-in at Duke Hospital. *A.M.A. Am. J. Dis. Child.* 80:879-881, Nov. 1950.

[This article is based on a paper presented before the Institute on Child Growth and Development, at Harvard University School of Public Health, Department of Maternal and Child Health on June 10, 1954.]

["New Techniques Of\nMaternity Homes\nIn U.S.A. Described", "\"Rooming-in,\" the name given to the system whereby mother and baby are cared for as a unit in maternity hospitals—instead of being separated for most of the time—was coming into favour in American hospitals, Professor M. P. Burnham, told a large attendance of parents and nurses in Wellington last night.", "Professor Burnham, Associate Professor of Education in the New Haven State Teachers' College, U.S.A., has been unofficially connected with the New Haven Hospital and Yale University School of Medicine, from which much of the pioneering work in trained childbirth and rooming-in in the United States has developed.", "Infant and maternal mortality had dropped spectacularly in the United States with the introduction of maternity hospital care, said Professor Burnham. A highly regimented hospital system, however, meant that babies were often left to cry in central nurseries, while their mothers were anxious and had little opportunity to become acquainted with them.", "The nurse who helped and supported the mother with demand-feeding and general care of the baby was a key figure in rooming-in.", "\"Nurses, like parents, have been thrilled at the new atmosphere,\" Professor Burnham, said.", "'ROOMING-IN'\nTECHNIQUE\nON MATERNITY", "Mothers and their babies should not be separated in maternity hospitals. This conviction has been reached by experts in maternal and infant welfare as well as in mental hygiene. Professor M. P. Burnham told a well-attended meeting of the Wellington Parents' Centre and the Wellington Nursery Play Centres' Association last night.", "Professor Burnham, who is associate professor of education in the New Haven State Teachers' College, U.S.A., described the trend in American hospitals towards \"rooming-in\"—the system whereby mother and baby were cared for as a unit, with the father able to take part in the baby's care and the nurse a key figure in early parent education.", "There was no objective proof that rooming-in was better for babies, though many people believed that close contact with the mother was most important, said Professor Burnham.", "There was proof, however, that rooming-in mothers were much more confident in the subsequent handling of their babies, and a happy, confident mother benefited the baby.", "Professor Burnham described a four-bed, four-crib rooming-in unit at the New Haven Hospital. A flexible routine, with the nurse helping the mother to feed the baby \"on demand,\" gave parents much more chance to know and understand their babies' individual needs and rhythms in the important early days.", "Parents and nurses who had participated in rooming-in were delighted with the new atmosphere, Professor Burnham said.", "THE BOSTON DAILY GLOBE—THURSDAY, OCTOBER 20, 1955", "Baby's Living-in Favored", "Old Idea of Childbirth Care\nHailed at Nurses' Conclave", "BY FRANCES BURNS", "The most modern theory on child-birth care is similar to that in grandmother's day, a woman, a woman, a woman, a woman, a woman, a

CONV 1955

TUESDAY, OCTOBER 18

8:00 a.m. **REGISTRATION**
EAST LOBBY
Members must show 1955 registration card
See information on registration

9:00 a.m. **OPENING BUSINESS MEETING**
(3rd annual meeting)
PRINCESS BALLROOM
Presiding: MARIE FARRELL, President

10:30 a.m. **General Session**
REGENCY ROOM
Presiding: MYRTLE FORD, associate professor,
Boston University School of Nursing

A. LET'S WORK TOGETHER, a play on teamwork
(Adapted from playlet by Mrs. Henry Blaustein and Miss Rita Doyon, Montreal, Canada)

Participants:
Basic Collegiate Students—Boston University
School of Nursing

Chairman of Planning Committee:
ELIZABETH ERNST, assistant professor, Boston
University School of Nursing

B. WHAT AFFECTS THE QUALITY OF
OUR CARE?
Speaker: MARGUERITE KAKOSH, Director,
Nursing Studies and Consultant in
Nursing, Veteran's Administration

1:00 p.m. **LUNCHEON MEETING**
(REGENCY ROOM)
(see reservation)

Presiding: MARGARET VARLEY, assistant professor, Harvard School of Public Health

YOU KNOW IT, I KNOW IT, BUT DOES THE
PATIENT KNOW IT?

Speaker: MARGARET ARNSTEIN, Chief, Division of Nursing Resources, Department of Health, Education and Welfare, USPHS

2:30 p.m. **SPECIAL INTEREST SESSIONS**
REGENCY ROOM

A. SETTING OUR SIGHTS
A discussion of problems and standards of nursing education in Massachusetts

Presiding: SISTER WINIFRED, Director, Catherine Labouré School of Nursing

Speaker: RITA P. KELLEHER, Chairman, Board of Registration in Nursing

Panel Participants:
ROBERT COCHRANE, M.D., Secretary, Board of Registration in Medicine

ELEANOR FLEMING, Supervisor of Schools of Nursing

IMELDA GAUTHIER, Registrar, Board of Registration in Nursing

Other speaker to be announced

12:30 p.m. **LUNCHEON MEETING**
REGENCY ROOM

Presiding: MRS. SYLVIA BRUSSEL, Associate Director, Nursing Service, Beth Israel Hospital, Boston, Mass.

Speaker to be announced

2:00 p.m. **SPECIAL INTEREST SESSIONS**
REGENCY ROOM

A. EXPERIMENTATION IN
CLINICAL NURSING

Presiding: MARY A. MAHER, Director, School of Nursing, University of Massachusetts

Participants:
DOROTHY SMITH, Assistant Director in Nursing, Hartford Hospital School of Nursing

JULIE GUAY, Instructor in Surgical Nursing, Hartford Hospital School of Nursing

DEBORAH PRATT, Instructor in Surgical Nursing, Hartford Hospital School of Nursing

VERONICA LYONS, Associate Dean, Cornell University — New York Hospital School of Nursing

RACHEL LONG, Instructor in Nutrition, New England Baptist Hospital School of Nursing

PHILOMENA SERPICO, Instructor in Nutrition, New England Baptist School of Nursing

JESSIE GREEN, Instructor in Nutrition, Boston University School of Nursing

RACHEL JONES, Instructor in Nutrition, Massachusetts General Hospital School of Nursing

B. THE EXPERIMENTAL PRINCESS BALLROOM

SEMINAR IN INTERPERSONAL
RELATIONS

Presiding: ANN LYONS TWOMEY, Mental Health Consultant, Visiting Nurse Association of Boston

Panel:
Moderator: HELEN MANOCK, Assistant Professor, Boston College School of Nursing

Participants:
Students from Boston College and Newton-Wellesley Schools of Nursing

RAM TO THE MEETINGS

Editor of the Visiting Nurse Service and Child Health Moderator was

NOTES

Organizers:

MYRTICE FULLER, Director, School of
Nursing and Nursing Service, Newton-
Wellesley Hospital

DR. PEARL ROSENBERG, Clinical Psy-
chologist, Human Relations Service,
Wellesley

HELEN MANOCK, Boston College School
of Nursing

C. PLANNING TOGETHER EMPRESS ROOM

Presiding: EDNA LEPPER, Associate Director of Nursing Service, Massachusetts General Hospital

Participants:

CECIL G. SHEPS, M.D., Executive Director,
Beth Israel Hospital

ANNA J. KALMANOWITZ, Director, School
of Nursing and Nursing Service, Beth
Israel Hospital

4:00 p.m. CLOSING BUSINESS
MEETING, MLN

REGENCY ROOM

REGISTRATION FEE

* Registration fee for all members MLN will be $1.00.

* Non-members will be requested to pay a registration fee of $2.00. Members without membership cards will pay a registration fee of $2.00, one dollar of which will be returned on proof of membership.

* Students will be requested to present identification. No fee will be charged.

* Graduate nurses, awaiting registration numbers, will be requested to present identification.

* Full-time registered nurse students, non-member registered nurse students, will be required to present identification. Fee 50 cents.

* Psychiatric Aides will be admitted to special interest meeting of Interdivisional Council of Psychiatric Nursing and Mental Health on Tuesday afternoon, October 18, without payment of registration fee.

* Non-member lay persons will be admitted to special lay interest meeting on Wednesday morning, October 19, without payment of registration fee.

* REGISTRATION BADGES WILL BE REQUIRED FOR ADMISSION TO ALL MEETINGS.

THE INFLUENCE OF DEGREE OF FLEXIBILITY IN
MATERNAL CHILD CARE PRACTICES ON EARLY
CHILD BEHAVIOR*

ETHELYN H. KLATSKIN, PH.D.,† EDITH B. JACKSON, M.D.,‡
AND LOUISE C. WILKIN, M.S.S.§

Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut

THE present paper is a report on the analysis of a selected group of cases from the files of the Yale Rooming-In Research Project,¹ a longitudinal study of parent-child relationship focused on observing the effect of certain specific parental child care practices on child behavior. The research program has utilized a team approach to collect data on the developing family unit during the prenatal period, in the hospital during the puerperium, and during the first three years of the child's life. The details of the development of the Project and the methodology of data collection and organization have been reported elsewhere (3).

The study had its inception during a period which marked a cultural shift from rigid to permissive practices in child training. For the previous twenty years, medical trends and Watsonian behaviorism had influenced pediatricians and educators to advocate inflexible techniques in child training (2). Beginning around 1935, increasing familiarity with Freudian analytic tenets and the necessity to deal with an apparently increasing number of behavior problems led a number of child psychiatrists to propose the use of more flexible practices in early child care. This orientation was in large part due to the conviction that many of the then observed problems in early child development were the result of rigid parental child care practices. The ensuing twenty years have witnessed an almost complete shift in popularity from inflexible to flexible practices, both as advocated by specialists in the field (4, 6) and as accepted by the general public (5).

In neither the preceding period of rigidity nor the current period of permissiveness, however, has any body of statistical evidence been presented to substantiate the claims of the proponents of either type of child training. The present research was organized to amass just such a body of data. In general, the Project has been predicated on the hypothesis that a demonstrable relationship can be shown to exist between parental child care

* Presented at the 1954 Annual Meeting.

† Assistant Professor of Psychology (Pediatrics and Child Study Center).

‡ Clinical Professor of Pediatrics and Psychiatry.

§ Research Assistant in Pediatrics (Psychiatric Social Work).

¹ This project was supported by grants-in-aid from 1) Mead Johnson and Company; 2) the George Davis Bivin Foundation; 3) the Field Foundation; and 4) the National Institute of Mental Health, of the National Institutes of Health, Public Health Service.

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FLEXIBILITY IN CHILD CARE AND CHILD BEHAVIOR

practices on the one hand and the child's behavior on the other. Specifically, the hypothesis investigated was that either extreme of rigidity or permissiveness in parental practices would be associated with problem behavior in the child, within the area of the parental deviation.

## SUBJECTS AND PROCEDURE

The subjects of the present study were 50 mothers and infants chosen from the families followed for three years through the research project. Two factors determined selection of this group: the mother's parity and the completeness of the case history. In order not to obscure the initial parent-child interaction, the records of primiparae were chosen for analysis. The first 50 records were then selected which met the requirements of including all of the major research procedures: office visit and psychological examination, social worker's home visit, and parental report by questionnaire, at one, two and three years.

The socioeconomic composition of this subgroup is given in Tables 1 and 2. In defining the occupational groupings, the categories of the United States Census were used. In both tables, students in training were classified according to educational and occupational expectation. In Table 2, the mother was classified according to either previous or present type of employment; actually, only 11 of the 50 mothers studied were working during any period of the three year follow-up.

The tables show that approximately half of the group was composed of families in which both parents had college or advanced degrees, and that in one-third of the group both parents were at some time in professional or managerial positions. There was no representation from the highest or lowest socioeconomic groups. The relationships within the sample can best be described in terms of Hollingshead's socioeconomic grouping for the New Haven area (1); Class II (professional and managerial), 19; Class III (white collar and skilled workers), 19; and Class IV (semiskilled and unskilled workers), 12.

A rating scale technique of analysis was used to reduce the data contained in the fifty case histories to statistically manipulable form.² Independent scales were constructed for rating both parental and child behavior in the areas of feeding, sleeping, toileting, and socialization. Additional scales were constructed for the data on mother's adjustment to the maternal role, and for evidences of emotional disturbance in the child, other than those which might be included in the four behavior areas. Since the data broke logically at the child's first, second, and third birthdays because of the timing of the research procedures, each year was scaled separately.

In scaling the areas of feeding, sleeping, toileting, and socialization, the

ª For details of method of construction of these scales, see (3).

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TABLE 1. PARENTS' EDUCATION*

<table><thead><tr><th rowspan="2"></th><th colspan="4">Mother's Education</th></tr><tr><th>Grammar School</th><th>High School</th><th>College</th><th>Advanced Degree</th></tr></thead><tbody><tr><th rowspan="4">Father's Education</th><th>Grammar School</th><td>3</td><td>1</td><td></td></tr><tr><th>High School</th><td></td><td>16</td><td>6</td></tr><tr><th>College</th><td></td><td></td><td>6</td></tr><tr><th>Advanced Degree</th><td></td><td></td><td>13</td><td>5</td></tr></tbody></table>

* Classified according to attendance at or completion of the given level.

major variable for the mother's behavior was defined as degree of rigidity in handling the child, and for the child's behavior, degree of problem. The scales of maternal behavior ranged from extreme rigidity (point 1) at one end of the scale to extreme permissiveness at the other (point 5), with flexible handling as the mid-point (point 3). The scales of child behavior ranged from severe problem at one end of the scale (point 1) to absence of problem at the other (point 5), with "problem within normal limits" as the mid-point (point 3). Either extreme of the scale of maternal behavior was assumed to represent deviant handling leading to the development of problems in the child, while the mid-point of the maternal behavior scale was assumed to represent optimal handling associated with normal development. The one exception to this assumption occurred in the evaluation of maternal behavior in toileting during the first year. In this instance, any rating below the mid-point of the scale was regarded as rigid and any rating above the mid-point as optimal.

TABLE 2. PARENTS' OCCUPATION

<table><thead><tr><th rowspan="2"></th><th colspan="5">Mother's Occupation*</th></tr><tr><th>Professional-Managerial</th><th>White Collar</th><th>Skilled</th><th>Semi-skilled</th><th>None</th></tr></thead><tbody><tr><th rowspan="4">Father's<br>Occupation†</th><th>Professional-Managerial</th><td>10</td><td>9</td><td></td><td></td></tr><tr><th>White Collar</th><td>2</td><td>9</td><td>1</td><td>2</td></tr><tr><th>Skilled</th><td>1</td><td>2</td><td></td><td>1</td></tr><tr><th>Semiskilled</th><td>1</td><td>2</td><td>1</td><td>2</td></tr><tr><th></th><th>Unskilled</th><td></td><td>2</td><td>2</td><td>2</td></tr></tbody></table>

* Classified according to present or previous occupation.

† Classified according to present occupation or occupational expectation.

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The scale for rating the mother's adjustment to the maternal role ranged from complete rejection at one end, to complete absorption at the other, with "balanced adjustment" as the mid-point. The scale for other evidences of emotional maladjustment in the child ranged from severe and/or numerous problems at one end to absence of problems at the other, with mild and/or infrequent problems as the mid-point.

Two considerations determined the application of the scales to the evaluation of the case records: the necessity to have an independent rating for mother and child; and to have a rating which would be both reliable and valid. To meet these requirements, six raters were used,³ who were assigned in groups of three to either mother or child. Both assignment to a group and to a subject was successively randomized among the six raters. In this way, three independent judgments for each segment of behavior were available for both mother and child, except in those instances where insufficient information was available in the record. A reliable judgment was assumed to be one on which two or more raters agreed, and only these were recorded for subsequent correlation. The assignment of raters to successive groupings provided a measure of the extent to which any given rater consistently deviated from the other two, it being assumed that the ratings were more valid if no significant variability occurred within the group. That is, if no rater was found to deviate consistently from the others, the probability would be increased that all were using the same bases for their judgments. The alternation between rating mother and child was planned to focus the raters on the scales themselves as a reference point, rather than on the consecutive records. No significant differences were found between the raters in either number of times they deviated from the group, or number of times they reported insufficient data.

## RESULTS

The initial step in analysis of the data was to plot the distribution of the consensus judgments for both mother and child for each segment of the four behavior areas. With two exceptions, both in the area of toileting, the ratings tended to assume a normal distribution around the mid-point (3) of the scale. In the area of toileting, when the mothers' ratings were plotted, it was found that at the first year, only 15 mothers fell below the mid-point of the scale, and at the third year, no information was returned by 21 of the group. In these 21 cases, the mothers replied that the child was trained, although according to the scale for the child's behavior, only 11 were rated as being trained. The handling of these data therefore constituted an exception to the type of analysis described below.

Since the various points on the mother's and child's scales did not corre-

³ Nilda Shea, M.N.; Betty Casher, B.A.; Marjorie W. DeGooyer, M.S.; and the authors.

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spond directly to each other (as the mother's scale represented a progression from undesirable rigidity through optimal handling to undesirable over-permissiveness, while the child's scale represented a progression from undesirable to desirable behavior), this fact had to be taken into account in analyzing the relationship between the two. A chi-square rather than cor-relational analysis was therefore planned. The mothers' scales represented a fairly absolute judgment of deviant behavior, since the extremes of over-permissiveness and rigidity for the various areas were defined so as to take into account marked departures from the normal attitude. In each area, approximately half of the group (between 43% and 60%) fell into the op-timal category, while the position of the remaining half varied somewhat according to the behavior area rated. The mothers were therefore initially divided into those obtaining ratings of 1 or 2 (rigid), ratings of 3 (optimal), and ratings of 4 or 5 (overpermissive). The child's scale, however, was found to indicate a more relative degree of disturbance. When the ratings for the various areas were plotted, all tended to assume a normal distribution, but the mode varied slightly for the different years and variables. Thus, the modal score for socialization, first year, was 4.0; for socialization, second year, it fell to 3.5; and for socialization, third year, it was 3.0. In order to maintain a consistent reference point, ratings for the child in each area were therefore dichotomized at the median of the group, dividing the children into those with more or less problem behavior in a given area. Dividing the children's group in this way arbitrarily resulted in a range of incidence of "problem" behavior for the various areas of 33 to 53 per cent. It should be kept in mind throughout the subsequent presentation of results that when "presence of problem behavior" or "absence of problem behavior" is dis-cussed, the child is being assessed relative to his position in the present group of subjects, and not in terms of more absolute standards which might be applied to "problem children" in a child guidance clinic.

The data for maternal attitude toward toileting in the first and third years were treated as follows: at the first year, the mothers were dichotomized into those falling below the mid-point of the scale and those at or above the mid-point. For the third year, in view of the lack of data, the mothers' ratings at two years were correlated with the child's behavior at three years.

