EDUCATION

EDUCATION

ROLEOF THE PEDIATRICIANIN A THERAPEUTIC

NURSERYSCHOOL

Robert S. Mendelsohn, M.D.

D ISTURBEDbehavior in the preschool-age child has become a matter of increas ing concern to the pediatrician. As parents have become aware of the importance of early emotional development in determining future adjustment, they have consulted the pediatrician concerning observations on their children. In addition, there has been a remarkable expansion of nursery schools and prekindergarten facilities in recent years, and the pediatrician is increasingly faced with behavior disorders called to the parents' attention by schoolteachers.

Much of this behavior represents varia tion within acceptable norms for the par ticular period of growth; other symptoms

may be handled by the pediatrician using

either traditional techniques or those of the “¿newpediatrics.―13 But occasionally the problem is complex and persistent, and deeply involves other members of the

family. When this is the case, the situation is often best managed by an approach at

the community level, where various disci plines, including pediatrics, can combine their skills in study and treatment of the whole family.

The intent of this report is to describe an unusual community effort directed at the preschool child and his family, and to indi cate the relationship of the pediatrician to this organization.

DESCRIPTIONOF FACILITIES

The Virginia Frank Child Development Cen ten°was established in 1956 in an attempt to

deal, in a therapeutic environment, with certain children of nursery school age who exhibit signs of disturbance in development. It is de

o A division of the Jewish Family and Community

Service, Chicago, Illinois.

signed, as stated in the school's brochure,° to

help families whose children have serious

trouble in “¿controllingor expressing feelings, getting along with other people, playing or enjoying activities, sleeping, eating, learning to use the toilet, or giving tip babyish ways.― Its purpose is, by providing a corrective ex

perience, to help the children adjust better at

home and to achieve success in primary school and later life.

The physical arrangements will be briefly

described. The school is temporarily located on the second floor of one of the Jewish Commu

nity Centers in Chicago; there are three large

indoor playrooms, a kitchen, and administrative

and interviewing offices. There is a large out

side play area immediately adjacent to the building. On the first floor of the building

there is a separate “¿normal―nursery school. The physical plant and play apparatus of the

Child Development Center is similar to that used in the regular nursery school downstairs and in general to other nursery schools that adhere to the recommendations of the National

Association of Nursery Education.4 The play

activities, too, are similar to those found in other nursery schools, with provision for more

individualization in determining the child's

activities.

There are 20 children and they attend 4 hours daily, 5 days a week, including lunch and a rest period. Bus service is provided. School fees are based on family income and expenses

and are determined according to a sliding scale. Although this is a community-supported agency, it should not be inferred that this is

strictly a charitable project. The children de rive from a wide range of income and occupa tional groups; there may be a very minimal

charge or the fee may range from a few dollars

* Available from Miss Claudeline P. Lewis,

Director, Virginia Frank Child Development Center, 3715 West Wilson Avenue, Chicago, Illinois.

P@rn@vrrncs,September 1960

THERAPEUTIC NURSERY SCHOOL

to $100 or more monthly. There is no volunteer help, and all nursery personnel are paid at pro fessional rates.

The unique character of this school lies in the joint interaction of nursery schoolteachers, social workers, psychologist, psychiatrist, and

pediatrician, all working in an outpatient set

ting under the auspices of a family service

agency, designed to evaluate and treat con

currently children and their families.@ This is in contrast to the child-oriented residential treatment center, and to the child guidance organizations where the emphasis is on helping the child through his own individual treatment, and by working through the parents.

The advantages of treating preschool chil dren for prolonged periods every day in a

group situation, together with counseling for

the parents, motivated the family-centered nur sery school approach exemplified in the Child Development Center.

The full-time professional staff consists of the director (trained in social work), a case worker, a supervisory head teacher, and four nursery teachers. The child psychiatrist and pediatrician meet with the group weekly dur

ing the school year for a staff session. Records of these joint meetings are incorporated with the

reports of the teachers, social workers, psychol ogist, psychiatrist, pediatrician, and outside pertinent sources. The psychiatrist frequently visits the school for first-hand observation. The psychologist conducts periodic testing of each child, and often personally elaborates on the results at the staff meetings. The role of the pediatrician will be discussed in greater detail in another section.