Chi-square was then computed for all the relationships, with the exception of first year toileting, on the basis of a six-cell table, trichotomizing the mothers' group into rigid, optimal, and overpermissive, and dichotomizing the group of children into those above and below the median incidence of problem behavior. Of the 12 possible relationships, 7 were found to be significant at or below the .01 level. However, it was apparent that because of the small number of cases, some relationships between deviant maternal behavior and the development of problem behavior in the child were ob-

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TABLE 3. SIGNIFICANT VALUES OF CHI-SQUARE BETWEEN DEVIANT OR OPTIMAL MATERNAL HANDLING AND PRESENCE OR ABSENCE OF PROBLEM BEHAVIOR IN THE CHILD

<table><thead><tr><th rowspan="2">Year</th><th colspan="4">Area</th></tr><tr><th>Feeding</th><th>Sleeping</th><th>Toileting</th><th>Socialization</th></tr></thead><tbody><tr><td>1</td><td>—</td><td>χ²—11.77*<br>p&lt;.001</td><td>χ²—9.91<br>p&lt;.01</td><td>—</td></tr><tr><td>2</td><td>χ²—13.00<br>p&lt;.001</td><td>χ²—8.42<br>p&lt;.01</td><td>χ²—12.74*<br>p&lt;.001</td><td>χ²—7.18*<br>p&lt;.01</td></tr><tr><td>3</td><td>χ²—5.75<br>p&lt;.02</td><td>χ²—15.25*<br>p&lt;.001</td><td>χ²—13.97*<br>p&lt;.001</td><td>χ²—12.58*<br>p&lt;.001</td></tr></tbody></table>

* p < .01 for six-cell table.

scured. The chi-squares were therefore recalculated on the basis of a four-cell table, dichotomizing the mother's handling into optimal and deviant, without regard to direction. The results of these latter calculations are given in Table 3; those values of chi-square significant when computed on the basis of the six-cell tables are also indicated. Because of the number of significance tests calculated in analyzing the data, the criterion for a "significant" relationship was set as probability of occurrence by chance less than twice in a hundred. Consequently, only those relationships significant at or below the .02 level of confidence will be reported here.

The direction of the maternal deviation associated with "problem" behavior in the child is indicated in Table 4. It is apparent from this table that a consistent relationship exists between type of maternal deviation and the behavior area in which this is shown.

Tables 3 and 4 indicate that the relationship between maternal behavior and child behavior tends to be a discrete one, in that the child develops "problems" in response to specific deviations from optimal handling. As a

TABLE 4. DIRECTION OF MATERNAL DEVIATION SIGNIFICANTLY ASSOCIATED WITH PROBLEM BEHAVIOR IN THE CHILD

<table><thead><tr><th rowspan="2">Year</th><th colspan="4">Area</th></tr><tr><th>Feeding</th><th>Sleeping</th><th>Toileting</th><th>Socialization</th></tr></thead><tbody><tr><td>1</td><td></td><td>Overpermissive</td><td></td><td></td></tr><tr><td>2</td><td>Rigid</td><td>Overpermissive</td><td>Both</td><td>Rigid</td></tr><tr><td>3</td><td>Rigid</td><td>Overpermissive</td><td>Both</td><td>Rigid</td></tr></tbody></table>

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further check on this conclusion, interarea relationships were tested to determine whether maternal deviation in one area was associated with problem behavior in the child in a different area. For example, maternal behavior in feeding was related to the child's behavior in sleeping. No significant relationships of this type were found.

The question might still be raised as to whether some over-all factor of adjustment or maladjustment in the child resulted in the presence or absence of problem behavior. The child's ratings on the scale of "Other Evidences of Emotional Maladjustment," which had been designed to assess the child's general emotional stability, were therefore analyzed in relation to his ratings in each of the four areas for the three years. The only relationships found (p <.02) were in the area of socialization, where during the first and third years, children with "problems" in socialization tended to fall below the median of the group in evidencing "emotional maladjustment." Because of the possibility that this relationship might have arisen from use of the same data in rating both areas, the ratings at the third year were checked for such duplication. Of the 307 individual items of behavior listed by the judges as the basis for their ratings of the child's social adjustment in the 50 cases, only 39, or 13 per cent, were repeated as evidence for additional emotional maladjustment.

Finally, major environmental events in the child's life were related to his behavior in the four areas as well as to his rating with respect to the "emotional maladjustment" scale. The factors studied were: intelligence, dividing the children into below average (5 cases), average (30 cases), and above average (15 cases); duration of breast feeding, dividing the group at the median duration (3 months); birth of a sibling (20 cases); nursery school attendance in the third year (16 cases); and severe and/or recurrent illness (10 cases). The only positive relationship found was that between birth of a sibling during the second year and the presence of greater emotional maladjustment ($\chi^2=8.75, p <.01$).

Since it appeared from the foregoing data that the mother's handling of the child was the major variable in influencing his behavior, the next step in data analysis was to investigate what factors might be influencing the maternal attitude. These fell into three general categories—the mother's general emotional stability, as measured by her adjustment to the maternal role; environmental factors current in the home situation; and the mother's social class membership. When the mother's adjustment to the maternal role was related to her behavior toward the child, significant relationships were found in the areas of handling of sleep and socialization. The chi-square values for these, based on dichotomizing the mother's adjustment as deviant or balanced, and her handling of the child as deviant or optimal, are given in Table 5. In the case of sleep, rejection of the maternal role tended to be

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associated with rigid practices in this area, and absorption tended to be associated with overpermissive practices. The most striking relationships, however, were found in the area of socialization. During the first year, of the 16 mothers judged as rejecting of the maternal role, 13 used rigid methods of socialization; in the second year, of 20 judged as rejecting, 17 used rigid practices; and in the third year, of 17 judged as rejecting, 15 used rigid practices.

An attempt was next made to evaluate the importance of environmental factors in influencing both actual handling of the child and the mother's adjustment to the maternal role. The following "deviant home situations"

TABLE 5. RELATIONSHIP BETWEEN ATTITUDE TOWARD MATERNAL ROLE AND MATERNAL BEHAVIOR

<table><thead><tr><th rowspan="2">Year</th><th colspan="4">Area</th></tr><tr><th>Feeding</th><th>Sleeping</th><th>Toileting</th><th>Socialization</th></tr></thead><tbody><tr><td>1</td><td>—</td><td>χ²= 8.16<br>p&lt;.01</td><td>—</td><td>χ²=24.42<br>p&lt;.001</td></tr><tr><td>2</td><td>—</td><td>χ²=11.94<br>p&lt;.01</td><td>—</td><td>χ²=12.09<br>p&lt;.001</td></tr><tr><td>3</td><td>—</td><td>χ²= 5.92<br>p&lt;.02</td><td>—</td><td>χ²=14.28<br>p&lt;.001</td></tr></tbody></table>

were selected for analysis: marked discrepancy in parental background, inadequate housing, prolonged illness of either parent, atypical employment hours for father, and mother working or out of the home. It was found, however, that these variables occurred too infrequently to permit statistical analysis, and though the presence of any one or constellation of them was of obvious importance for the dynamics of the individual case, such analysis is not within the scope of the present paper.

Because much emphasis has been placed on the mother's social class membership as a determinant of maternal child care practices, the mothers' behavior in the four areas was analyzed for the three classes represented in the present group of subjects. Here, definite trends were observed which, because of the small number of subjects, were not statistically significant. A summary of these data is presented in Figure 1, which was arrived at in the following manner. Since 12 attitude ratings were available for each mother (one for each of the four areas for each of the three years), a total score could be assigned to her based on the category into which the majority of the ratings fell. For purposes of the present summary, a mother was assigned

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at all three years) and inconsistent (those who received a different rating for
any or all of the three years). When the consistent mothers were contrasted
with the inconsistent mothers, no difference was found in incidence of
problem behavior in the children. However, when contrasts were drawn
within the group of consistent mothers, significant differences were found
in incidence of problem behavior between the children of consistently op-
timal mothers on the one hand and the children of consistently rigid or over-
permissive mothers on the other. In each instance, the children of the
consistently optimal mothers had a significantly lower incidence of problem
behavior. The chi-square values for the four areas are as follows: feeding—
4.24, p <.05; sleeping—8.69, p <.01; toileting—12.62, p <.01; and socializa-
tion—4.24, p <.05.

The hypothesis has been advanced that fewer problems would develop
among children handled deviantly by mothers who were well adjusted to the
maternal role than among those whose mothers were rejecting or overab-
sorbed. Because of the small number of cases in the present sample, and the
high correlation obtained between maternal adjustment and optimal han-
dling, it was not possible to contrast the effect on the child of deviant handling
by the different types of mothers. It was hoped that this type of breakdown
would yield information as to the effect on child development of overpermis-
siveness or rigidity in mothers who felt at ease in such practices (that is,
those mothers adjusted to the maternal role), as opposed to deviation which
was the outgrowth of superficial adherence to "popular" advice or repre-
sented rejection of the child (that is, those mothers overabsorbed or rejecting
of the maternal role). Of the 50 cases, 14 mothers were judged as adjusted to
the maternal role at all three years; 20 were judged as maladjusted at all
three years; and in 16 cases the mother's type of adjustment varied from
year to year. As might be anticipated from the data given in Table 5, the
majority of the well-adjusted mothers showed optimal handling, and the ma-
jority of the maladjusted mothers showed deviant handling. Consequently,
no contrasts were possible.

DISCUSSION

The present results show that child behavior during the first three years is
more consistently influenced by maternal handling than by other environ-
mental factors. However, in view of the stress which has been placed on the
role played by early infancy experience in subsequent development, it is
notable that fewer significant relationships were found within the first year
than for the two subsequent years. Not only was no significant relationship
found in the first year between maternal practice and child behavior in the
areas of feeding and socialization, but when the mother's first year practices
were related to the child's behavior in the second year to determine whether

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a delayed effect could be shown, no significant relationships appeared.

There is no ready explanation to account for the fact that in these areas the type of maternal handling during the first year does not here have the same obvious effect on the child's behavior as it does during the second and third. However, three possibilities suggest themselves. The first is that the present techniques were not sufficiently sensitive to detect greater individual variation among the children in these areas than was found during the first year. This is suggested by the fact that although in the first year about the same number of mothers fell into the categories of rigid, optimal, and over-permissive as during the second and third years, a higher proportion of the children fell above the mid-point of the scale (point 3) in the first year than during the second and third years. Using the present techniques of dividing the children's group at the median and thus making a relative judgment as to presence or absence of problem, in the area of feeding, 19 fell below the median and 27 above; in the area of socialization, 22 fell below the median and 26 above. However, dividing the group at the mid-point and thus making a more absolute judgment as to presence or absence of problem, in feeding only 5 fell below the mid-point, with 40 above it; in socialization, only 7 fell below the mid-point, with 42 above it. Thus, while it appears that this group of children were relatively problem free in these two areas during the first year, it is possible that if finer discriminations could have been made between them, a stronger relationship to type of maternal care might have been found. According to this hypothesis, incipient problem behavior actually existed among the children, but the research techniques were not sensitive enough to detect it.

An alternative explanation is that while this group of mothers showed variation in type of maternal handling, none showed the gross distortions in child care that have previously been correlated with the development of feeding and socialization problems during the first year. It is plausible to assume that, as in the area of toileting, overpermissiveness during the first year in feeding and socialization may not represent the gross mishandling that it does during the second and third years. On the other hand, it is possible that the judgment of rigidity made for the present mothers did not represent the same extreme of control that characterized child care practices 20 years ago. Both interpretations would decrease the probability of finding a significant relationship between maternal care and child behavior. According to this hypothesis, the group of children would be regarded as relatively problem free in these two areas because minor variations in handling among an essentially homogeneous group of mothers would be less likely to produce problem behavior during the first than during subsequent years.

A third possibility is that, because of the nature of the group and the

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amount of pediatric supervision received, less variation existed among the mothers' attitudes toward the child in the first year than in the second and third. It will be recalled that the present group of subjects were drawn from an "average" population of women routinely attending an obstetrical clinic. In all but 14 of the 50 cases, the baby was planned, and was presumably desired and responded to with affection and acceptance at his birth. During the first year, the mothers—either through attendance at a Child Health Conference of the Visiting Nurse Association or through a private pediatrician—received more intensive supervision than during the second and third years of the child's life. A situation therefore arose in which the mothers received more help in understanding the child when the needs to be met were the basic ones of feeding, sleeping, and protection from injury, than subsequently when he became more independent and active in exploring his environment and the cultural pressures for his "socialization" were increased. Although the mothers could be categorized as rigid, optimal, or overpermissive during the first year, it seems plausible to assume that less variation in underlying attitudes would be found during the child's infancy than later in his life, when his demands became more individual. As a result of the necessity for increased discipline, and for meeting the demands of society that he be toilet trained, learn appropriate techniques in eating, and acquire recognition of the distinction between his property and that of others, the degree of interaction between mother and child is heightened, and presumably a wider range of maternal attitudes are elicited. According to this hypothesis, the attitudes underlying the child care practices during the first year within this group would be more homogeneous than during the second and third years, when the mother's own anxieties and conflicts would be aroused by the child's increasing independence and by the increasing demands of society, and when, because of less intensive pediatric supervision, she would have to deal with him more in terms of her own individual personality and previous experiences.

Another striking aspect of the data which requires explanation is the discreteness of the relationships found between maternal handling and the child's reaction. It is apparent that poor handling in any given area is likely to be associated with "problem" behavior in the child in that area, but that this does not generalize in the child to other areas. It is also apparent that the type of maternal deviation varies in effect in the different areas of child behavior. Thus, in the area of sleep, overpermissiveness produces problems, while in the areas of feeding and socialization, rigidity produces problems. Here again, there are several possible explanations. One is that such specificity is due in part to the structure of the group. Thus, on the one hand, very few of the mothers were rated as falling at the extremes of the scale (points 1 and 5), so that the rigid and overpermissive groups were composed largely of

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mothers who received intermediate ratings between the mid-point and the extremes. If the mothers had shown more gross deviation from what would be regarded as acceptable child care practices, greater spread of effect might have been found among the children. This interpretation derives some support from the fact that few of the present group of children evidence any severe emotional disturbance of the kind that would lead to a pervasive disruption of behavior. The hypothesis that greater generalization of problem behavior would occur if the child were more generally disturbed is borne out by further analysis of the present data. If, at each year, the children are divided at the median of the scale of emotional maladjustment into those more or less emotionally maladjusted, the median number of problems is always greater in the group judged as more maladjusted. Thus, at the first and second years, the median number of problems for the more maladjusted group fell between 2 and 3, for the less maladjusted, between 1 and 2; at the third year, the median for the more maladjusted group again fell between 2 and 3, but for the less maladjusted, between 0 and 1.

It can also be hypothesized that the relationships between child behavior and parental child care practice may be more discrete at the time of origin of problems than later in the child's life. The observation that certain neurotic components of personality represent anxiety displaced from early childhood experience is undoubtedly a valid one, but it has been deduced for the most part from the treatment of older children and adults. The present direct observations of early childhood suggest that initially the effect of deviant parental handling is more discrete than has been supposed.

Although some of the results of this study lead to conclusions which seem obvious at the present date to psychiatrists, psychologists, pediatricians and other educators in the field of child development, their apparent clarity is probably more the result of hindsight based on ten years' experience than foresight in predicting the effects of a pendulum swing from rigidity to permissiveness in child care. At the formulation of the research in 1946, no actual documentation existed as to the effects of various types of maternal practices on child development. In the ensuing years, two main difficulties arose which probably could not have been anticipated. The first of these was the focus of teaching on the early infancy period, because of professional interest in changing maternity routines, the encouragement of breast feeding, and the emphasis on "ad lib." care during the neonatal period. As a result, although the limits of permissiveness were tacitly implied, they were not explicitly stated. A situation was thereby created in which the mothers were encouraged to handle the child permissively during his infancy, but received less professional assistance in setting limits on such practices as the child grew older. The second difficulty was the rapidity with which the concept of permissiveness was popularized in lay publications. However, here a

The family and the sick child

The little girl in this eloquent picture states the problem: what is hospitalization going to mean to her? Will she come through the experience not only in good physical health, but without emotional scars? Is there a possibility that she will even gain something from learning to cope with strangeness and pain in an atmosphere of friendly understanding?

These are questions that doctors and all others who work with children during illness, hospitalization and convalescence, are earnestly seeking to answer in the affirmative for her and for all children. More and more they are coming to believe that such results can best be accomplished if the bond between the sick child and the family is kept as nearly intact as possible.

The idea is sound. But ideas are not enough. They must be carried over into individual action, institutional procedures, community resources. They must be carefully planned and introduced, too, and not gulped down or forced on people to whom they are not congenial. Experiment and adaptation are both in order, and we need not feel that all is lost if changes are sometimes slow in coming.

Meanwhile, there are a number of hopeful signposts, to which this issue of Child Study draws attention. They are only a sampling of many excellent projects in this country and elsewhere. But they provide encouragement and command admiration. All of them—however they vary in detail—point to the vital importance of a concept that is as old as the hills and yet as new as the most fabulous wonder drug: *the medical care of the child is a family concern.*

The Editors

By Miriam Hemmendinger

Rx: "Admit parents at all times"

This moving account shows what can happen when new ideas of med-
ical child care are put into actual practice. The articles that follow,
describing other hopeful developments, will gain added meaning from
such a heartening report. For this, truly, is "what it's all about."

This is an account of a hospital and a child. The child is mine, and though I am as fatuous as the next mother, I cannot claim he is an unusual child. The unusual part of this narrative is the hospital. I believe it is so singular, its philosophy and techniques have so many implications that I feel impelled to tell about it the only way I can-through our experiences there when our youngest child developed polio.

Hundreds of children come down with polio every year and countless articles appear about individual cases. Mark's case, a combination of bulbar and spinal, was comparatively mild and simple; and there would be absolutely no reason to dwell upon it were it not for the way he was handled, by a hospital which seems to feel that medicine stands on no loftier plane than the patient, and that the reduction of terror demands almost as much attention as the reduction of a fracture.

Mark is seven; a lively uncomplicated seven, though prior to this illness very shy with strangers. He suddenly became ill late on a Saturday night, with some of the traditional polio symptoms: fever, stiff neck, and violent headache. By Sunday afternoon he was no better, and overcoming my ostrich-like impulse to call it a "virus," I took him to our family doctor. He promptly suggested hospitalization for definite diagnosis.

The hospital was the Hunterdon Medical
Center, just outside of Flemington, New

Jersey. This was a new hospital then in its
second year of operation; an experiment in
bringing to rural areas the same broad range
of medical services as are offered in a large
city. We knew a little about Hunterdon as
Mark had had his tonsils removed there the
previous winter. I had been impressed with
the hospital then, particularly with the pro-
visions made for parents to spend the night
with their children, and with the careful
pre- and post-operative care. However, hos-
pital is a horrid word to most parents.
We're grateful for these institutions but we
dread them for ourselves and doubly for
our children. The mixture of suffering and
fear, the curious withdrawn attitude of the
staffs, and false standard of the "stiff upper
lip," the lack of real communication . . . all
make up the average hospital atmosphere.
The sicker a child becomes, the harder it is
to relinquish him to those skilled, devastat-
ingly efficient and impersonal hands. Add
to this the hated word "polio," and you can
imagine my emotions as I put Mark in the
car and headed for Flemington, maintain-
ing a calm exterior only because I was too
numb to maintain anything else.

As we approached our destination, I ex-
plained to Mark that he might have polio
and that going to the hospital was the only
way to find out. Our family has never talked
of this disease as different from any other
serious illness, so Mark was not particularly
impressed by the word polio, his only anx-

iety being, "How will they find out? What will they do?" I replied as honestly as I could, explaining about the spinal tap, which would hurt like an injection. He was naturally apprehensive but trusted my explanation. I was also apprehensive, dreading not only the diagnosis but the shock of hospitalization, the treatment and all that might lie ahead. Mark, lying quietly beside me in the car, seemed suddenly very small and unprepared for pain.

## The admitting office

When we walked into the admitting office, (Mark limping stiffly but insisting he could walk, and I too intent on fooling myself to argue) the lady in charge suggested that we go right up to pediatrics and went along with us to record the routine admitting particulars. As she stood chatting with Mark while we waited for the elevator, I vividly recalled another hospital where I had had to wait one hour with my older boy who had a fever of 104°, before he was admitted and escorted to his room.

Pediatrics, like all other floors at Hunterdon, is a cheerful, non-hospital-like wing which, either by virtue of its newness or some other magic, lacks the usual hospital aroma composed of equal parts of disinfec tant, ether and floor polish. The interior walls are finished in natural wood, and all rooms boast large "picture" windows with gay draperies. The isolation room was warm with yellow drapes and a painted mural, and Mark was settled there by a friendly nurse. The door was left open and we could see and hear the children across the hall, and watch two lively boys "hot-rodding" in wheel chairs up and down the hall.

Remember, this was a Sunday afternoon when only a skeleton staff is on duty at any hospital. The resident intern who came in was not the one assigned to pediatrics, and from his conversation with a colleague, was clearly being rushed off his feet with emergency accident cases. However, he managed to keep any disturbing sensation of urgency from Mark, patiently taking time with each step. When Mark asked worried-

ly, "When are you going to do the spinal tap?" the doctor raised his eyebrows at me and replied, "Well, if you know about it, we'd better do it right away, then you won't have to think about it." While he waited for the equipment he explained what he was going to do and how Mark was to lie, impressing upon him, without any threats, the need to lie still. He neither mitigated the fact that it would hurt, nor dwelt upon it. Then they went ahead as fast as possible. Mark howled but he managed to lie still and listen to our encouragement between yells. It was a hard few minutes, but certainly not devastating, and I noted how nurse and intern were quick with praise and no one uselessly urged Mark not to cry. The need and right to cry is respected at this hospital.

## "Direct and honest"

The usual blood tests followed the spinal puncture, and then we could comfort Mark by promising "that's all for today." Everyone had been so direct and honest, he cheered up immediately and followed the rest of the procedures without anxiety. By this time Dr. H., chief of pediatrics, had arrived from his home, and a technician had been called in to analyze the spinal fluid. It seemed an amazingly short time before Dr. H. reported that Mark probably had polio, although meningitis or encephalitis were still possibilities. (With that "choice" we could only feel fortunate when it was definitely established as polio the next day.) "Would you like to stay with your son?" asked Dr. H. Would I! Nevertheless, I hesitated. Did this mean that I would be isolated, too, for the duration of the contagious period? I had a husband and two children at home to consider. No, indeed; I was told I could come and go as I wished. I had only to conform to the same isolation techniques observed by the staff: the sterile gown to be worn when in the room, the careful washing of hands. I could be with my child, minister to him, comfort him. And comfort myself!

When I expressed my relief and surprise,

4

Dr. H. remarked that although little is known about polio, all experience points to the fact that doctors and nurses caring for polio patients do not carry the disease home to their families. If hospital staffs can exercise the necessary precautions, which are essentially ones of cleanliness, so can parents. I might add here that we obtained Gamma Globulin serum for our other children and two neighbor children, but neither my husband or I bothered to have the injections, although we were with Mark constantly. Perhaps the most contagious period is over by the time polio is diagnosed.

## Recognizing emotional factors

Hunterdon's attitude toward polio is not one composed purely of calm common sense. This hospital recognizes the emotional factors in children's illnesses, particularly in the case of hospitalization. They believe that mothers and fathers can play a large role in the recovery of a child. Fear is reduced if a parent is on hand, and the awful feeling of being deserted, and even sometimes (in the child's imagination) punished, is practically non-existent at Hunterdon.

Think of what this means not only to the youngster but to his mother and father. I have seen anguished parents standing helpless as their little ones were born off screaming to a ward marked "Isolation." I have heard doctors tell mothers not to visit their children because the strain of leave-taking at the end of visiting hours would be too devastating for the child. But at Hunterdon *any hour is visiting hour for parents*, and they are encouraged to stay if they can, particularly in the beginning. There is a stack of roll-away beds ready to place in any room, and as there are no more than two patient beds to a room, and four cribs to a nursery, there's ample space.

How do the nurses feel about this parental invasion of their sanctum? Some of them confided to me that they would never have believed that the presence of a parent could make so much positive difference to a hospitalized child. Most of these nurses

had trained in hospitals where the very opposite attitude was prevalent, and where parents were considered an emotional burden to be endured as briefly as possible. Now they discovered that with some few exceptions parents were really a help. "If anyone had told me I'd want mothers around!" one nurse said with humorous astonishment.

As the concept of the value of parent attendance is basic to the hospital's philosophy, there is no charge for the privilege of staying there. I stayed every night of the first week with Mark, until he was out of isolation, and paid for nothing but my meals. There was no fee for my bed and linens, for the coffee and sandwiches the nurses shared with me at night, or the variety of juices put at my disposal. And there could be no price set upon the patient answering of questions, the sharing of information, the way parents are accepted by the staff and allowed to help in the nursing of their children. Small wonder that there is so little weeping. Small wonder that Mark slept, fitfully, painfully, but with complete security at night, and that in between times I slept too instead of tossing in a nightmare of anxiety at home.

## An approach with many facets

This consideration of a child's needs in terms of his whole personality rather than in the narrow terms of his specific physical disorder, is apparent in every technique. The record taken by the resident pediatrician, Dr. T., covers every facet of the child's physical, emotional, and social life. I was asked very careful questions about Mark's symptoms, of course, but I was also encouraged to talk about his behavior at home, his fears, likes, attitudes, relationships with other members of the family, etc. I am well aware that I was under scrutiny, too!

The nurses keep similar daily records, not only of the child's temperature and other physical data, but also of his emotional reactions, how he plays, how he reacts to visitors, whether he seems restless, angry, fearful, etc. Dr. T. wanders, with

5

deceptive casualness, in and out of the rooms during the day, constantly adding to her understanding of each child through conversation or just observation.

Under these circumstances it is not surprising that nurses and doctors always explain before they do anything to their patients. If pain will be involved, they say so honestly, the tone being one of confident assumption that the child will cooperate. But if the child is unable to face the treatment, if force has to be employed, that force is used in a kindly impersonal way with neither threats nor moral persuasions about being "bad" or a "sissy." There is much good-natured teasing and there is also much real loving. Babies are cuddled and held on laps, little children rocked in understanding arms, older children are held, too, played with and read to. Each child is a real individual and treated accordingly. Of course, there is discipline, the kind of adult control that leads to self-control. Simple manners and courtesy are encouraged in the children, and much consistent courtesy is shown by the staff.

## The "extra" that counts

But beyond all this, there is an extra sensitivity and perception. For example, from the very first, Mark decided that the bedpan was not for him. Like many youngsters whose toilet-training days still linger faintly in their memory, the conception of being toileted in bed was alarming to him. No doubt he could have been persuaded or forced; in fact, I immediately set about to do so in order to prepare him for what I felt would be inevitable. The very first nurse who met with his anxiety, however, respected his feeling promptly, and cheerfully carried him to the isolation bathroom. She must have noted his reaction on his record for the bedpan did not appear again. There was never the slightest indication on the part of any nurse that this was an unnecessary extra burden, which it obviously was, as Mark had to be completely supported and had great difficulties due to his weakened stomach muscles. It was a month be-

fore he could sit even partially by himself, but during that period the question of the bedpan was never raised.

Similarly, in the early days of his hospitalization, if some treatment or examination could wait until I was on hand (I daily went home for a few hours), Mark's anxieties were respected and the treatment was postponed. In this way such a feeling of trust was established that Mark began to manage more and more on his own, and needed me less and less.

Another small but telling example of this sensitivity was the manner in which nurses went off duty. Day nurses usually made the rounds and said goodnight to their charges, reminding them they would be back the next day, or not, as the case might be, and mentioning the name of the night nurse and her aid. That nurse in turn would pop in as soon as possible after she took over simply to say "Hello, I'm here if you want me." This must be a big reassurance to bed patients, giving a real feeling of continuing awareness and care.

And a final example on a different level: during that first week, while his body was still reacting to the paralysing effects of polio, Mark was closely watched, tested three or four times a day, and examined by a variety of doctors. At an early point the orthopedic surgeon was asked to check Mark's muscles. The first time that surgeon managed to get to pediatrics, Mark was attempting one of his first light meals. Dr. K. immediately backed out of the room and said, "Don't bother him now, I'll be back when he's done." He returned within the hour to find that Mark had dozed off. Again, Dr. K. refused to have the patient "bothered." He came a third time... Mark was still asleep, and he finally examined him the next day. This was a busy surgeon who left his quarters in another part of the hospital on four separate occasions, rather than disturb a sick seven-year-old at an inconvenient moment!

As soon as Mark's fever subsided, hot pack treatments were introduced to relax the spasms. This was done three times a

6

day, the period being slowly increased from 10 to 25 minutes. I was shown how to distribute the packs along his small body, how to place him, etc., and given that heavenly feeling of really helping when I so wanted to help in the battle. In my absence, one of the nurses set up the treatment and stayed to read to Mark or play records to while away those long heated minutes. And after he was out of isolation there were frequently two or three convalescent children in the room during hot pack time, listening to the story, or singing along with the records.

## Setting a goal

Mark was still young enough not to be frightened by the immobility of certain limbs. He knew this was one of the results of polio, but as everyone was so casual he obviously assumed the helplessness would go in time. As there are no wards atHU-lderdon, he was not exposed to some of the more frightening aspects of polio, nor the unthinking remarks of visitors. We told him it would be a long time, made no promise, and set our immediate sights on getting out of isolation. His door was left open whenever he requested it, so he could partially observe what went on outside. There was an older girl across the hall who had been seriously affected by polio throughout her whole body, and a four-year-old who was beginning to walk again. We watched both children, sympathizing with the slow progress of one, rejoicing with the increasing skill of the other, and Mark quite naturally identified himself with the latter. We used to see those two patients go off daily to hydrotherapy, and the therapist and her assistant dropped in at Mark's room taking time and effort to become his friends long before he began to go along. They told him all about the equipment upstairs, and urged him to acquire some water toys to use in the pool. The other two children with their boats and water pistols made Mark anxious to join them and gave him a simple goal which he knew he would soon reach.

The hydrotherapy room is well equipped

with whirlpool bath, Hubbard tank, and a variety of exercising equipment. The room is even better equipped by virtue of its therapist. She knows just how to mix work and fun, praise and discipline, and gets a fine response from her young patients. Many of the stretching exercises are sharply painful, and this pain is fully acknowledged while the need for the exercise is explained. "I'd cry too, if someone did this to me," Miss N. would say with cheerful sympathy. "Come on, we'll do it once more, and you yell all you want." Miss N. loves her young patients and treats them with humorous respect; and as she stretches their limbs she helps them grow with the pain rather than sink into it. Her young assistant sees to it that the trip up and back to pediatrics, whether in a wheel chair or a stretcher table, is an adventure in travel. Erratic speed, stops at points of interest, and general hullaballoo is always part of the journey, and Mark looked forward to those trips as the high spot of his day.

## When the isolation period was over

After the isolation period was over, Mark was moved across the hall and I went back to home routines, visiting him afternoons, while my husband visited at night. Mark could soon tolerate having his bed raised for short periods, and as time went on managed to sit up. Sometimes he was alone, frequently he had roommates; and he who had been so slow at making friends with strangers began to reach out with pleasure. Naturally his pile of gifts increased daily, and the staff cheerfully permitted us to set up an electric train a loving grandmother had sent. Imagine an extra table with an electric train set up in a hospital room! Everyone played with that train and no one seemed to be annoyed because the extra clutter made the room an obstacle course.

A month went by, and we were all settling down to a routine between home and hospital. Mark took our goings and comings easily, enjoyed our visits, but was not dependent on them. For a change of scene he was frequently put on a stretcher table

7

and wheeled into the play room or—which he preferred—down the hall to the nurse's station. There he would lie on his stomach, absorbing all the activity, asking innumerable questions, getting generally in the way . . . although no one ever said so. His brother and sister were allowed to visit once a week. It is worthwhile noting here that they had been permitted to stand at his door the end of the first week. Dr. H. evidently recognized the value of relieving the older children's anxiety, and therefore allowed a brief reassuring visit—another example of how the entire family is considered as well as the patient.

## Being part of his new world

New polio cases were admitted after Mark had been hospitalized for some time. Fortunately these cases were mild, and the children were able to leave fairly soon. These early departures could have been hard to take, particularly as the girl who had been most seriously affected had been transferred to Warm Springs, so that Mark was in the position of the "oldest" polio patient. I noticed that no one made useless promises to him about his going home or pretended, with that heavy pretence adults sometimes use, that he was perfectly content to stay in the hospital. However, the morning the pediatric floor was fairly deserted, Mark, graduated to a wheel chair by then, was invited to join the staff in the treatment room where they enjoyed a mid-morning break with coffee, cake, and conferences. Frequently thereafter, if the staff was not too busy, Mark was asked to join them for his share of cake and a couple of games of dominoes with one of the doctors. By such methods, without words, was he comforted and made to feel a real cog in this new world he was inhabiting. Small wonder Mark matured and became friendlier with adults.

## Same treatment for all

None of this "treatment" I have been describing is peculiar to polio patients alone.

Every child and parent at Hunterdon receives the same loving attention and respect. Sometimes, of course, parents would find themselves unable to stay with their children the first frightening couple of days. The nurses would then spend extra time with that child, and children soon identified a particular nurse as their own special one. When possible, other nurses would defer to such a preference. "Let so-and-so do it," I'd hear a nurse say, "Jane likes her the best." I have seen lonely children cuddled, played with, read to, settled in play pens, wheel chairs, or stretchers right by the nurses' desks, not as the exception, but as the rule. I have seen nurses making checking rounds with a baby on the hip, for all the world like a mother going about home chores with a fretful baby in tow.

I saw a two-year-old so blistered with some sort of allergy that it was agony for the child to be touched, let alone handled by white-clad strangers. The baby's mother was encouraged to do all the handling, doctors and nurses observing and doing as little directly as was necessary. It was considered as important to treat the child's terror as to locate the source of the allergy.

Another infant was brought in in a coma, needing immediate oxygen. The mother was desperately frightened, and could hardly bear to relinquish the child for treatment. As soon as possible after examination, the infant was returned to the mother's arms, and the mother shown how the oxygen was to be administered. The door to the nursery was open and I stood watching as the nurse went swiftly in and out. When the baby was settled, she brought comfortable slippers and slipped them on the mother's feet. She wrapped a blanket across the shaking thin shoulders. She kept a vigilant eye on the infant, but the mother was in that magic circle of observation and care, not shut out. The following evening, the baby, with the amazing resiliency of infants, was already convalescing and a nurse carried the infant about in her arms in order to permit the exhausted mother to sleep.

I saw countless accident cases brought in,

8

broken bones being the most common
emergency. No matter how busy the staff
seemed to be, each child was carefully pre-
pared for whatever treatment was in store.
The anaesthetist came down to the child's
room and briefly explained the process and
instruments of anaesthesia before the child
was taken away into the forbidding atmos-
phere of the operating room. Whatever
could be done to alleviate the terror of the
unknown was always attempted, yet no one
ever lied to a child to make things easier for
himself. How many of us can claim such
consistency!

The underlying philosophy

Are these nurses and doctors a special
breed, the cream of their professional crop?
No, I don't think so. Hunterdon pays no
more than other hospitals and has the same
problems of staffing. The difference lies in
the hospital's philosophy which must be well
explained to each and every staff member,
for everyone seems to practice the same un-
failing understanding and controlled tend-
erness. It is as if the nurses were told not
only the importance of the psychological ef-
fects of illness and the destructive power of
fear, but also as if they were reminded that
they are women and potential, if not actual,
mothers as well as nurses.

One of the lucky ones!

On October 8th, still muscularly weak
and in need of future therapy, Mark walked
out of Hunterdon Hospital. He was one of
the lucky ones—he walked! Because his
spine was involved, the possibility of a fu-
ture spinal curvature and an operation has
still to be considered. It may take two or
three years before we can be sure one way
or the other. But no matter what happens,
Mark is lucky! A crippled spirit is far hard-
er to support than a crippled spine, and
Mark's spirit is whole and unself-centered.
He has learned about pain, patience, and
people in a positive way. He has greatly
matured in these months, and in a situation
which might have been very harmful to his
sense of security, he gained both trust and
self-assurance. I do not doubt that his
physical progress would have been equally
good at any number of other hospitals, but
I sincerely doubt he would have grown as
emotionally healthy in the fairly rigid im-
personal atmosphere of the average ward.
Yes, Mark is lucky, and we are lucky, for we
have access to a hospital where efficiency is
never developed at the expense of the pa-
tient, where sterile refers only to cleanli-
ness, and where love is a recognized anti-
biotic!

By Andrew D. Hunt, Jr., M.D.

An experiment in teamwork

Hospitalization can actually be a constructive experience for a child. That is the belief of Dr. Hunt, Director of Pediatric Services at the Hunterdon Medical Center in Flemington, New Jersey, where cooperation between hospital and parents is considered a potent medicine

The opening of a rural medical center
in July 1953 offered an opportunity to test
certain ideas about the hospitalization of

children which, although theoretically
sound, have been viewed with some mis-
givings by physicians, nurses, and hospi-

9

tal administrators. The basic one of these principles is the acceptance of parents as members of the "team" taking care of a sick child. The vigorous and often passionate protests of most mothers at being separated from their sick children suggest that this concept is basically right from the standpoint of feelings and family relations. Medically, too, the possibility of poor effects from such separation has been clearly demonstrated.¹ Yet the fear of practical difficulties has often kept a different, more "humanized" procedure from being put into practice.

There seemed, therefore, to be a need to experiment with an in-patient service in which participation by parents was encouraged; to evaluate the experience; and to consider the possibility of initiating such a policy in other hospitals. A pediatric service to meet these requirements was set up at the Hunterdon Medical Center, in Flemington, New Jersey, over three years ago, and this article could be considered a preliminary report on the results to date.

To start a program of hospitalization such as this, real readiness to try out a departure from traditional procedures must exist. For this reason, a good deal of difficulty is generally encountered when efforts are made to convert a pediatric service from traditional restricted visiting hours to a more liberal policy. Usually, the hospital personnel sees this simply as an extension of the "visiting hour" confusion into a prolonged nightmare.

The author is able to sympathize with such an attitude since, earlier in his career, he shared these feelings. His first year in residency was spent in a large teaching hospital where visiting hours were looked on with dread by nurses and physicians because the peacefully submissive children suddenly became whining, clinging little monsters attached like barnacles to their distraught, tearful mothers. At the termination of visiting hours, the din was unbe-

lievable, and it was many hours before the ward was restored to order. The thought of expanding this harrowing period by having the parents constantly present was unthinkable. Indeed the standard dictum was "children would be all right if it were not for their parents." Such strong feelings on the part of pediatricians and nurses cannot be changed abruptly. In the author's case, this transformation of attitude required several years of experience and participation in a program of psychological pediatrics in a children's hospital.

### Policy must be interpreted

However, for a program of children's hospitalization such as this to be possible, it is not sufficient that the chief of pediatrics be sympathetic to the policy. The hospital administration, director of nurses, nursing supervisors, and staff nurses must all understand the reasons and purposes of the plan, and support it firmly and vigorously. The remarkably smooth operation of the pediatric service at Hunterdon Medical Center is largely due to the fact that all professional personnel were sympathetic to the pediatric visiting policy at the opening of this new institution.

The history of Hunterdon Medical Center has been well documented.² However, a word here might be appropriate to describe the steps leading to the selection of a staff with interest in mental health principles.