CRITERIA OF ADMISSION

The method of selection of children is of paramount interest to the practicing pedia trician since an appreciation of this may help him to refer these children who may most profit from this type of service. At the outset it should be stated that this program is geared to the child whose disturbance originates from emotional causes, and not to the physically handicapped child. However, children have been referred with previously suspected organic lesions such as “¿post concussion syndrome,― “¿braindamage,― “¿mentalretardation@― or deafness. Often

these diagnoses have been abandoned, or their significance altered, as a result of the initial diagnostic investigations, or ob servations of performance after starting the school.

Other determinants of admission include the age of the child (3 to 6 years), the will ingness or ability of the parent to enter

treatment, the number and composition of

existing groups in the nursery school, the availability of bus service, and the immi nence of entry into grade school. There are flO racial or religious barriers to admis sion. Since this program is still experimental in nature, the criteria for admission are necessarily flexible, and specific diagnostic classification is not usually a controlling factor. To illustrate selection, the source and reason for referral of some of the appli cants are presented in tabular form (Tables I and II).

Many such applicants with gross brain damage and severe psychoses have been referred to other more appropriate agencies. Thus the influence of this form of multi disciplinary approach is radiated to other community facilities.

TREATMENT

While treatment cannot be discussed in detail, some brief remarks will serve for orientation. Treatment is based on dynamic concepts of personality development. The children attend school daily and share in a collective experience, or when necessary, receive individual periods of attention. The mother, and frequently the father, meet

at weekly intervals for counseling with the

Nt).(yr)ReferralReferral14+@Neighborhood SourceReason for

nursery schoolIntense fears; extreme difficulty in separating from mother;

overconcern with “¿badness―and sexual identification; in ability to participate in any structured activity (listening to

a story in a group, participating in games or music); dull

culty in relating to others; preoccupation with vacuum clean

ers (asks everyone in building if they have one, visits vac

uum cleaner departments in downtown stores)..5Speech

and Hearing Clinic of Michael

Reese HospiuilPossible

emotional causation of speech failure and hearing difficulty.S44Neighborhood

nursery schoolOverly sensitive and reacts with extreme fear to normal cor rection; shy; separation terror; general anxious and tense

state; very frequent masturbation; severe temper tantrums.4SflOriginally

seen at Northwestern Uni versity Speech Clinic and referred to

the Jewish Family Service Agency

and the Child Development CenterMild

speech impediment and severe emotional problem.5Mother

of child in attendanceFrequent crying; temper tantrums; “¿toobabyish―; “¿spoon fed too often―; stuttering and infantile

speech.6S@Neighborhood

nursery schoolAnxiety; obsessed with fear of body damage, separation and of trusting adults; frantic running from one activity to an other;

soiling.734-iNewspaper

publicityWould not eat unless cajoled or spoonfed, “¿hungerstrike― for 3 weeks; long periods of somnolence during the day; sepa ration fears; difficult to understand speech; unable to dress

himself at all; didn't know his name; extreme babyish ways

with lack of muscle skills.

TABLE I

SOURCE AND REASON FOR REFERRAL OF SEVEN CHILDREN ACCEPTED FOR TREATMENT IN A

THERAPEUTIC NURSERY SCHOOL

the various disciplines are integrated, prog ress is evaluated, and plans for future man agement are evolved. While we are greatly encouraged by the progress of children in overcoming their problems, there are obvi ous inherent difficulties in evaluating re suits in a program of this nature. In general it is believed that these children, left to their natural courses, would probably deteriorate further and not succeed in adjusting to the

environment of grade school. However,

further evaluation is necessary. This and

study by the Research Center of the Uni

versity of Chicago School of Social Service

Administration under a grant from the Elizabeth McCormick Foundation.

DISCUSSION

How does the pediatrician function with in this general framework? He participates in the diagnostic study procedures, in medi cal problems arising during treatment, in interpretation of medical situations to the school staff, in promoting proper public health measures in the school, and in the staff development program. He does not

serve as personal physician to the children.