A meeting of the County Board of Agriculture was held in 1946, at which the lack of either hospital or specialist in this semi-rural New Jersey county with a population of 43,000, was deplored. As a result of this meeting, a Board of Trustees was set up which, with extraordinarily enlightened leadership, sought counsel from several groups, including the Commonwealth Fund, with its interest in community mental health.

Early in the planning stage, it was determined that among the specialists who

¹ A graphic presentation of this is given in the film, "A Two Year Old Goes to the Hospital", a scientific film produced at the Tavistock Clinic in London by James Robertson.

² *Hunterdon Medical Center*, by Ray E. Trussell, Harvard University Press, 1956.

would work as a group in the 120-bed hospital, in collaboration with the county's general practitioners, would be a child psychiatrist and a pediatrician who was psychiatrically oriented. The first Medical Director, with a background in preventive medicine and an interest in mental health, was largely responsible for the recruitment of the specialist staff. The pediatrician and child psychiatrist were the first specialists to arrive, and they did so one year prior to the opening of the hospital. This year was spent largely in exploring relations with the general practitioners, assisting the Director in many ways, and in setting up plans for policies regarding the hospitalization of children. Thus, a pediatric policy of unlimited visiting hours was established even before the Director of Nurses had been interviewed. Recruitment of nurses and other hospital personnel was carried out on the basis of this policy.

The Director of Nurses arrived approximately three months prior to the expected date of opening, and recruitment of the nursing staff began forthwith. The candidate for Pediatric Supervisor was interviewed by the author, and the proposed plan for parents' visiting was discussed at length with her. Her pediatric experience had been in a traditional setting with limited visiting hours, and her initial enthusiasm for our plan was no more than mild. However, she accepted the position, is still with us, has written, with a parent, a paper describing the service³, and is to a great measure responsible for the success of the project.

Frequent meetings also were held at this time by the medical staff, consisting of the growing specialist group, and the score or so of family physicians practising in Hunterdon County. Among the topics discussed and included in the bylaws was that of visiting hours, and the reasons for unrestricted admission of parents to the pediatric service were outlined in considerable detail. Resistance to the plan was surprisingly light.

A few of the family physicians expressed apprehension, but the policy was voted in without opposition.

At the time of the above-mentioned staff orientation, the hospital building was nearing completion, and the public, who had given so remarkably to the building fund drives, was invited to see the Medical Center in conducted tours. As the tours passed through the unfinished pediatric section, the guide informed the people of the visiting hour plans. The public was also told about this policy in one or two articles in the local newspapers.

Therefore, a new hospital, new staff ready to try something different, careful orientation of all personnel, and an informed public enabled us to establish the visiting hours program without the need of battling against taboos or fixed concepts.

## Operation of the program

The actual mechanism of the program can be briefly stated. (A more detailed description has been published elsewhere.⁴) On admission, the mother is told that she may visit her child at any time, and that her husband has the same privilege. The admission procedure is one in which the mother takes an active part, accompanying the child to the ward, helping the nurses weigh him, take his temperature, and the like. Thus, even if she is unable to spend the entire night with the child, at least her connection with him has been maintained to a degree.

A roll-away cot can be provided for her, should she wish to spend the night. There is no additional charge for this service, but she must get her own meals, which can be purchased at the hospital snack-bar or cafeteria. We are careful, in most cases, to keep the mother's visiting a permissive affair. We have found that parents who stay with their children because they think it is expected of them may lend them very little support. If parents do not really want to stay, or are distracted by the thought of other demands

³ Parents Invited by M. C. Morgan and B. J. Lloyd, in "Nursing Outlook," Vol. 3, May, 1956.

⁴ They Let Parents Help in Children's Care, by A. D. Hunt, Jr. and R. E. Trussell. "Modern Hospital", Vol. 85, Sept. 1955.

11

at home, they may find it difficult to give
the child the relaxed, whole-hearted atten-
tion that would reassure him.

Reports from mothers who have had ex-
perience in other hospitals, our observation
of children returning on follow-up visits,
and the reaction of children being rehospi-
talized on our service all give us the im-
pression that seriously untoward effects
from hospitalization in this setting are rare.
Indeed, it is remarkable how frequently
mothers state, "My child seems to have a
better disposition since he entered the hos-
pital," or, "He eats well for the first time in
his life," or, "He seems to have grown up."
Whereas such statements are undoubtedly
heard by physicians from time to time re-
gardless of the visiting policies of the hospi-
tals involved, we feel that our set-up in-
creases the chances that hospitalization, in-
stead of a trial to be forgotten as soon as
possible, may actually be a constructive ex-
perience for the child and his family.

To use hospitalization to the best possible
advantage, members of the hospital staff
must recognize that it is not a child, but
rather a parent-child unit, that is being ad-
mitted to the hospital. The nurses are en-
couraged to note the behavior and attitudes
of mother and child as they are admitted,
and to record in nurses' notes observations
on the mother's approach to feeding, sleep-
ing, stooling, and the like. Apparent cal-
lousness about leaving a child with us, as
well as unusual difficulty in separating from
a child, is observed and noted. Thus, with-
in a day or two, a fairly good impression is
obtained of a parent-child relationship.

Current cases are usually discussed at a
daily meeting held by the nurses and doc-
tors during the morning coffee break. The
history taken by the house officer, which
emphasizes the growth and development of
the child from an emotional and relation-
ship standpoint, is related to the physical
findings, laboratory work, and observations
of behavior. Discussion concerns possible
ways of helping to solve any difficulties that
have been uncovered. Such help may con-
sist of counseling offered by the nursing

staff to parents, or may call on the services
of the child psychiatrist member of the spe-
cialist staff. The degree of help offered de-
pends upon many factors. The readiness of
the parent to become involved is perhaps
the most important of these considerations.

We have found that our policy of unre-
stricted visiting hours can be used in an-
other beneficial way, too. Pediatricians, in
discussing our program, sometimes say that
we are pampering the children and that at
times children profit by a separation from
their parents. It is true that occasionally we
find cases in which the inseparability be-
tween mother and child exists to such an
abnormal degree that limitation rather than
extension of the visiting hours seems to of-
fer the best therapeutic possibilities. In our
setting, this limitation also is possible, and
has been successfully carried out. It is im-
portant, however, that the mother is not ex-
cluded because of an administrative regu-
lation, but rather agrees to a separation that
is mutually planned as a helpful measure
for her and the child. It should be empha-
sized that such a situation is not at all us-
ual, and that problems like those we will
discuss are solved, in the great majority of
cases, by methods far less drastic than hos-
pitalization. Nevertheless it is interesting to
note that flexible visiting hours can be used
in this way as well as in the permissive
sense of allowing parents to stay with the
child. Actually, it is part of the same phil-
osophy in that it allows the parent to parti-
cipate in the child's care, although here the
accent may be on separation rather than on
frequent presence at the child's bedside.

For example, we have hospitalized sever-
al small children (approximately two years
of age) because of severe sleeping diffi-
culties. The characteristic history is that of
a child who has begun crying at night, and
whose weary parents have tried rocking him
to sleep, taking him into their own bed, and
the like—all attempts to take away fear
from the child, rather than plans to help
him to live through such feelings. The re-
sult is usually a vicious cycle in which the
child becomes increasingly demanding, and

12

the parents increasingly frustrated. One
such father and mother had not been out of
the house together in the evening for more
than a year.

Our policy with our very small series of
such cases has been to hospitalize them
with the understanding that the mothers
will go home at night. The mother brings
her child in, puts him in his crib, feeds him
his evening meal, plays with him, puts him
to bed, and says good night. On this first
night, considerable encouragement may be
required to help the mother leave, and the
process may take the better part of an hour.
The amount of crying time of the child dur-
ing the night is recorded, and reported to
the mother the next day. It is usually sur-
prisingly short. The nursing staff, which is
skilled in the art of substitute mothering,
keeps close watch on the child, making sure
his fear does not verge on panic, comfort-
ing him and talking with him. The nursing
staff is always prepared to call the mother
back to the hospital should it seem neces-
sary. On the second night, the separation
process is apt to be easier.

Three or four nights of such hospitaliza-
tion seem to be sufficient to give parents a
feeling that they can follow through at
home, letting the child cry a little if neces-
sary, and having faith that this is the most
helpful course in helping him to grow up.
During the hospitalization, meanwhile, we
have worked hard with the parents, spend-
ing perhaps one hour per day discussing
their feelings concerning the child, reassur-
ing where necessary, and suggesting ways
of coping with specific situations.

Guidance services offer help

Similar methods are applicable where
there is a serious struggle involving feed-
ing. Most such situations are, of course,
dealt with on an out-patient basis. How-
ever, in the rare case where the problem has
become so severe as to result in a signifi-
cant amount of malnutrition, hospitaliza-
tion may be indicated. The first day or two
in the hospital, during which we combine
the use of laboratory data and observation

of parents and child during feeding, usually
serve to make clear a great portion of the
problem. In some instances, the parents
readily agree to a more extended hospitali-
zation, during which the actual feeding of
the child is managed by the nurses. It may
be useful to call on the social service to
work through the family's problems and at-
titudes, or it may develop that referral to
the child guidance service, which is part of
the Medical Center operation, is advisable
for continuing help. Severe feeding prob-
lems handled in this way have been uni-
formly alleviated; in a few cases this im-
provement has been extraordinarily grati-
fying. The flexible visiting hour policy also
has been used as a major tool in treating
unusually difficult and complicated cases of
infantile "colic" and constipation.

A new hospital function

The need to hospitalize children because
of infectious disease has decreased tremen-
dously with the introduction of new drugs
and methods of treatment. Pediatric serv-
ices everywhere are operating at low rate of
occupancy. However, general practitioners
and pediatricians are being called upon in-
creasingly to diagnose and treat emotional
problems of varying degree in children. Al-
though an enlightened and well-trained
physician can deal with many such situa-
tions in his office, there are some more re-
sistant difficulties which, in our opinion, can
be managed more readily, more efficiently,
and more effectively in a hospital atmos-
phere which is appropriately oriented.
Thus, modern medical progress not only has
saved countless young lives and prevented
much suffering, but may make available
hospital space and personnel for action in
the presently most important medical bat-
tle: the battle for mental health.

We feel that by encouraging parent par-
ticipation in the hospitalization of children
for physical illnesses or surgery, trauma for
the child can be minimized. We even be-
lieve that the hospitalization for the child
and the family as a whole can be a con-
structive experience. Further, we are find-

13

ing some reason to believe that a hospital
functioning along the lines we have indi-
cated may have a place in the treatment of

emotional problems, the solution of which
is within the ken of the pediatrician and
other members of the hospital team.

The impact of illness
on the child and his family

By James Marvin Baty, M.D.
and Veronica B. Tisza, M.D.

A child's illness is usually upsetting to him and his parents, though reactions vary greatly. From the Boston Floating Hospital and the Tufts University School of Medicine comes a discussion that will help parents understand these problems and possible ways to handle them

Parents have become increasingly aware of the psychological disturbances which may be precipitated by children's illness and separation and are anxious to know what can be done to prevent, or at least to minimize, such upsets.

How should the child be prepared for the
hospital experience? What should the par-
ents do when their child must be taken
there? How often and for how long should
they visit? Should they remain with him if
possible in the particular hospital? These
and many other questions plague parents
and doctors as well, as a result of the grow-
ing concern about emotional adjustment
and the problems of mental health, includ-
ing the effect of hospitalization on a child.¹

There are no ready answers to most of
these questions. Each child and the prob-
lem which leads to his hospitalization con-
stitute a completely individual situation af-
fected by such factors as the age of the
child, his emotional and intellectual devel-
opment, the emotional climate of the home
and the hospital facilities which are avail-
able in the community.

At the moment, different experiments are
going on in most of the children's hospi-
tals² of this country, designed to gain a
better understanding of the problems in-
volved and to improve the methods of child
care. This article will describe the program
which has been evolving in The Boston
Floating Hospital during the past 10 years,
and present some of our ideas based on the
things we are learning about the impact of
illness and hospitalization on children and
their families.

An acute illness in a child, severe enough
to require a visit by the doctor, is usually
an upsetting event to the family. Parents
naturally become anxious, and their uneasi-
ness may be increased by many things such
as an epidemic of poliomyelitis or some
other dreaded disease in the community, or
the recent critical illness or death, either of
a member of the family or of a friend.

As a result, the emotional reactions of the
family undergo more or less marked
changes which may have various effects on
the sick child. He may be gratified to find

¹ For lists of books and pamphlets that may be helpful in preparing the child for hospitalization see pps. 35 and 36.

2 The term "children's hospitals" is used in this discussion to include not only the relatively few hospitals which give care solely to children, but also the children's wards of the larger general hospitals.

himself the focus of his parents' time and care, often lavished on him to the point of unusual indulgence. He may be confused by his mother's attitude, for anxious mothers tend to forget, or at least to relax, all the good principles which usually determine their behavior towards the child. Mothers who under ordinary circumstances would never deceive or force their children will unhesitatingly pretend that applesauce is the only thing in the spoon containing a bitter-tasting medicine. They may give an enema without preparing the child or force fluids or food with an intensity which can be explained only by their desire to get the child well as quickly as possible.

The child senses his parents' apprehension and the changes in their approach to him, but does not understand what has happened. At the same time, he has to give up gains in independence which he may only recently have acquired. He has to stay in bed—and there is nothing harder on children than restriction of motion, unless they are too sick to move. His bowel movements and his urinary functions become a matter of concern again. How much or how little he eats is now a major issue and his diet frequently changes to “baby food.” At the same time, the child has to handle the effect of illness on his own body and emotions. He may become withdrawn and want nothing to do with anyone, or he may change into a clinging, whiny, contrary “brat” demanding to be held and comforted constantly by his mother. Other children revert to an infantile state, sucking their fingers, wetting themselves and wanting to be babied.

## What does it mean to parents?

If the doctor recommends hospitalization, there may be little time to prepare the child beyond saying that mommy and daddy will take him to the hospital and that they will bring him home again after the doctors and nurses have made him feel all better. What does it mean to parents, especially mothers, to take their child to a hospital under such circumstances?

It means different things to different people, of course, and parents will vary widely in their reactions. However, they are apt to feel that their worry about the illness was justified. At the same time, there is a sense of relief that the responsibility will be removed from their shoulders and assumed by trusted professional people—for most people do trust their doctors and do feel that their children will receive good care in the hospital. This sense of relief often is followed by, and becomes mixed with, feelings of uneasiness and helplessness and, probably, with ill-defined feelings of guilt. In addition, the mother who always has taken care of her child suddenly finds her place being taken by the nurses and other hospital personnel, and may react to this situation with further distress or resentment. All of the parents' feelings—anxiety over the illness, relief when the doctor takes charge, and grief over the pending separation—are sensed, but poorly understood, by the child.

## Understanding these reactions

As the effect of all these reactions, both on the child's health and the family's well-being, has become better understood, doctors and hospital personnel have re-examined traditional procedures. The admission procedure, for instance, is a crucial one. The first impact of the hospital on the child and his family is usually the entrance hall, which makes this area one of the most important places in the entire hospital. Much of the family's “lost” feeling will be relieved if, on coming into this strange and unknown place, they find that it doesn't look so “different” after all. Comfortable furnishings and colorful decorations can give it an almost homelike atmosphere; a friendly and thoughtful receptionist can convey the feeling that she understands their concerns and will help them in coping with an unknown situation.

The problem is entirely different, of course, when the period of hospitalization has been planned either for diagnostic studies or for an “elective” operation. Then it

15

becomes important to prepare the child for
the experience of being away from home
and for the things, many of them unpleasant, which will be done to him. Again, generalizations cannot be made. But in such preparation it seems wise to allow the child sufficient time to adjust to the plan (which is a threat to him) and to pull together his own resources. A few days are usually sufficient for this, and at the same time not long enough to allow the child to mull over the coming event and develop too many frightening fantasies. The effectiveness of such preparation will be modified more by the attitude and feelings of the mother than by what is said to the child. If she is very anxious and tortured by threatening fantasies, or feels guilty about "letting her child down" or sending him away, no amount of reassurance is apt to allay the child's apprehension.

## Admission: the first encounter

In most hospitals, children are examined on entrance in an admitting room or suite by one of the resident physicians, in order to plan location and treatment. This admitting examination can be a trying experience for the child and whenever possible should be postponed until he is settled in his bed. Even though the doctor and the nurse are gentle and kind, they are strangers, and most children do better if the mother does the undressing, permits the nurse to help her and holds on to the child's hand while the physician does the examination. However, some children, when frightened (apparently feeling the protection of the mother's presence), give vent to their fears and revolt to such an extent that a satisfactory examination is impossible until the mother leaves the room. Under such circumstances, most children over three years of age will behave quietly when left with the doctor and nurse, not because they are less frightened and upset but because they tend to draw on their own strength when the mother's support is removed.

We believe that whenever feasible the
mother and the father, if he is along, should

go with the child when he is taken to his
room or to the ward. This initial visit, allowing the mother to get acquainted with the nurses and to see the child's crib or bed, is very reassuring both to her and to the child. When the child sees the mother talk to the nurse in a friendly manner, he realizes that he also can trust the nurses, and when the mother leaves with the reassurance that she will be back tomorrow, the nurse's task in quieting the child will be less difficult. It is natural for younger children to cry as if wounded and angry when their mother leaves them in a strange situation. But if the mother comes to the hospital each day, most children will be reassured and realize that although mother is going away she will come back. They then turn to the people around them for love and protection in her absence. It also helps a child in this age group to have a familiar and beloved object in his crib—the favorite toy or doll or blanket seems to be a tie to home, a consolation in loneliness and a token of the child's identity.

The importance of the crib or bed should be mentioned. The crib seems to represent security, a symbol of mother, home and protection, and recently admitted young children appear to cling to it as one familiar object which surrounds them in a big strange world. But the slightly older child who has graduated to a bed should not be humiliated by being put in a crib.

## How will the child take separation?

The trip to the hospital is frequently the first time a child has been so far away from home and his reaction to separation will depend on many factors. The young child is most disturbed by the separation from mother and home. The older one is more concerned with the things that are done to him and is anxious to show that he is an individual of some strength and status. He is afraid that he will be a "sissy" or a "cry-baby." The reaction of the older child may also reflect his idea of what "hospital" means. Some have been to the hospital before and their reactions will be determined

16

largely by their former experience. The first-time patient may have heard from his playmates what happened to them, how many needles were stuck into them and how much it hurt and about being "cut open." Such stories, enlarged by imaginative minds, may put him in a state of terror at the thought of being taken to a hospital.

## The "comprehensive" approach

At the Boston Floating Hospital, a general pediatric hospital, an experiment has been in progress during the past several years in an effort to translate into practice the concept of "the total care of the child." The basic philosophy of this development is the so-called "comprehensive" approach which emphasizes that, for the best results, a sick child's physical, emotional and social needs should all be met concurrently. Once the staff of the hospital became aware of the complex and manifold needs of the child, it was seen that under no circumstances could he be considered as an isolated human being, but must always be recognized as part of the family unit. It became clear to the people who took care of hospitalized children that their feelings, needs and reactions could not be understood unless those of their parents were also recognized.

This "family orientation" is fundamental to the practice of comprehensive pediatrics and is one of the basic principles upon which the mental health program of The Boston Floating Hospital is built. The aim of this program is to alleviate the tension and anxiety created by children's illness and hospitalization. It should be pointed out that while the framework of the program remains the same, details constantly change to meet varying situations.

It is important that everybody who works in the hospital be imbued with a common philosophy. Accepting the whole family as a unit, and starting the "mental health program" when the parents and child arrive at the threshold of the hospital, are essential points. The importance of this general approach by both the professional and non-

professional groups cannot be over-emphasized. From this starting point, certain organized preventive mental health measures emerged, some of which we would like to describe.

Liberalization of the visiting hours was the very first step. The actual policy went through many changes, from more or less restriction of the visiting hours to complete freedom, until the Hospital arrived at its present policy—which is probably not the last one. At present, the daily visiting hours are from 2 to 3 p.m. and from 7 to 8 p.m. Parents who wish to do so may come at both times. Those for whom the hours are inconvenient can get permission to come at an hour of their choice. Those who want to stay all, or part, of the day have to get permission from the child's doctor. The extension of the visiting hours is always granted, but the doctor sometimes feels that some regulation of hours is wise. For instance, the mothers of small children, especially babies, who want to spend the whole day in the hospital, are usually reminded to arrive in time to feed their babies. On the other hand, the mothers of older children are sometimes asked to come after the main meal is over, because the child who at this point may need the food and fluid often does better when not under the mother's watchful and anxious eyes.

## Active participation by the mother

The mother who wishes to, may take quite an active part in the child's care. She can feed, hold, and diaper him and perform all the mothering functions to which the child is accustomed. Simple hospital procedures may be performed in the mother's presence. When it comes to more complicated medical and nursing functions, the mother is asked to leave the child's room or cubicle unless she wants, and obtains, the doctor's permission to stay. Medical procedures are generally upsetting to lay people, and more so to mothers. Besides, the mother may be put into an unhappy situation if the protesting child turns to her for protection which she is not able to offer.

17

One of the latest developments at the Boston Floating Hospital is an experimental "living-in" unit. Mothers sleep in the same room with, or next door to, their children and spend the greater part of the day with them. According to the nursing staff, the constant presence of the mother at the child's bedside is sometimes a challenging, but in general a rewarding, experience.

One may ask why, if permission to stay is granted so easily, visiting hours should not be completely free. Perhaps the answer lies in the fact that there are always some situations in which restriction is advisable. Sometimes, because of the nature of the mother-child relationship, both parties become more relaxed when they are not constantly together. Also, there are times when the mother needs to feel that limited visiting hours are the regular and accepted thing; otherwise she may be torn between the desire to stay with her sick child and the knowledge that the rest of the family needs her at home. While the child is very sick, he comes first, of course. But once he is on the road to recovery, the mother also begins to feel the pull of other duties. In this case, realistic restrictions become helpful in handling the child's demands and they alleviate the mother's guilt about not being able to stay with him all day long.

## The play program is important

Another important feature of the hospital's comprehensive approach is the Play Program. The play staff is interested in every child in the hospital. The play teachers make their rounds in the morning, stopping at every bedside and giving toys, games and books to the children. Patients who have medical permission spend most of their day in the playroom. The playroom service is essentially a non-directive activity program supervised by trained nursery-school teachers. The child is given adequate space and play material and freedom of choice in using them. This environment places the emphasis on the healthy part of the child and we feel that the wide range of choice in play activities helps children to

work out anxieties caused by hospitalization.

The hospital's Child Guidance Unit, through its close working relationship with the doctors and the members of the social service and nursing departments, keeps track of what goes on in the playroom and on the wards. The child psychiatrist visits the playroom frequently and is always ready to discuss with the teachers problems relating to their charges. Sometimes the psychiatrist is asked for direct participation, but in most cases she acts only as a consultant and coordinator.

## Children have their own resources

In the foregoing, we have noted some of the meanings of illness and hospitalization, have pointed out that it is, potentially, a traumatic experience and have described certain aspects of a program which is geared toward helping the parent and the child. However, many adults, thinking back to their own childhood, will recall hospitalizations which were quite different from today's ideal, and still not feel that they were significantly hurt by the experience. Likewise, children today may spend days or weeks in excellent hospitals without benefit of all of the helpful measures described above and yet, a few weeks after they go home, seem to be unaffected.

That is true especially with older children who can understand reality and who have faith in themselves and in others grounded in a satisfactory relationship with their parents. The older child may say "I am a big boy," mustering his own courage and self-reliance, and also may be flexible enough to use the emotional support offered by a nice nurse, a kindly doctor or even by another child patient. The parent is helped through this trying period by trust in the doctor's judgment and in the competence of the hospital. When the parent and the child meet, they may pool their strength instead of sharing anxieties. Thus, even where the circumstances fall short of the ideal, hospitalization is not necessarily a traumatic experience for a child.

18

The family whose child will need home care for a long period needs help with the various problems that arise. Dr. Cohart, Professor of Public Health at the Yale University Department of Public Health, tells of community resources that stand ready to offer vital aid

*Where to turn for help with*

the convalescent child

By Edward M. Cohart, M.D.

The thoughts expressed in this article grow out of the experience of the staff of a large city health department with a program for handicapped children. This experience has taught us that, though hospitalization may loom to parents as the most critical part of a child's prolonged illness, the return to his home and to everyday living poses special problems with which they may need a good deal of help.

There are many resources that can add greatly to the success of a child's convalescence, promoting his return to normal life and giving his parents both the practical aid and emotional support they are likely to need during this period.

The child should have continuing attention to his medical, psychological, social and educational needs. First, he should have the benefits of general pediatric care as well as medical supervision for his primary illness. Because the child has one major disease does not mean that he is immune to other health problems, and in fact such children may be more prone than the average to develop complications. Johnny's heart or his leg or his back may be coming along fine, but there is more to Johnny than a limb or an organ. We must not focus our attention on the disease to such an extent that we forget about the whole child.

The importance of medical follow-up in the home cannot be stressed too strongly, since our experience has shown that it is often either inadequate or non-existent. One must never lose sight of the fact that the condition of the patient with a prolonged illness does not stay the same, even though changes may occur at a much slower pace than changes in acute illness. Also—the child himself is growing and should be helped to find new challenges, as well as to cope with new problems. For this reason it is essential that the original treatment and management of the child be altered from time to time, and that the medical follow-up be made at intervals geared to the individual child's progress at each stage of his convalescence. Often when children have been in the hospital a number of times, a treatment regimen has been set up. But at home, modifications of this plan will have to be thoughtfully worked out.

To arrange the best possible conditions for the child may put quite a burden on the parents and on the whole household. Fortunately, it is often possible not only to improvise home facilities that will serve the purpose of the more elaborate hospital equipment, but to arrange with one or more community agencies to furnish the needed services. The visiting nurse association, the

19

rehabilitation center, the health depart-
ment, the voluntary health agency, or the
hospital itself may be of assistance. They
may be able to help with the design and
construction of the needed equipment or to
furnish such equipment on loan. The pub-
lic health nurse in the health departments
and visiting nurse associations is prepared
to provide many services in the home. In
many localities special therapists, such as
physical therapists, occupational therapists,
and others, belonging to one or another of
the previously mentioned agencies, can also
help with home care. Working under the
direction of the doctor, they will come into
the home to perform necessary services
themselves or to teach a member of the
family how to carry on.

The importance of good nursing

It has often been said that good nursing
care is one of the most important compo-
nents of good medical care; this is especial-
ly true in prolonged illness. Frequently,
when a child returns home from the hospi-
tal, his nursing care is not fully discussed
with the family; more often, the family may
be told *what* to do but not *how* to do it.
Many of us in the medical profession are
apt to assume a level of understanding and
technical competence which does not al-
ways exist among laymen. We do not take
the time to explain to our patients and their
families exactly what it is we want them to
do, why we want them to do it, and how it
is to be done.

In this situation, too few families know
where to turn, and often struggle along
needlessly without the expert help they
could get. For instance, the public health
nurse is prepared to do a number of things.
Besides offering the nursing and teaching
services we have mentioned, she may sug-
gest practical modifications of the nursing
procedure to meet varying conditions in the
home. Often she takes over the functions
of the social worker, physical therapist, oc-
cupational therapist, and nutritionist when
the services of these personnel are not avail-
able.

A resource sometimes overlooked

To the family confronted with the care
of a sick child at home, the services of a
public health nurse can mean the difference
between a confident, skillful approach and
an unsuccessful and harassing experience.
Despite the contributions that the public
health nurse can make in this situation, it is
surprising how often her services are not
used, either because the family does not
understand the many ways in which she
can help or erroneously thinks that her serv-
ices are limited to families in certain eco-
nomic brackets. This latter misconception
is very common, and has deprived many
families of a valuable ally in their effort to
give a convalescent child careful attention,
while at the same time keeping the home
atmosphere as normal as possible.

Feeding problems

In a lengthy convalescence, feeding prob-
lems often arise. The child's enforced in-
activity and restricted social stimulation,
coupled with the direct effects of his illness,
may make him indifferent towards food, es-
pecially when a special diet is required for
medical reasons. Some visiting nurse asso-
ciations and health departments provide
the services of a nutritionist who can sug-
gest different ways of preparation or sub-
stitute foods that will excite the child's in-
terest and appetite. Where they do not, ar-
rangements can sometimes be made with
the hospital for consultation with a nutri-
tionist.

When the care of the sick child, in addi-
tion to her other family responsibilities,
makes demands upon the mother which
she cannot meet, it is possible in some com-
munities to arrange for homemaking assis-
tance through one of the social agencies. A
more unusual arrangement provides short-
term care for the child in a convalescent in-
stitution, to give the mother the chance to
regain physical and emotional strength.
While this may be desirable for all con-
cerned, it should be remembered that the
child will probably need some sympathetic
preparation for even a temporary change.

20

## Parent-Teacher anniversary

News of the 50th anniversary of the National Parent-Teacher, official journal of the National Congress of Parents and Teachers, marks an important milestone in the annals of parent education. CHILD STUDY salutes a fine editor, Eva Grant, and extends a grateful "Well done!" to a publication whose first half-century of service has strengthened—and given vitality to—an entire movement.

A disabling illness in a child is apt to wreak havoc with the emotional stability of the family. Family relations involve complex emotional reactions even under ordinary circumstances; an extended period during which one child needs special care often reenforces these emotional problems and sometimes creates new ones. The feelings of the various members of the household are reflected in ways which may either speed or retard the child's convalescence. They also have important effects upon the other members of the family.

## The dangers of overprotection

One of the most commonly encountered patterns of behavior in such a situation is that of the family's overprotection of the sick child. Many parents—and sometimes other members of the family—tend to shield the convalescent child from his environment, both material and human, to a much greater extent than his illness warrants. This emphasizes and perpetuates the child's dependency, which has already been stressed by the illness itself. No one would argue that a convalescent child be pushed too fast in the difficult task of giving up the special privileges and attention he has become accustomed to. But maximum recovery is achieved only when the child readjusts himself to a normal everyday mode of living. Neither parents nor brothers and sisters can do this for him. Overprotection is a disservice to him: at best, it will prolong his convalescence; at worst, it may permanently damage the child's chances of making an appropriate adjustment to life.

## The objective look

It is well-nigh impossible for any of us to evaluate our own behavior objectively in an emotionally charged situation; and the family involved in the prolonged care of the sick child at home is certainly no exception. Psychiatrists, psychologists and social workers are trained to help us make these evaluations. The social worker can be of assistance in assessing the emotional atmosphere of the home and its impact on the child. Every family faced with this problem should have the benefit of at least one visit by the social worker soon after the child returns home.

If the relationship between the family and the child is found to be slowing the child's convalescence, the social worker may be able to work with the family to correct this situation, or she may refer the family to the appropriate community resources for help. Social service in the home can sometimes be obtained from, or through, the Social Service Department of the hospital, the community family service agency, or other social agencies. Where a social worker is not available, again, the public health nurse can often be of assistance.

Recreation is a vital aid to convalescence, and the child facing a lengthy recovery period should have such opportunities as his condition will permit. Here again the experienced public health nurse or the social worker can help. Also, the importance of continuing his education has long been recognized. Most school systems have a program of home instruction in which a teacher is assigned to work with the child at home a number of hours each week.

In a very small number of communities, organized home care programs have been established which offer many of the services discussed above, under one administrative aegis. Sometimes, medical care, as well as supporting service is given. In other places, the supporting services are provided, to be used at the discretion and under the direction of the private physician responsible for the medical care of the child.

21

Although highly-organized home care services are relatively rare, it is almost always possible to obtain a number of them if community resources are energetically explored and properly used. In our smallest communities, the public health nurse may have to "double in brass," as nurse and social worker, nutritionist and physical or occupational therapist. It is often gratifying to see the willingness with which she undertakes these many responsibilities and the competence with which she discharges them. In our larger communities, resources are, of course, more plentiful. But more often than not, these resources are not

tapped - not because they are not needed or not available, but because parents do not recognize their contribution to the care of the sick child, or know how to go about finding them.

Let us repeat: proper care of the child with prolonged illness in the home entails attention to his physical, psychological, social and educational needs. The parents and the physician share the responsibility to see that these needs are met, but there are many skilled and willing workers to help them. The means are at hand. Perhaps this article will point the way to a better use of them.

# The public health nurse:

a member of the mental health team

By Ilse S. Wolff, R.N.

The public health nurse, traditionally a friend of the family, has an added function today: prevention. How her friendly, expert guidance can help to forestall trouble is described by Miss Wolff, Mental Health Nurse Consultant at the Connecticut State Health Department

Whenever the popular subject of mental health and its role in child-rearing is discussed and we think of the people who could help parents in this area, our thoughts usually turn to the psychiatrist, the psychiatric social worker or the case worker with good psychiatric grounding as the main resource people and potential counselors of parents. And rightly so.

However, in recent years we have broadened our thinking about mental health. We have put our emphasis upon prevention, especially on the very early level. We realize that by the time questions and problems between parents and children come to psychiatric attention, a disturbed relationship

has already grown up which might have been straightened out in the early stages.

We feel the need for a much larger number of trained specialists, but are well aware of the fact that mental health efforts cannot wait for the time when thousands of psychiatrists, psychologists and psychiatric social workers will be trained, and when the general public will use their services as matter-of-factly as they now turn to the expert in physical illness.

Thus it is good news that a new approach has been developed whereby everybody whose business is dealing with people is on the mental health team. We began to think

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of the physician, the minister, the teacher, the foreman, the policeman, and certainly the nurse, as key people. Each of these groups has its own specific sphere of influence, and it is essential that each of them is aware of its role. In this article we would like to consider the contribution of the public health nurse, who has the double advantage of coming to the scene early and, by and large, being really eager to play her part in a preventive mental health program.

## Who is the Public Health Nurse?

Dr. Richardson describes the Public Health Nurse aptly when he says:

> "The Public Health Nurse bears a resemblance to the doctor in her interest in medicine; to the bedside nurse in her basic training; to the medical social worker in her knowledge of the community and its medical resources; to the family case worker in having a base in the community and an interest in the family as the fundamental unit of practice. The difference which is constant for all of these is her interest in prevention through which she gets into action earlier than the others, often before the disturbances of the family equilibrium have taken the form of an illness."¹

She is known under different names; she may be called community nurse, visiting nurse, county nurse, state nurse, public health nurse, and these different names may or may not mean a difference in the type of service she renders. She may be employed by a tax-supported agency like the city or the county health department, by a Red Feather agency, or by a combination service jointly administered by an official and a non-official agency. She may offer a broad, generalized service, including bedside nursing care in the home, and health supervision of expectant mothers, infants and pre-school children, while acting at the same time as the school nurse in the community. She may be active in the control of tuberculosis and other communicable diseases and carry out

the duties of an industrial nurse in small industries which need part-time nursing service for their employees. Or she may specialize in one kind of work and carry out only a part of these and other duties.

## A natural point of contact.

Whatever the specific conditions of her work may be, the public health nurse comes in a natural, easy manner into the lives and homes of a great number of people. It is not usually an acute emergency that causes her visit; as a matter of fact, public health is rarely dramatic-nothing, as Dr. Richardson puts it, "to write home about ... The essence of prevention is that nothing untoward happens."² Nevertheless, she is present at a crucial point in the life of a person or a family: sickness, frequently nowadays the long siege of chronic illness closing in; a new life in the process of being created; a brand-new baby to love, to care for, to worry about. She brings to these situations certain skills, experience and knowledge of an immediately convincing, practical nature, which provide an easy entrance and make her a person to be known and trusted by a large percentage of the population.

While the public health nurse has enough professional status so that she is usually listened to with a certain amount of confidence, this is not so awesome that people hesitate to speak frankly to her. Dr. Gerald Caplan³ speaks of the nurse's special effectiveness as arising from her closeness to people, and points out that in many countries the nurse is called "sister."

## Knock at any door

The public health nurse has been making the rounds in the cities and towns, the farms, houses and hamlets for more than 50 years. Fifty years ago her task was to fight death, disease, and poor sanitation. Today, though by and large a healthy baby crop is raised in the U.S.A., childbirth has been made so

² Ibid.

¹ *Patients Have Families* by Henry B. Richardson, in "The Commonwealth Fund", New York, 1948.

³ *The Mental Health Role of the Nurse in Maternal and Child Care* by Gerald Caplan, in "Nursing Outlook," January 1954.

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much safer, and most young interns and nurses have never seen a case of diphtheria or childbed fever, her day is not less busy. But it is filled with different tasks, and her visits in the homes, her work in the clinic and school and in industry have a different emphasis.

How is the day of a public health nurse spent now? Let's take a visiting nurse, employed by a Red Feather agency, and follow her rounds. More than probably her morning will be filled with bedside nursing care—patients with heart and vascular diseases, cancer, diabetes topping the list. Depending on the town and district she works in, she might visit in the housing projects, in the slums, in the so-called best neighborhoods. (It may be interjected in this connection that public health nursing agencies charge a fee, based upon the actual cost per visit, from those who can pay it, with provision for adjustment for those who can only pay part of it or cannot pay at all. It is a common misconception that public health nursing is a service for only a segment of the population, the underprivileged.) With the few exceptions of patients living in rooming houses or otherwise alone, she will meet family groups. Suppose grandmother, who has had a stroke, lives with her married daughter and a family of young children. The nurse is trained to consider the family group as her unit, and while she comes to give Grandma her bath and her massage and exercises, as she teaches the daughter to care for her in between her visits, she feels responsible to see to it that family life does not suffer unduly. Petey, age five, is getting very whiny and underfoot. His mother, who has her hands full, regards him as nearly a man, as compared with Barbara, age two-and-a-half, and the baby of seven months. When the nurse, in packing her bag, remarks to the mother that Petey seems out of sorts nowadays, it is as if she has opened a floodgate. He was such a good little boy, the mother says, and now he is getting really mean, actually hurting the baby if she leaves them alone; and while he was completely trained and knows

better, he wets his bed now every night.

The nurse is aware that these are symptoms of stress and that there are no hard and fast answers or recipes to solve them. In many cases she will find that her attentive and sympathetic listening, her warm and non-critical interest, do much to break the vicious circle between a mother, who may be demanding too much at a given time and is disappointed in her child, and the child who responds with unhappiness and slipping backward. If the trouble is more basic, she may use her friendly relationship with the family to make the idea of outside help acceptable and desirable.

## The importance of prevention

We have described here a situation of secondary prevention, because already there was some trouble brewing. The most important part of the public health nurse's health guidance is primary prevention; it is "anticipatory guidance," a somewhat cumbersome and awe-inspiring term, which really means just forewarning, helping parents to know what to expect next. She has a good opportunity to do just that in our family, because the baby, still indiscriminately friendly and jovial now, will soon notice the difference between kin and strangers—a compliment to his intelligence as well as to his family loyalty but nonetheless something which often distresses mothers. It will be comforting for the mother to hear that Barbara, who says "no" as the first word upon awaking is not getting mean, but just finding herself as a person who has a will of her own. She might also inquire whether the daughter has a babysitter—it is important for her to get out with her husband once in a while. This all is as much a part of public health nursing as the injection, the bath, the exercising of weakened muscle. It is time-consuming and explains why the public health nurse of today is kept busy in spite of the improved health of the population.