Case

No.Age (yr)ReferralSourceforReferralDisposition143@Mother

“¿heard about― school in neighborhood“Maybe

retarded, maybe not―;was ill with convulsions and nIeniligitis at 44 months of age.Staff

pediatrician conferred with private

physician; on the basis of this conversation, the history, physical and developmental findings, psychological tests, and observa tion by school teachers, it was concluded that child had a high degree of organic brain damage and would not be a candidate for this school. Case was then transferred for family counselling within the agency; child later admitted to a special school for the

retarded.934Private

psychi

atristOnly

words “¿bow-how―;some vocali zation and babble; few non-verbal

ways of communicating; rocked and

hummed to herself; aimless and “¿dis

interested― in most things; will play with another person, but looks right

past them; screeches a great deal to

show any kind of emotion.After

complete work-up by all disciplines,

including a period of observation, a staff

conference and discussion with private psychiatrist, it was decided that this child

was not feeble-minded, but autistic, and

too severely disturbed for this school. in

dividual therapy to continue. TABLE II

SOURCE AND REASON FOR REFERRAL OF Two CHILDREN NOT ACCEPTED FOR TREAT

MENT IN A THERAPEUTIC NURSERY SCHOOL

ventive services from a private physician or, in the case of indigent children, in a hos pital clinic. The children are examined by their personal physician prior to admission to the school; any deficiencies in immuniza tions are corrected, and the information is transmitted to the school.

The school pediatrician examines the child in the presence of the mother. In eliciting the history, detailed information is sought regarding such areas as the preg nancy, the delivery, and developmental achievements, especially regarding feeding and toilet training. Particular attention is given to the actual expressions used by the mother in relating the history. Any hospi talizations, operations, and illnesses are

carefully reviewed in order to establish

possible relationships to the present be havior. Sibling births and developments are closely questioned and comparisons are en couraged, again to obtain possible signifi cant etiologic factors in the present conch tion. This history may duplicate that taken by the caseworker, but the information de rived may be quite different, reflecting the

more “¿medical―orientation of the pediatri cian and the unique doctor-patient relation ship. At the pre-admission staff meeting it

is of considerable diagnostic value to com

pare the different answers obtained from the medical history and the casework his tory. Also, since many mothers (because of their own emotional stress) cannot give an accurate or meaningful history in their early contacts with the center, corrections are often discovered as treatment proceeds.

EDUCATION

completed. However, since the child had re

cently had a herniorrhaphy and had consider

able anxiety centering about his genitals, the nursery school staff felt that some of the symp toms might be emotionally determined. There fore, the staff pediatrician conferred with the

child's physician and the urologist; it was

agreed that, in the absence of imminent danger

of renal damage, urologic procedures should be held to a minimum. Accordingly, hospitali

zation was cancelled and, instead, one urethral

dilatation in the office of the urologist was per

formed. This proved to be successful on fol low-up examination and no further treatment was required. No adverse effects were noted by

the school staff.

In a 4@-year-old girl with strabismus, mus

cle recession was advised after attempts at cor

rection with eyeglasses proved unsuccessful.

She had recently been admitted to the school

and the schoolteachers noticed her eye condi tion seemed to be worse when she was anxious. She had been unwilling to wear corrective lenses and, in fact, had broken her glasses in a fit of rage. The teachers felt that this situation might be favorably influenced as her general tension and anxiety diminished. The pediatri cian agreed that the ophthalmologist be con

suited with a view toward deferring surgery. This was accomplished, the girl and her pa rents responded well to the nursery school

environment, and she was able to wear her

glasses comfortably and regularly. Several

months later, since the strabismus was not com pletely corrected, surgery was performed. At

this time, both the child and the mother were

able to handle the operation without the pre vious hysterical pattern of behavior.

A 43k-year-old, highly allergic girl was fre quently kept out of school by her mother, al

legedly because of “¿colds―.These repeated ab sences were nullifying attempts at therapy.

The staff pediatrician oriented the school staff regarding this common problem. On his ad vice, the mother was encouraged to send the

child regularly in spite of the allergic symp

toms. At first, she found this difficult and fre

quently called the nursery school in the morn

ing to describe the symptoms and infer that probably “¿sheought to stay home today.―How ever, the staff, supported by medical advice, was able to take a firm stand, and the child's attendance became regular. The mother was then also able to attend regularly her inter view sessions and became more involved in pediatrician was informed in advance by

the caseworker that one child had a strong fear of the tongue depressor following a recent tonsillectomy; his reluctance to enter the office softened when he was assured no “¿stick―would be placed in his mouth. Modi fled methods of examination or even post ponement may be required. Another mother

was very concerned about a small scar left by chickenpox on her daughter's forehead

and expressed resentment at the lack of serious consideration by previous examiners. Advance knowledge and consultation with the caseworker led the pediatrician to han die this in a fashion which complemented the psychotherapeutic approach. Often the child exhibits such terror of the impending examination that it is not attempted until the pediatrician and the child have de veloped mutual friendliness over a period of several months. This deferred examina tion may then serve the therapeutic func lion of helping the child over his fears of body damage by physicians.