Her afternoon might include a visit to an expectant mother. Here, if anywhere, anticipatory guidance is indicated, especially if this is the first baby. One is reminded of the

24

story Cornelia Stratton Parker⁴ tells, when she enlisted the advice of Sigmund Freud on her projected classes for mothers, in an early attempt in 1923 at organized parent education. Upon his objection that it would be too late, as the mothers coming to her would already have started their children wrong, she announced with some pride that these classes were for expectant mothers and that she would be able to exert an influence upon the babies not yet born. "It won't do any good," he repeated. "You would have to get the mothers before they were born." This actually is what public health nurses are attempting, for many of the oldtimers are attending the second generation in the same family.

## Any starting point a good one

The nurse feels confident that any starting point is a good one, but that an especially good one is when a new life begins again. Again the point of departure is the nurse's interest in the mother's physical condition, her appetite, sleep, physical exercise, and weight. She knows that pregnancy is a time of changing emotions and ambivalent feelings and that in most women the joy of expectancy is accompanied by an undercurrent of apprehension concerning the coming events which truly will change her life forever. Being aware of these mixed feelings, the nurse will react sensitively to expressions of doubt, uncertainty, and fear. She'll try to reduce concern about the unknown: the hospital and its procedures, the mechanism of birth, the mode of anesthesia to be used, etc.

She may have to listen somewhat more intently and with "the third car" to catch undertones of which the mother-to-be herself is only fleetingly aware: "What kind of a mother am I going to be? Is it really happening to me? Everything seems so unreal; one moment I want it, and the other moment I wish it had not happened." If the mother feels understood, and sees that her concerns are not belittled, she will be reassured

by a feeling of kinship with the millions of women undergoing the same experience. The nurse nowadays might invite the mother to attend one of the classes for expectant mothers or parents conducted by her or another public health nurse. Group teaching of that kind is gaining momentum, not only because it is more economical to teach ten or fifteen mothers together instead of one by one, but because people in groups come out with different answers which have more significance for them and are more likely to be translated into action. The nurse will be counted upon to provide facts and material for discussion, as well as to demonstrate certain nursing skills, letting the parents get "the feel of it." This provides real reassurance.

## The child health conference

Another much-used opportunity to reach groups is the child health conference, in which the public health nurse and the pediatrician, in conjunction with volunteers, periodically evaluate the child's health status, and give immunizations and parent counseling. In most clinics, the criterion for admission is that the parents cannot afford continuous private pediatric service for their children. The physician is unquestionably the leader of the conference team, but again the mothers see the public health nurse as a helping link and as being "close." "The doctor tells you what to do and the nurse tells you how to do it,"⁵ was the spontaneous phrase used by one mother to describe their respective roles.

Cooperation between physician and nurse takes on different forms in different conferences; often the nurse interviews the mother before she sees the physician. He is to many mothers a "status" person, not to be bothered by "trifles" like John's recent orneriness, Mary's crying spells whenever she is put on the potty, or Billy's habit of fighting sleep and acting scared as soon as the lights are turned out. Problems like this are more easily brought to a nurse who is

⁴ Wanderer's Circle by Cornelia Stratton Parker, Houghton Mifflin Company, Cambridge, 1934.

⁵ Reasons for Attending Child Health Stations, by Mary L. Foster, in "Public Health Nursing," March, 1952.

25

good at listening and helps to bring the story out by well-timed questions. If a mother needs more time than can be given in a conference, the nurse will visit the home. Such a home visit often reveals difficulties of an objective or subjective nature which may be preventing a particular mother from using the advice, reassurance, or practical suggestions given.

## All in a day's work

The examples given are representative, but in no way cover the field. The mother of the newborn, with her own folks miles and miles away, as is often the case, is a very receptive client for public health nursing service. There are few services as gratifying as helping a young couple (because the father is not the forgotten man, though, as any public health nurse will tell you, it is very hard to meet him at home between eight and five). Steering them through the uncertainties and fumbling of the first few weeks with the baby to the full enjoyment stemming from self-confidence is a satisfying experience.

The nurse in the school finds many children whose frequent appearances in her office signify that they need a friend, whether their troubles are physical or emotional.

In visiting children with temporary or chronic illness, the nurse has an opportunity to help lessen the threatening and painful aspects of this experience. Even with a rheumatic heart or diabetes the child still has to be seen as "a child first" and all the necessary modifications of his life have to be made with this consideration constantly in mind. Referral of a child to a hospital is not a routine procedure today for the public health nurse; it requires all of her skills in "anticipatory guidance" and interpretation to both parents and child. The saying that most people can stand what they understand is especially true for children.

These, and many other situations, are all in a day's work. They have nothing to do with therapy or the re-shaping of other people's personalities and lives. But they have to do with "the normal problems in the nor-

mal experience of normal people."⁶ Those problems need to be identified, understood, and dealt with as they occur. The infinite variety of these situations means that the Public Health Nurse's contribution is limited only by her own vision, her understanding of her function, her knowledge of human nature (her own uppermost!) and her willingness to make herself available to the people who need her.

## The know-how

How does a public health nurse acquire these prerequisites? Some of them have to do with knowledge and understanding of the wide fields of public and mental health; some with her own personality which, like any other member of one of the helping professions, she has to develop and use consciously as part of her professional equipment.

The schools of nursing have broadened their curriculum considerably within the last 10 years. They have made room for sociology and psychology. Courses on growth and development have gained momentum, focusing on the well child in order to understand the sick child and not vice versa, and utilizing a one-week to two-months experience in a nursery school for normal children. For some time, accredited schools of nursing have been required to give the student a minimum of three months' work in a psychiatric hospital. This will not make a psychiatric nurse out of her, but will give her an opportunity to learn something about how the human mind operates, defends itself, strives for equilibrium and deals with stress. The class instructions are designed to afford her more insight into herself, as well as a deeper understanding of human behavior in the so-called normal person.

## New teaching methods

Knowledge, of course, is not everything. It depends on how this knowledge is conveyed, since the finest course in interpersonal relations will be convincing only if it is given in a climate of freedom and respect

⁶ The Trials of Normalcy by Iago Galdston, "Mental Hygiene," January, 1956.

26

for the learner. It is fortunate that the pro-
gressive schools of nursing have shaken off
a good deal of the military tradition of the
earlier days and that many of the features
of modern education, as for instance, stu-
dent government and guidance programs,
have been adopted by them.

Over and above what the nurse learns
nowadays in her basic training, a fully qual-
ified public health nurse has to have either
a degree from a university program in nursing, approved by the National League for Nursing for its public health nursing content, or at least one year of study in a program for public health nursing also approved by the League. Programs of either kind contain, among other subjects, mental health, personality structure and development, cultural and anthropological factors, counseling, interviewing, and group dynamics.

Because so much depends on the public
health nurse's personality, her relation to
people, her appreciation of human effort

and sympathetic understanding for human
frailties, it is essential that she find good
leadership and an opportunity for personal
and professional growth. It is generally
recommended that in addition to academic
preparation, the public health nurse work at
least two years under qualified supervision.
This is an additional safeguard to ensure
professional competency and a disciplined
use of herself.

Some question has been raised at times as
to whether the functions of the public
health nurse as a family counselor and
friend make her intrude into the field of so-
cial work. It would rather seem that they
give her unchanging role on the health
team a deeper meaning and a wider scope.
We need nowadays nothing so sorely as
the care and protection of our human re-
sources. As in Biblical times, "the harvest
truly is plenteous, but the laborers are few."
We cannot miss any team member who is
willing and capable of being a friend to
parents and families.

Rooming-in
—a decade's experience

By Margaret C. Dawson

That a newborn baby should stay close to its mother was taken for granted for centuries. Yet a decade ago, this was not possible in U.S. hospitals. In 1946, a "new" program called rooming-in was introduced. Reports from two hospitals indicate progress and problems to date

Exactly ten years ago, as this article
is being written – in October 1946 – an
experimental unit was added to the ma-
ternity services at the Grace-New Haven
Community Hospital in New Haven, Con-
necticut. This unit was a converted solar-
ium with four cubicles and a partitioned-
off night nursery with nurse's station. The
walls were painted a soft rose, the curtains

were of gay chintz. The partitions between
the cubicles were glass above 30 inches,
with draw curtains, and stopped three feet
short of the ceiling to allow for good ven-
tilation and light, and easy communica-
tion, but also to permit privacy when
wanted. In each little roomette thus cre-
ated there were, besides the usual hospital
bed and other necessary equipment for

27

maternity cases, a basinette and a storage
space for supplies for a baby – and it was
these items, as well as the comfortable,
homelike atmosphere of the whole arrange-
ment, that told the story. For this was a
pioneer experiment in the application of
a new idea: rooming-in¹.

It has many times been pointed out that
having a baby remain close to its mother
during the first days of its life is not a new
practice, but one as old as the race. Never-
theless, it was a break with hospital rou-
tines prevalent in this country for the last
four decades, which decreed the separa-
tion of mother and child except at sched-
uled feeding hours. In any case, the nov-
elty of the procedure is not so much of
interest today as its present status after a
ten-year trial. Is it still advocated by those
who introduced it? Have mothers (and
fathers, too) benefited from it? Does it
seem to help the baby get a better start?
Do hospitals find it an administrative bur-
den or a convenience? How do nurses re-
act to it? Are there discomforts or disad-
vantages connected with it? Is it a goal
toward which more parents and hospitals
should work?

Programs and philosophy

The answers to many of these questions
demand data as yet not available. This ar-
ticle can only attempt to give some reflec-
tions on the program as it now functions
in New Haven and in a New York City
hospital and to review some of the phil-
osophy and history behind such programs
wherever they have been instituted.

Like most ideas with a future, rooming-in
had a complex origin: no one person
"thought it up." The term itself was first
used by Gesell and Ilg in their book *In-
fant and Child in the Culture of Today*,
published in 1943. The concept received

important impetus from an article in the
Winter 1944-45 issue of *Child Study* called
"Two Mothers Revolt" by Frances P. Sim-
sarian and Roberta W. Taylor protesting
against separation of mother and baby un-
der hospital rules. Dr. Edith B. Jackson,
who directed the Yale Rooming-In Project
at Grace-New Haven Community Hospi-
tal, says that she first heard mention of a
hospital plan for rooming mothers and in-
fants together from Dr. John Montgomery
of the Cornelian Corner in Detroit at a
meeting of child development specialists
in 1938. It was, Dr. Jackson says, "in the
air."

Several factors, besides general interest,
propelled the idea out of the realm of talk
and into that of experimental action. First,
it fitted well into current psychiatric con-
cepts which were then stressing (perhaps
even overstressing) the effect of a child's
early experiences on his future develop-
ment. Second, a number of mothers, like
Mrs. Simsarian and Mrs. Taylor, were
strongly stating their objections to the im-
personal, routinized atmosphere of the
whole hospital experience and to what
some called the "cruelty" of the separation
from their babies. Third, there was grow-
ing interest in flexible feeding schedules,
and it was obvious that here was a nat-
ural and practical tie-in between the "de-
mand" feeding prompted by nature and
the nearness of the baby to his mother.

It was particularly thought that room-
ing-in would offer encouragement to the
mother who wanted to breast feed her
child, since patient and repeated help from
the nurse is often a great asset in helping
the mother to breast feed successfully. In
the New Haven project the mother's desire
to breast feed was at first made a prere-
quisite for admission to the rooming-in
unit. This criterion was dropped when a
second rooming-in unit was opened, as it
was found that mothers intending to bot-
tle feed were just as anxious to have room-
ing-in, and derived as much satisfaction
from it. Now, about half the rooming-in
mothers there breast feed their babies.

¹ A series of single-room experiments had been carried on here since June 1944. Other early hospital experiments with rooming-in were made on a small scale in the George Washington University Hospital in Washington, D. C., in private rooms as early as 1941; and in the Los Alamos Hospital at the Atom Bomb Project from 1943 to 1947. In 1948 the new George Washington University Hospital became the first modern hospital to be planned and constructed with various types of rooming-in accommodation on the maternity wing.

28

The basic assumptions behind the rooming-in plan in New Haven, as stated in a report by New Haven staff members, are "that a mother's satisfaction with herself and with the attention and care bestowed upon her (by husband, parents, members of medical and nursing staff) is the best guarantee for her inclination and ability to satisfy and comfort her baby; ... that the infant's contentment not only bolsters the mother's self-confidence, but is the first requisite for his unimpeded growth and development ... for his uninhibited capacity to learn, and for his gradual acceptance of the disciplines and demands imposed by family and community life." This philosophy is also that of the rooming-in program of the Lying-In Hospital, a unit in that vast medical center known as The New York Hospital—and of other institutions where the method is now used.

### A small seed

It may be wondered whether these are not rather lofty goals to strive for, especially in the shortened maternity hospital stay of today, which may be only five days in the New Haven Hospital and covers an average of six to eight days at the New York Lying-In. Perhaps; but the quality of human relations cannot be measured in terms of time. If rooming-in sows only a small seed of assurance and relaxation, of family unity and warmth, it proves its worth.

Miss Verda F. Hickcox, Head of Obstetrical and Gynecological Nursing Service at Lying-In, and an ardent believer in the rooming-in program which she has guided since its inception, puts it this way. The let-up, she says, serves to "introduce" the baby to his mother; to give her more confidence in her own abilities; to prevent the fragmentation of the family which occurs when the mother and baby are treated as separate units, so to speak, and the father is a virtual outsider (for fathers, as we shall see, play a vital part in the rooming-in scheme of things); to give the mother some information about the care of the baby and of herself both during and after the hospital

stay; to give her a chance for observation and actual practice in the care of her baby while there is someone available to help her with every step; to introduce her to community resources that she may turn to after she leaves the hospital; and to make a plan for the continued care of the baby.

### Introduction to the baby

Why does a mother need an "introduction" to her own baby? Because, for one thing, each baby has his own reactions, temperament, rhythms. Something that is just "his way," may seem to the mother a startling deviation from what she imagines is "normal." Why does he "startle" that way at some sounds when her neighbor's child sleeps on peacefully? Does the mottled look of his skin mean that "something is wrong"? The unexpected sneeze or hiccup—have they some ominous significance? The baby may spit up, or have a bowel movement of a color that seems very strange to the inexperienced mother. Where there is a skilled and interested nurse at hand to give her individual attention, questions are more readily asked by the mother—and if they are not, the watchful nurse may slip in an observation as she works with the baby, or unobtrusively guide one of the informal discussions that so readily spring up among mothers in the friendly setting of a small room and a shared interest. A mother recently interviewed about her rooming-in experience said:

"As far as the baby [goes], I think it's kind of important to get used to it. Some like to be held more, and you have to know your baby, and it seems to me you have to know them very soon or they're going to be miserable, and you're going to be miserable if you don't know which cry means what, and you keep shoving food at them every time they cry."²

### Introduction to motherhood

And there's another side to it which concerns not so much, perhaps, getting to know

² Quoted from a verbatim interview in *Nurse-Patient Relationships in a Maternity Hospital* by Marion S. Lesser M.A., and Vera R. Keane, B.S., R.N., C.N.M., published by the C. V. Mosby Co., St. Louis, 1956.

29

your own baby as being introduced to
motherhood itself. A nurse, speaking of
this aspect, said:

"Most people, and mothers too, have an idea that mother love just sort of turns on like a tap. It doesn't work that way—and they get to feeling very guilty and anxious about it, and they think they're a freak because they don't feel the way they ought about their baby. I think a whole lot of them go through that and don't say anything. I think you can do an awful lot to help them, and to ease them through if you just have an idea that somebody is going through something like that. If you can sit down and start talking to them, and sort of get across that most mothers do go through that kind of experience—that it's normal. And if they let themselves have the time to get used to the baby, and to discover that the baby is a person, they'll learn to love their baby—but that it does take time, and they shouldn't feel upset about it if it does."³

There is also the question of the well-known post-partum blues, which call for understanding support from the nurse, doctor and family. As one nurse remarks: "I don't think people appreciate how high a woman is emotionally, when she's ready to give birth. It's a very high spot, and she comes way, way down."⁴ The young mother is fortunate who is told sympathetically—and not too briskly—that this is a passing phase.

## Rooming-in helps the father, too

It is not only the mother who needs introduction to the baby, and it is one of the great advantages of rooming-in that it gives the father a much better chance to feel that the baby is his, too—to indulge his pride and show his tenderness and learn the first steps that can make its future care more of an enterprise to be shared by him and the mother. The father whose first real family experience in the home is that of helplessly watching a flustered and nervous wife care

for a "little stranger" may find the glow of
fatherhood a bit dimmed. Rooming-in aims
—though it cannot guarantee—to prevent
this from happening.

In the Lying-In Hospital's program, fathers may see their wives and babies after delivery, and at any visiting hour thereafter, from three to four in the afternoon and seven to eight in the evening—the evening hour is reserved solely for fathers. In the New Haven rooming-in, there are also two visiting hours, one in the afternoon and one in the evening, but only one visitor—either the father or grandparent—is allowed by the bedside at any given time.

In both hospitals the father, after washing his hands and putting on a gown, may try his hand at holding the baby, bottle feeding it, bubbling it or perhaps changing the diaper. He will no doubt be interested in the baby's day chart, which in the Lying-In is the nurse's responsibility but may be kept by the mother too, and which shows the baby's activities, weight, feedings, times of bowel movements. Or he can just sit and get used to his baby and learn a bit what to expect of this mysterious little creature and begin to sense what it will be like for him and his wife to be a father and a mother. This is quite a different matter from peeking at a squirming bundle through a glass pane and then going to visit at his wife's bedside. The father of a baby born in the New Haven Rooming-In unit said, "It is a tough experience for a father who has known and loved his wife and then cannot see either his wife or baby for a while, and then, afterwards, the baby most infrequently. I believe it can be the cornerstone to start differences in the family—where the baby belongs to the woman alone, where the father is excluded..."⁵

## Some questions

So far, this report has reflected the enthusiasm of both staff and parents participating in the two programs referred to. The literature about rooming-in is full of glow-

³ Ibid.

⁴ Ibid.

⁵ Report on a panel discussion reprinted from "Journal of the American Medical Women's Ass'n.," Vol. 9, No. 3, March, 1954.

30

ing reactions from mothers — who often choose to repeat the procedure with second, third and fourth babies. There does seem to be, as one parent said, “an aura of happiness” about it. Yet for all this, the mother-to-be may hesitate to choose this system. She may have many questions—the most frequent one being: “Won’t it interfere with my rest?” She may think that the learning process which is part of rooming-in will be too much of a chore and will spoil the little holiday she badly wants before assuming home responsibilities. Many wonder how, in a week or less, they can learn anything they can’t pick up quickly at home with the help of relatives, doctor or visiting nurse.