Each child is examined before admission, at annual intervals thereafter, and also after illness. In each instance, the physical ex amination, while not neglecting the tradi tional review of organ systems, is patient oriented; it is specifically utilized to help the patient in a positive manner and is pur

posefully integrated with the other disci

plinary efforts.

The staff pediatrician may also be helpful when medical problems arise during treat ment. Some examples will serve to illustrate the point:

A 4-year-old child in the school had a her niorrhaphy. Several weeks later he complained of some discomfort in urination. Furthermore, for some time previously, both the mother and the pediatrician had noted the child seemed to have a small urethral orifice and a thin uri

nary stream. He was referred to a consulting

urologist who advised hospitalization for me totomy and informed the mother that follow ing hospitalization several urethral dilatations would probably be necessary. When brought to our attention, all arrangements for hospitali

tion, including orders for blood cell count,

496

cian often has information which is of value to the psychotherapist, and this may in

crease the respect of the caseworker or

schoolteacher for the physician's decisions and actions. The pediatrician is thus in an excellent position to enhance the apprecia tion of each group for the other and ulti mately improve interdisciplinary communi cations.

This has indeed been the case over S years of functioning. There has not been a single instance of conflict between medical care and psychologic considerations. Where physical care was immediately required,

psychotherapeutic techniques were used to

mitigate undesirable reactions. And, as de scribed above, modifications of the program for physical care were effected in appro priate situations.

While it is generally accepted that treat ment of this nature may prevent future neurotic traits, delinquent behavior, and mental breakdown, results are understanda bly difficult to evaluate accurately. How ever, a few statistics may be indicative. The school has had 40 children : there have been

26 graduates; 24 are in public school; 2 are in special educational schools. In all in stances there has been exchange of infor

mation between the Child Development Center and the public school. In some of

these, therapy of the parents is continuing.

We anticipate more objective measurement of the effectiveness of this facility from the evaluation study now in progress.

SUMMARY

A therapeutic nursery school and the role of the pediatrician in this school have been described. This type of treatment facility is of importance to pediatricians who in creasingly are confronted with behavior dis turbances of children of preschool age.

Acknowledgment

I am deeply grateful for the help given by Miss Claudeline P. Lewis, Director of the Child Development Center.

therapy. This family responded well to the psychologic management; the child had no ill nesses during the year and, in fact, as she im proved emotionally, her allergic symptoms either decreased in intensity or were less of a problem to this family.

There are other examples, including de

ferring of tonsillectomies, proper prepara

tion and timing in cases of elective hernior rhaphies, handling of anxiety about epilepsy, and determining activity in con valescent periods, which cannot be elabo rated upon here. In addition, many minor items requiring medical knowledge for management and clarification constantly arise, and the staff pediatrician is frequently consulted by phone.

The pediatrician has a role in situations regarding public health, such as advising in the management of contacts of contagious disease and in other ways explaining and executing the rules of the local health au thorities.

Finally, the pediatrician participates in the education of the school staff by orienting the teachers on appropriate health meas ures, normal growth and development, and

availability of medical resources.

REFERENCES

1. May, C. D.: Mental hygiene in the new

pediatrics(Editorial).PEDIATRICS, 24:355,

1959.

2. Idem: Can the new pediatricsbe practiced?

(Editorial). PEDIAi'nlcs, 23:253, 1959. 3. Richmond, J. B.: Some observations on the

sociology of pediatric education and prac tice. PEDIATRICS, 23:1175, 1959.

4. National Association of Nursery Education:

Some ways of distinguishing a good nursery school. Distribution Center: Uni

versity of Rhode Island, College of Home

Economics, Kingston, Rhode Island, 1942. 5. Lewis, C. P.: The family-centered approach

1960;26;491

Pediatrics

Robert S. Mendelsohn

SCHOOL

EDUCATION: ROLE OF THE PEDIATRICIAN IN A THERAPEUTIC NURSERY

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Robert S. Mendelsohn

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EDUCATION: ROLE OF THE PEDIATRICIAN IN A THERAPEUTIC NURSERY

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