To give such people some further basis for deciding, it may be useful to review the rooming-in process step-by-step as it is carried out in the New York Lying-In. But before doing so, it should be said that no one who feels a real resistance to rooming-in, even when she knows how it works, should feel that she “ought” to choose it. As with breast feeding and “natural” childbirth, there are legitimate differences in individual reactions to this idea. And with rooming-in, the whole point—to send home a mother and a baby who feel comfortable together and a father who feels part of the team—would be lost if strong feelings of reluctance were involved. Moreover, facilities for rooming-in still are not widely available, and most parents will have to

## Children's hospitals abroad

A three-way conference of architects, pediatricians and administrators on new directions for children's hospitals was held at the International Children's Center in Paris this June. Delegates considered problems and principles in planning a children's hospital, as well as ways and means of bringing to the hospital setting a warmer, “maternal” atmosphere. The group stressed the key role of preventive medicine and urged close working relations with families, family physicians and public health agencies. In another recommendation, the group called for facilities which would permit mothers to stay in the hospital whenever this course seemed advisable.

continue, as in the past, to swing into the rhythm of family living without benefit of this short period of preparation.

## Program at the Lying-In

At the Lying-In hospital, then, the steps are somewhat as follows. We say “some-what” because it is a basic principle here that no mother shall be pushed into doing things before she wants to—she will be allowed and encouraged to go at her own pace.

There will be a bit of orientation any time after delivery that the mother feels ready for it, to brief her on the activities of the hospital day, on visiting hours, and such formalities as the birth certificate. She will be introduced to the other patients in the room and to the nurses, and will be told about the call system and the chaplaincy service. Perhaps, if she feels like it, there will be a little discussion of the general philosophy of rooming-in, during which she can bring up questions or state her ideas and hopes in the matter.

As soon after the birth as the mother wishes—not necessarily the first day—she will see her baby receiving “morning care” and will be told about various aspects of the process. She may want to try doing some things herself. In any case, as she watches her baby being cleansed, a dozen questions may come into her mind. Even if she hesitates to ask all of her questions, the skillful nurse will slip in a comment and will, for instance, explain about the fontanelle (the soft spot in the skull), the care of the genitalia and other parts of the body. Morning care is an individual demonstration, given at each mother's bedside, but it often turns into a general discussion as other mothers listen and raise their own questions.

Then—again, the time is flexible—comes the moment when the nurse asks, “Would you like to try holding the baby?” Beforehand, probably every mother thinks that at least she will know by instinct how to hold the baby. But when she actually sees it—so tiny, and squirming, or just lying there

31

without giving any particular sign of en-
thusiasm or cooperation—it suddenly seems
a mighty task. It is good to have the nurse
there to show where the baby needs sup-
port, what is the most comfortable position,
how to relax.

Next, mothers may learn how to take the baby's temperature and how to dress it. Feeding, of course, comes in for fairly extensive discussion and demonstration, whether the mother is breast or bottle feeding her child. And a demonstration of diaper changing will soon be in order. Gradually, in all these matters, the nurse and mother exchange roles, until it is the nurse who is the observer, and the mother the star performer.

During her hospital stay the mother learns a good deal about herself, too—how to keep herself comfortable, what are the steps in the return to normal living after she gets home, and when to attempt them. Although she will be up and about far earlier than used to be the practice, and will be doing for herself many things formerly done by the nurse, she will be most strongly urged to rest, and then rest some more. (Many patients, incidentally, report that they feel so well on getting home from the hospital that they take on all sorts of activities, only to have fatigue “hit them” the second week. Wise the woman who heeds the nurse’s advice to rest as much as possible at home during those first days, as well as before she leaves the hospital.)

In addition to individual help and in-
struction, the mother may, if she wishes to,
attend four different conferences which are
open to all maternity patients from both the
rooming-in and non-rooming-in floors.
These are:

1. A demonstration of the daily care of the baby, including a tub bath given to a live baby, discussion of equipment and clothing and of any questions that come up.

2. A discussion of breast feeding, which is “really conducted by the mothers—they ask so many questions.”

3. A demonstration of formula-making, done by the hospital nutritionist.

4. A conference with the resident pedia-
trician who is responsible for the babies in
the nursery, and who takes up with the
mothers such diverse questions as when to
take the baby outdoors; where and to whom
to go for further care of the baby (if the
patient does not have a private pediatri-
cian); care of the navel; thumbsucking, and
various other matters, including the relation
of the new baby to other children in the
family.

Reactions from "alumnae"

If this procedure seems to reinforce the
fear of the doubter that rooming-in will cut
into her rest and freedom, reassurance
comes from "alumnae" with both rooming-
in and non-rooming-in experience who, al-
most without exception, say that they found
the former the *more* restful of the two. One
reason for this is that the mother who hears
a wail from the nursery down the hall is
usually sure it comes from her baby and is
wakeful and nervous because she fears
nothing is being done to comfort it. Where
mother and baby are together, the crying
baby is quickly cared for, either by mother
or nurse, and except for the colicky baby
or the occasional chronically fretful one,
there are no prolonged sounds of distress.
On the contrary, Dr. Jackson reports that
visitors and doctors both have been amazed
at the atmosphere of calm and peace that
pervades these rooming-in units. Further,
Miss Hickcox says that experience at the
Lying-In shows the patient on the rooming-
in service tends to nap more than the one
who, left to her own devices, becomes rest-
less and spends her time wandering around,
visiting other patients, listening to radio,
reading, etc.

The concern with intangibles

The patient who is not eager to under-
take an educational process at this time
must remember that she will not be pushed
to do so. Though roomers-in are presumed
to be more or less interested in picking up
information and practice, the philosophy of
rooming-in is basically more concerned with

32

such intangibles as feelings, attitudes and relationships than with techniques. One proof of this is that women who already have one child or more at home still feel that there is an advantage in getting to know the new one—the always different one—from the very start. (A mother with four boys recently chose rooming-in because she was sure the fifth was going to be a girl and thought both she and the father would need "some time to get acquainted with a girl.")

## Modifications

Since the introduction of rooming-in, there have been modifications of procedure both at the Grace-New Haven Hospital and at the Lying-In. Both found that the original plan of having the babies with their mothers around the clock did not allow enough uninterrupted sleep for the latter, and both now keep the babies in the nursery overnight. At New Haven, this was at first optional, but the mothers themselves pointed out that when it was left completely up to them they felt under moral pressure to demonstrate their motherliness by keeping the baby at the bedside. Following this tip, the nurses took the initiative in advising removal of the babies from the mothers' bedside during the night. This became routine procedure when it was found that the great majority of mothers preferred it.

In New Haven, the feeding was at first completely "ad lib"—as often and as long as the baby seemed to want to stay at the breast. Some mothers took this to mean that every whimper was a call for food, and that it must be answered instantly. Since both mother and baby reacted badly to this extreme interpretation, a general rule was introduced: that the baby be fed not oftener than every two hours, although the interval might be longer if the baby were sleeping. The time of the breast feeding was not definitely limited after the first few days, as the traditional twenty-minute period often is insufficient and is hard for the mother to maintain after she gets home.

Another modification has had to be in-

introduced under certain circumstances because of the nursing shortage which has plagued most big hospitals all over the country for more than a decade. One registered nurse to every four mothers and babies can do a good job under the rooming-in set-up, but if she must handle more, some of the finer points get overlooked. Miss Hickcox is frank to say that fluctuations in the nursing staff, with consequent variations in the program, are the "big heartbreak," and that some patients who have chosen rooming-in because of friends' glowing recommendations are disappointed for this reason. The hospital that does not have to cope with a similar nursing shortage today is rare indeed.

## Developments elsewhere

This brings us to some comments on the extent of rooming-in facilities and the response of various hospitals and doctors to it throughout the country, as well as the attitude of the general public.

A report on the Yale project published in 1953 showed that obstetricians, pediatricians, child psychiatrists and teachers of nursing all saw important values in it from the point of view of their own specialties. There were those, too, who looked on it as a stimulus for better hospital architecture and administration. Informally gathered data from a conference on *Problems of Int fancy and Childhood* in 1950 showed as many as 50 hospitals in the U.S. which offered some form of rooming-in, and doubtless a number of other hospitals have since been added to the list. But parents who are enthusiastic about the rooming-in idea and yet cannot find nearby facilities for the experiment may not feel that this is a very encouraging showing.

It must be remembered that the change from traditional procedures to rooming-in presents many difficulties for the hospital. There is an understandable reluctance on the part of some doctors and nurses to break with accepted routines. New facilities are expensive. The widespread nursing shortage also complicates the situation in

33

some hospitals, though it is interesting to
find that in others, rooming-in has been
adopted just *because* of this shortage. With
the early ambulation of maternity patients,
it has been found that the mother who has
her baby nearby can actually be of help to
the nurse, and provides careful supervision
for the infant. (The U.S. Military Hospi-
tals, for instance, seem to have instituted
rooming-in plans as routine maternity care,
perhaps for this reason.) It is also inter-
esting that whereas the central nursery was
originally introduced to protect infants from
infection, rooming-in is now frequently seen
as a way of preventing epidemics—reports
from teaching centers show either no, or
reduced, incidence of cross infection among
babies cared for by this method.

One other consideration may have some
bearing on the seemingly slow spread of
rooming-in; it may be that despite fairly
wide publicity in the initial experimental
phase, rooming-in has not been requested
by a large number of young mothers and
fathers—either because they do not know
about it or because they see it as merely a
“new wrinkle” in maternity care. Actually
it is part of a broad trend working toward
the restoration of some human values in
family life that have been sacrificed to
scientific advances. Prenatal classes, na-
tural childbirth, rooming-in, flexible feeding
schedules—all these are part of this trend.
It is true that an individual parent may
choose one or some of these methods while
rejecting others; and it cannot be said too
often that the right to consult one's own
tastes, capacities and spontaneous responses
in all these matters should be safeguarded
at all costs. However, this new-old philoso-
phy has a far outreach—it has already been
reflected, for example, in the hospital care
of older children described elsewhere in
this issue of *Child Study*. It may not be too
grandiose to see it as part of an even larger
effort of tremendous importance in today's
world—the effort to strike a better balance
between the swift onrush of intellectual
knowledge and the abiding truths of the
heart.

News from other hospitals

Two articles in this issue of CHILD STUDY
report on interesting new developments in
the pediatric programs of the Boston Float-
ing Hospital and the Hunterdon, N.J.,
Medical Center. Below we note briefly
some experiments and innovations being
carried on in other parts of the country.

The Children's Hospital of the East Bay
in Oakland, has, for the last six years, been
testing ways of helping children adjust to
hospitalization. These efforts include: prep-
aration of parent and child before admi-
sion; a relaxed visiting policy; encourage-
ment of parent participation in the child's
care. A booklet, "What My Parents Should
Know," is given to parents before the child's
hospitalization, and suggests that the child
will be helped if he knows beforehand
about such things as bed baths, hospital
procedure at mealtimes and play activities.

At the *Hospital for Joint Diseases* in New
York City, parents, and children old enough
to talk about their feelings, are interviewed
before the youngster's admission by a social
worker, who frequently takes the child to
see the children's ward and to meet the
nurses, occupational therapists and other
members of the staff. Daily visiting hours
at this hospital are from one to six p.m.,
and fathers, as well as mothers, are en-
couraged to visit often. The chief nurse on
pediatrics, the senior social worker from
pediatrics, the children's occupational ther-
apist and the hospital teacher daily discuss
ways of relating their services to the all-
round care of the individual child.

A highly developed recreation program
is carried on at the *Children's Hospital* in
Cincinnati. Staffed by six full-time workers,
this program offers morning, afternoon and
evening activities. In addition to three
people trained in child development, two
in elementary and art education, and a
trained nurse-aid, some 40 volunteers do
two or three hours' work twice a week. A
full-time librarian is in charge of the chil-
dren's library, which has nearly 3,500
books.

34

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DR. BAYARD CARTER, NORTH CAROLINA, ELECTED PRESIDENT OF THE AMERICAN COMMITTEE ON MATERNAL WELFARE.

CHICAGO: The Seventh American Congress of Maternal Care, Sponsored by the American Committee on Maternal Care held at the Palmer House, June 7-12, 1957, came to a close after five full days of conferences and technical discussions.

Samuel B. Kirkwood, M. D. of Boston, Massachusetts, Program Committee Chairman, disclosed that during the five day meeting, 150 Round Tables and 200 Breakfast conferences were held.

30 Scientific Exhibits were displayed, Committee Chairman, William J. Dieckmann, M. D. of Chicago, Illinois. 70 Technical Exhibits were shown, Edward M. Dorr, M. D. of Chicago, Illinois, was Chairman of Committee on Technical Exhibits.

The Congress Banquet was attended by 500 people. Program Chairman, Frederick H. Falls, M. D., of River Forest, Illinois.

Local Arrangements Committee consisted of Robert A. Beebe, M. D. of Chicago, Illinois, and Martin W. Green, M. D. of River Forest, Illinois. Mrs. Joseph P. Greer was Chairman of the Ladies, Entertainment Committee.

Edith B. Jackson
Program

SEVENTH AMERICAN CONGRESS ON MATERNAL CARE

Sponsored by

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WHAT IS IT?

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## SCIENTIFIC AWARDS:

**1st Place:** A Study of Fetal Cardiac Energy, Edward H. Hon, M. D., Orvan W. Hess, M. D., Yale University School of Medicine, New Haven, Conn.

**2nd Place:** Fetal and Maternal Circulation of The Uteroplacental Organ, Carl T. Javert, M. D., Leon Metyloff, M. D., Stanley J. Birnbaum, M. D., William Davis, M. D., Women's Hospital Division of St. Luke's Hospital, New York, New York,

**3rd Place:** Preparation For Childbearing, Teaching Aids For Obstetricians, Hospitals, Health Departments and Other Agencies Engaged in the Instruction of Expectant Parents, Hazel Corbin, R. N. Director, Maternity Center Association, New York, New York.

## HONORARY MENTION:

The Role of Anesthesiology In Preventing Maternal and Infant Mortality, William A. Cull, M. D. Robert A. Hingson, M. D., Western Reserve University School of Medicine, Cleveland, Ohio, Walter A. Tillman, M. D., Oral B. Crawford, M. D. Springfield,

The Body Fluid Imbalances: A Bird's Eye View M. D. Snively, Jr., M. D. Micheal J. Sweeney, M. D., R. V. Kron, M. D., St. Mary's Hospital, Evansville, Indiana.

Congenital Handicaps From Malnutrition, The Importance of Adequate Nutrition Preconceptually, Elmer L. Severinghaus, H. Pfaltz, Hossmann-La Roche, Inc. Nutley, New Jersey.

The Significance of Melituria In Pregnancy, Milton Gross, Robert V. Dorfan, Robert E. Sexton, Margaret Hague Maternity Hospital, Jersey City, New Jersey.

Rooming-In Care, Edith B. Jackson, M. D., Yale University School of Medicine and School of Nursing, Grace-New Haven Community Hospital, New Haven, Connecticut.

SUPPLEMENT TO BIBLIOGRAPHY ON ROOMING IN APPEARING IN
"FAMILY CENTERED MATURITY AND INFANT CARE," PUBLICATION OF
THE JOSIAH MACY, JR. FOUNDATION, NEW YORK (1950)

1. Berlin, Ingeborg. A student looks at rooming-in Amer. J. of Nursing, 50, 316 (May 1950)

2. Clarke, Erma E. A small hospital plans for rooming in Amer. J. of Nursing, 53, 570-571

3. Clifford, Stewart H. and Daxson, Wilburt C. The origin of pediatric nurseries J. Pediat, 44, 205-212 (Feb. 1954)

4. Danes, Claire. Report of a panel discussion on rooming-in J. Amer. Medical Women's Assn, 9, 80-83 (Mar. 1954) Reprinted in Child Family Digest, 10 (May 1954)

5. Daxson, Wilburt C. Rooming-in increases breast feeding Child Family Digest, 7, 27-28 (Oct. 1952)

6. Dawson, Margaret C. Rooming-in--A decade's experience Child Study, Winter 1956-57

7. Didd兒, C. F. Don't start a rooming-in program unless you are prepared to continue it. Modern Hospital, 75, 79-80 (Nov. 1950)

8. Harris, Antoine. A public health nurse in rooming-in. Pub. Health Nursing (Oct. 1952). Reprinted Child Family Digest, 8, 96-103 (Jan. 1953)

9. Heustes, A. E. Meeting the administrative problems of rooming in Hospitals, January 1948, 18

10. Hoff, B'Anne. Our nursing experiences Child Family Digest, 8, 94-95 (June 1953)

11. Hoover, William Mitchell. Childbirth and the family unit plan Child Family Digest, 11, 3-10 (Apr. 1954)

12. Hyder, Kate. Basic preparation in obstetric nursing Amer. J. Pub. Health, 41, 90-94 (Nov. 1951)

13. Isbister, Clair. Management of the newborn baby Child Family Digest, 14, 3-10 (Apr. 1956)

14. Jackson, Edith B. The development of rooming in at Yale Yale J. Biology and Medicine, 25 (June 1953)

15. Jackson, Edith B. Philosophy and practice of rooming-in Hospital Topics (Dec. 1953)

When the New Baby Rooms In

By DOROTHY BARCLAY

A YOUNG mother we know came home from the hospital recently with a little baby and a big complaint. "I've been a mother for seven whole days," she said, her first afternoon at home, "but the baby's been mine for just the past four hours. Seems like there's something wrong some place when a mother has to wait a week to get acquainted with her own child!"

Like many other mothers today, this young woman had seen her baby for only short intervals during her stay in the hospital. He had been brought to her and whisked away as hospital routine dictated. "Just as I began to get used to the idea of him, they'd take him back to the nursery," she explained.

When making her hospital arrangements before the baby came, we asked her, had she thought, to inquire about rooming-in? "Rooming-in?" she asked. "What's that? Sounds like a college dormitory."

If our young friend had had her baby five or six years ago or had even been contemplating eventual motherhood at that time, chances are she would have known all about this new-fashioned, old-fashioned plan. In those days just about every woman's magazine in the country, and most newspapers as well, were carrying stories about the revolutionary "rooming-in" arrangement which was bringing babies out from behind the hospital nursery's plateglass window and putting them into their parents' arms.

P LANS varied widely from one hospital to another. In some the baby stayed in a special bassinet at his mother's bedside day and night and the mother was responsible—with nurses' help, of course—for his entire care. In others he was returned to the communal nursery at night, during visitors' hours and at any other time when his mother requested it. In certain hospitals, dad, long the forgotten man of early family life, was actually allowed to hold the child, even to change his diapers and give him a bottle. Feature writers made the most of this radical development.

For the past several years, little has appeared about rooming-in in the popular press. It's not strange that our young friend had missed

the idea entirely. Yet this development is no passing fad—though there are medical men and nurses who still think it is, or should be! Although there have been setbacks in some places, the program, which is entirely voluntary in most institutions where it exists, has grown steadily and quietly, depending on those who have appreciated it to spread the word of its virtues.

Delighted mothers have been the best saleswomen.

One example of this steady growth may be found at the Lying-In Hospital of New York Hospital, where a form of rooming-in was begun in 1949. Two hundred and eighteen mothers, or 4½ per cent of the hospital's total, took part in the program that year. This number has gradually grown until last year, even though the service could not be offered during July, August and September, 728 mothers, or 18.3 per cent, took part. The hospital has made no special effort to promote rooming-in—except by showing its interest in doing the best possible job.

Pediatricians, as a rule, are more in favor of the rooming-in development than are ob-

stheticians. The former are primarily concerned with getting their young charges off to the best possible start. The latter, at least those outspoken "foes" of the system with whom we've talked, are determined to protect their patients—the mothers—from drains on their energy.

"These women deserve a rest," the head of obstetrics at one hospital told us, "and I,

for one, am going to see that they get it." Although this attitude is quite prevalent, there are signs that it may be waning. At the latest conference of the American Congress on Obstetrics and Gynecology, opportunity for discussion of rooming-in was provided for in the program and constructive interest was apparent, especially among the women taking part.

Many observers have noted that women who want to be with their babies in the hospital—and few advocates of rooming-in wish to impose the plan on those who would not freely choose it—are likely to rest better with their infants beside them than they would fretting—or entertaining visitors—in childless isolation. Rooming-in is not for every-

one, even its strongest champions admit. However, those who do want it—described by one nurse as "the self-reliant, do-it-yourself types"—claim that whatever rest they may possibly miss in the hospital is more than compensated for by the increased ease with which they approach baby care on their return home.

"It's one thing to hold a baby for twenty minutes or so at feeding time," a mother told us. "It's something quite different to have him beside you all day, sleeping, waking, making strange faces and even stranger sounds." For parents who can rely on experienced nursing help at home, developing this early acquaintance may not be so important, this mother held. But one who must take over alone on leaving the hospital may well be terrified—as she was—at the prospect of meeting "a stranger's" needs unaided.

Rooming-in is far more, then, than a cozy living arrangement for mother and child. It is an important form of parent education which requires for real success a special kind of attitude on the part of nurses and other staff. (Mothers who have insisted on keeping their babies with them against the resistance of hospital personnel have often had a less than satisfactory experience.)

A ACCORDING to Dr. Edith B. Jackson of Yale University, one of rooming-in's strongest advocates, genuine and timely help offered early by an understanding nurse can actually help promote a mother's good feelings and devotion to her infant. (Grandmothers served this purpose once.) Learning to care for the baby in the hospital, secure in the knowledge that a nurse is there to take over if necessary, eliminates the sense of pressure or anxiety that often exists among young mothers alone at home. Having her baby beside her gives a mother opportunity to observe and note his reactions and to develop some trust in her observations, feelings and judgment.

For those who want and need it, the rooming-in plan serves a valuable purpose. Its present slow spread may be somewhat hastened as more young parents request such arrangements from their physicians and hospitals.

THE NEW YORK TIMES MAGAZINE

# Daunt Our Kids

## face the unexpected with cool confidence

BY JEAN KOMAIKO

WHEN a crisis hits our house, I ask the children to remember John Dewey. Not as an educator, philosopher or prime mover in the field of child development. Just as the father of a particularly quotable son. My two, Debby and Bill, never tire of hearing about the day Dewey saw water trickling through the ceiling of his study— and rushed to the bathroom, site of the ooze. There he found his small son sailing a boat, oblivious to the overflowing tub. Dewey launched into a sharp lecture. His son, however, wasn't having any lectures. "Good gosh, John," he retorted. "Don't just stand there and scold! Get the mop!"

Many times in the past decade, that remark has kept the Komaikos calm, collected and cheerful throughout our quota of bruised knees, locked doors, fallen hopes and raised welts. Like any family, we've had emergencies—moments when fear swelled to panic and when *doing not discussing* was necessary. At those times, it's always helped us to remember the spur to action of "Get the mop!"

Of course, my husband and I believe in preventing emergencies first; preventing ceilings from collapsing by watching water levels in the tub, preventing fires by teaching safety rules at home. But we both know that, despite this, accidents can and do happen. So we're convinced that along with training in prevention must go teaching for emergencies.

This doesn't mean trying to prepare a child to deal with every possible mishap. Many, of course, are too overwhelming for the brightest of youngsters. Nor does it mean frightening kids with excessive talk of danger or potential danger.

What it does mean is that we're trying to make our children able to act, to turn for help when the situation demands it, to feel adequate about their own ability to cope and trustful about the helpfulness of other people.

It isn't easy teaching a small child to meet pain and danger wisely. The oldest and smartest among us find fear a formidable foe. (For children the unexpected and the adverse are even more frightening, lacking as they do the comfort of previous experience.) Our nervous and glandular systems key us up in time of trouble, stepping up circulation, sending warnings to the brain. Handled well, this bodily SOS can be a help. Handled poorly, it can result in panic, disaster, sometimes even death.

Our youngsters start life as safe as a caterpillar in a snug cocoon. Parents are on deck as lifeguards 24 hours a day protecting the toddler from hot stoves, sharp knives and a thousand other dangers. In time, though, the tot emerges like the moth, ready for a life away from that parental cocoonery. At this point come the big (Continued on page 127)

DRAWING BY RAY PROHASKA

Some of today's children will grow up concentrating all their efforts on the achievement of success. Others will strive less hard, but they may lead happier lives. What are the factors—at home, at school, on the playground—which determine how much need for achievement your child will carry into adult life?

# What Price SUCCESS?

BY RUTH AND EDWARD BRECHER

Two boys cavorting in a lake. Both are swimming and diving—but there the resemblance ends. Bruce enjoys the rippling coolness of the water against his skin, the rhythmic, effortless stretching and contracting of his muscles, the fun and freedom of the hour. Sometimes he yips a yippee from the delicious pleasure of it. Sometimes he floats quiescently, giving himself to the sun's warmth.

Chris? He's concentrating on the improvement of his skills. Out to the raft and back he races, timing himself on each lap. Whenever he breaks his own record, he lets out a whoop of triumph. He practices his back stroke, side stroke, crawl. Even when he floats idly on his back, it's with a serious purpose in mind: to rest up for the next strenuous effort. His pleasure comes not from the swimming itself but from his success in bettering his previous performance.

Which swimmer does your child resemble? Which would you like him to resemble? And what steps, if any, can you take to develop in him more of Bruce's capacity for simple enjoyment—or more of Chris's drive and ambition?

At Wesleyan University in Connecticut and at Harvard, Professor David C. McClelland and his associates have been exploring this aspect of human personality. While their findings are in some respects still tentative, they have turned up much

data of interest to parents. They report, for example, that Chris's ceaseless striving to excel is a characteristic pretty well established by the age of nine or ten. And they've found that boys and girls differ puzzlingly in this respect.

Children have many complicated needs. They have a need for affiliation, Professor McClelland explains—the need to be socially accepted, a welcome member of the gang. They have a need for power, a need for prestige and, high on the list for many American children and adults, a need for achievement, or "N. ACH." (pronounced "en-atch"). Children like Chris who turn an hour of fun into a striving for competitive excellence are exhibiting a high N. ACH.

To measure N. ACH., the McClelland group has developed a number of tests. One is based on the kinds of stories children tell when presented with simple pictures of people like themselves. Like our dreams, such freely invented stories often reflect our deepest inner motives. Here, for example, is a picture of a boy gazing out the window into space. "He's lonely and sad," one boy explains. "All the other kids have gone to a dance and he has no one to talk to." This boy is revealing his need for affiliation.

"He has a scholarship examination tomorrow," says another boy, "and he wants to do his best. If

42

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## HOW ROOMING-IN WORKS

(Continued from page 40)

a nurse whenever they are in a quan-dary and lights flash frequently.) "Still, we feel it's better for common perplexities to be met and solved in the hospital where experienced prac-tical help is available, than after mother and baby are home on their own."

"It isn't just mothers who get bet-ter acquainted with their babies through rooming-in," she went on. "It's fathers, too. They get to hold the baby, not just look at him through a glass. That never did seem right."

"You've sold me on the advantages of rooming-in for new mothers," I told the nurse. "But I still don't see why experienced mothers want it."

"Why don't you call on Mrs. Pen-ning?" she suggested. "She's the one to answer that question. She's a doc-tor's wife and has eight children. She roomed in with the last five."

Mrs. Penning is a slender, attrac-tive woman with a quiet, relaxed man-ner. "My husband and I first became interested in rooming-in by reading about it," she explained. "He likes to keep up with new ideas."

She is a firm advocate of nursing on demand and feels rooming-in facili-tates breast feeding. "Babies gain so much better on demand feeding," she said. "But unless you have the baby right in with you, how can you tell when you hear a hungry cry from the nursery whether it's your baby or not? With my last baby, my milk came in twenty-four hours because I had him there with me where I could let him nurse whenever he wanted to.

"I like rooming-in, too," she went on, "because in my large family it's the only chance I have to get ac-quainted with my new baby without other people around."

"Really getting to know" their ba-bies seems to be why a lot of mothers these days are looking for hospitals with rooming-in facilities. It's the best reason in the world.

## MORE ABOUT ROOMING-IN

**How Much Does It Cost?** In hospi-tals already set up to provide this service, rooming-in costs no more than regular care. Mothers may have pri-vate, semi-private or ward accommo-dations at the hospital's customary prices. Many doctors and veteran rooming-in mothers feel that semi-private accommodations—four mothers and their infants, in a spacious room—provide the most satisfactory arrangements for mothers and babies. Under such conditions, one nurse and one nurse's aide, assigned to their eight charges (mothers and babies), can give each mother and baby all of the instructions and care needed.

If your hospital does not yet have a rooming-in plan, unless you can ar-range to share a room with one or more other women who wish this service, you will probably have to take a private room, thus raising other hospital costs as well, since delivery

110

["WHERE TO BUY FASHIONS", "(Prices slightly higher west of the Mississippi)", "Playwear shown in color on page 97", "Atlanta, Ga.---\nDavison, Paxon Co.\n altimore, Md.---\nStewart & Co.", "Boston, Mass.---\nFilene's", "Heltenham, Pa.---\nGimbel Bros.\nayton, Ohio---", "Rike-Kumler Co.\nort Worth, Tex.---\nMeacham's", "artford, Conn.---\nG. Fox & Co.\nIndianapolis, Ind.---", "L. S. Ayres & Co., Inc.", "Milwaukee, Wis.---\nMilwaukee Boston Store", "Hinneapolis, Minn.---\nDayton Co.", "New Orleans, La.---\nD. H. Holmes Company,", "Ltd.", "New York, N. Y.---\nSaks Fifth Ave.", "Norfolk, Va.", "Rice's Fashion Corner,\nInc.", "Pasadena, Calif.---\nBullock's Pasadena", "Philadelphia, Pa.---\nGimbel Bros.", "Phoenix, Ariz.---\nGoldwaters", "St. Louis, Mo.---", "Stix, Baer & Fuller Co.\nSan Francisco, Calif.", "Macy's California\nSyracuse, N. Y.---", "Flah & Co., Inc.", "Upper Darby, Pa.---\nGimbel Bros.", "Washington, D. C.---\nWoodward & Lothrop", "", "Turnabout blouse, shorts on page 99", "Baltimore, Md.---\nHutzler's", "Louisville, Ky.---\nStewart Dry Goods Co.", "New York, N. Y.---\nB. Altman & Co.", "Oklahoma City, Okla.---\nKathryn Lipes, Inc.", "Striped and plain coordinates on page 100", "Bakersfield, Calif.---\nMalcolm Brock Co.", "Barre, Vt.---\nTots & Teens", "Binghamton, N. Y.---\nMcLean's Dept. Stores,\nInc.", "Elgin, Ill.---\nAckermann Bros.", "Hartland, Mich.---\nTots & Teens", "Highland Park, Ill.---\nMildred Cargill", "Los Angeles, Calif.---\nThe May Co.", "Madison, Wis.---\nCradle To Teen", "Oakland, Calif.---\nH. C. Capwell Co.", "Pocatello, Idaho---\nThe Peoples Store", "Princeton, Ill.---\nBig Top", "Riverside, Ill.---\nLikens Shop", "St. Paul, Minn.---\nSchuneman's, Inc.", "Walnut Creek, Calif.---\nH. C. Capwell Co.", "Woodland, Calif.---\nBreits", "", "Boy's striped shirt, white shorts on page 100", "Bellingham, Wash.---\nWahl's, Inc.", "Braddock, Pa.---\nJ. M. Balter Co.", "Columbus, Ohio---\nKhourie's, Inc.", "Borbin, Ky.---\nBelk Simpson Co.", "Newport News, Va.---\nLeggett Dept. Store", "Parkersburg, W. Va.---\nDils Bros. & Co., Inc.", "Tacoma, Wash.---\nPeoples Lakewood", "Toledo, Ohio---\nLamsons", "", "Checked top, white pedal pushers on page 101", "Baton Rouge, La.---\nD. H. Holmes Co. Ltd.", "New Orleans, La.---\nD. H. Holmes Co. Ltd.", "New York, N. Y.---\nBonwit Teller", "Richmond, Va.---\nMiller & Rhoads", "Spokane, Wash.---\nThe Crescent", "Winston Salem, N. C.---\nL. Roberts", "Striped swimsuit, terry jacket on page 102", "Green Bay, Wis.---\nH. C. Prange Co.", "St. Petersburg, Fla.---", "Schuster's Dept. Store", "Shreveport, La.---\nRubenstein's, Inc.", "Plaid swimsuit on page 103", "Boston, Mass.---\nR. H. Stearns Co.", "Cedar Rapids, Iowa---\nKillian Co.", "Cincinnati, O.---\nThe H & S Pogue Com-\npany", "Dallas, Tex.---\nA. Harris & Co.", "Milwaukee, Wis.---\nT. A. Chapman Co.", "New York, N. Y.---\nBest & Co.", "Philadelphia, Pa.---\nJohn Wanamaker", "Providence, R. I.---\nGladding's, Inc.", "Richmond, Va.---\nMiller & Rhoads", "Rochester, N. Y.---\nSibley, Lindsay & Curr\nCo.", "Daisy print swimsuit on page 103", "Chicago, Ill.---\nFairland", "Cincinnati, Ohio---\nHansen & Gretel Shop", "Cleveland, Ohio---\nHush-A-Bye", "Concord, Mass.---\nThe Country Store, Inc.", "Los Angeles, Calif.---\n* 3 to 6x only", "J. W. Robinson Co.\nNew York, N. Y.---", "Lord & Taylor*---\nPoughkeepsie, N. Y.---", "Harry's Youth Toggery\nSalem, N. J.---", "The Carousel Shop\nSan Antonio, Tex.---", "Jordan-Oppenheimer\nSchool", "", "Boy's and girl's robes on page 104", "Chicago, Ill.---\nMarshall Field & Com-\npany", "Detroit, Mich.---\nThe J. L. Hudson Co.\\*", "Hartford, Conn.---\n\\* Girl's robe only", "G. Fox & Co.\\*---\nNew York, N. Y.---", "B. Altman & Co.\nPhiladelphia, Pa.---", "John Wanamaker", "Makes Scuffed-Up\nShoes", "Shine like new!", "GRIFFIN Scuff Cover", "SELF-SHINING SHOE POLISH", "Best thing ever for\nschool or play shoes", "Just spread Scuff Cover on ... see scuff marks disappear! Even deep scars are gone. And Scuff Cover shines itself to a lasting brilliance ... no rubbing, no \"painted\" look! Water-resistant, too ... won't run or rub off when wet as ordinary liquids often do! Get Griffin Scuff Cover!", "FOR ALL SCUFFEN SHOES", "... IN YOUR HANDS", "Will You Guide Him Wisely?", "Few mothers have had the specialized training to understand the ever-changing phases of her child's unfolding personality. Will you know how to help your child acquire the right work habits, good behavior patterns, and a pleasing personality so necessary to success in school and later life?", "Send for FREE BOOKLET\n\"So Little Time\"", "Tells how habits are formed, what to expect during each phase of your child's growth, what you can do to help in his important early years.", "Fill Out and Mail Today!", "THE BOOK HOUSE FOR CHILDREN, Dept. P-558", "Tangley Oaks, Lake Bluff, Illinois", "Name.", "Address.", "City.", "State.", "Children's Names", "and Ages are:", "My BOOK HOUSE", "A Complete Plan of Child Development", {"bbox": [379, 781, 576,

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WHEN ARE THEY READY FOR CAMP?

(Continued from page 50)

CO-AUTHORS OF THIS ARTICLE, Hedley S. Dimock, Ph.D., and Hedley G. Dimock, Ed. D., are a father and son who have been camping together for many years and recently introduced a third generation to the pleasures and duties of camp life.

behavior in situations like these sug-
gests what he is likely to do when
he gets to camp.

**Physical condition.** Good physical condition is highly important for most camping experiences. Camp is a very active place and some children even find it overstimulating. If there is any question about your child's health, consult your pediatrician. (A camp wants a medical report from him in any case.) Any special physical problems should be considered. Some that may make it difficult for children at camp are persistent headaches, allergies, serious deviations in eating or sleeping, persistent irrational fears and bedwetting. A good camp has resources for dealing with such problems and a successful camping experience may be anticipated for the children if their particular needs are known.

Many children with more serious
disabilities—diabetes, blindness, car-
diac conditions, orthopedic handicaps
—are also successful campers. Many
camps operate with one particular
handicap in mind. For example, there
are camps for the blind, for diabetics
and for cardiacs. There are also
camps where youngsters with many
different kinds of disabilities are
brought together in the same cabin
groups. Some camps even have facili-
ties for children who are confined to
wheelchairs or who require frequent
medical treatment. (A booklet listing
these various camps can be secured
from The American Camping Associa-
tion, Bradford Woods, Martinsville,
Indiana, for fifty cents.) The ques-
tion of whether a child with any such
difficulties should go to a regular
camp or to one that specializes in
handicapped children is important.
It's a good idea to discuss it with
other people who have some train-
ing and who know the child—his
doctor and teacher, for instance.

The child's interests. How does your child feel about going to camp? If he initiated the camp idea and continually asks you about going, you can be pretty sure he is interested. It helps to talk with him about typical camp activities and see how he responds. It will also help if he can talk with children who have been to camp and see movies of camps. Seeing that some of his present interests can be satisfactorily followed up at camp is an additional incentive. The more the child can share in the decision about going to camp and in selecting the camp, the higher his "readiness quotient" is likely to be.

A child's saying he wants to go to
camp, however, should not be con-
fused with his real interest or readi-
ness. Many children go through a
stage where they talk with great en-	husiasm and apparent determination
about what they want to do. Paul, a
five-year-old, would talk all week
about sleeping outdoors over the
weekend. When Saturday night ar-
rived, he'd announce he was sleeping

in the cabin but was sleeping out
next week. Here again, it is chiefly a
matter of knowing your own child.

The family situation. The needs and interests of the rest of the family are just as important in the long run as the needs and maturity of the child. For some special reason, such as ill health in the family, it may be essential for a child to go to camp for the summer. The working widow with a child often has no alternative. Perhaps parents feel they need time together, away from the children.

A feeling that you need a break
from your child may be the factor
that tips the scale. There is no doubt
the great "improvement" that par-
ents often see in their child at the
close of camp is partly a reflection
of their own relaxed feelings because
they've had a vacation, too.

Occasionally, one child's going to
camp upsets the harmony in this
home. Try to spot the possible com-
plication before you make a decision.
Often, complications do not relate di-
rectly to a child's readiness for camp
but to the family's readiness for
child to go to camp. And this is
something to answer honestly, too—
not just is the child ready, but is the
family ready, are you ready?

MS HOPE CHEST
Needs Your Help

MULTIPLE SCLEROSIS—MS, a widespread, crippling, usually progressive disease of the central nervous system, has been termed by D. H. Houston Merritt, Professor of Neurology at Columbia University, “the greatest cause of chronic disability among young adults.” Since MS strikes mainly at people in the 20- to 40 age group—many of whom are young parents and bread-winner— it profoundly disturbs the lives of entire families with an inevitably damaging effect on the community. Contributions to the MS HOPE CHEST are used to finance scientific programs aimed at bringing MS under control and to help MS patients and their families. Please send contributions to your nearest MS chapter to the National Multiple Sclerosis Society, 257 Fourth Avenue, New York 10, New York.

114